Diagnosis and treatment planning in FPD with related articles

Diagnosis and treatment planning in FPD with related articles

1. DIAGNOSIS AND
TREATMENT PLANNING IN
FIXED PROSTHODONTICS
Presented by,
NamithaAP
2
ND
MDS DEPT.OF PROSTHODONTICS

2. Contents
Introduction
History
Chief complaints
Medical history
Dental history
General examination
Intraoral examination
Diagnostic aids
Treatment planning for single tooth restoration
Treatment planning for missing teeth
Related articles
References

3. INTRODUCTION
DIAGNOSIS
Is the determination of the nature of a disease process.
TREATMENT
Isanymeasureddesignedremedytodisease
thorough diagnosis
made of the patients
dental condition
Considering both hard and
soft tissues
mitigated to a
variable degree
by his or her
medical,
psychological
and personal
circumstances.
formulate a
treatment plan
based upon
the patients
dental needs

4. FIVE ELEMENTS
HISTORY
TMJ OR
OCCLUSAL
EVALUTATION
INTRA ORAL
EXAMINATION
DIAGNOSTIC
CASTS
FULL MOUTH
RADIOGRAPHS

5. HISTORY
Allpersistentinformationconcerningthereasonsseeking
treatment,alongwithanypersonalinformation,including
relevantpreviousmedicalanddentalexperiences.
Name
Age
Sex
Address
Contact No
Family history
Socio-economic status

6. CHIEF COMPLANT
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)

7. Comfort
Pain
•location, character, severity, and
frequency should be noted
•what factors precipitate it ? (e.g., hot,
cold, or sweet things)
•any changes in its character ?
•Is it localized or more diffuse in nature?
•It is often helpful to have the patient
point at the area while paying close
attention.
Swelling
•location, size, consistency, and colorare
noted
•how long it has been felt and whether it
is increasing or decreasing

8. Function Social
Difficulties in
chewing
fractured cusp or
missing teeth
more
generalized
malocclusion or
dysfunction
Bad taste/
smell
Periodontal
disease
Compromised
oral hygiene

9. Appearance
Missing
teeth
Fractured
restoration
Crowded
teeth
Unattractively
shaped teeth
Mal
positioned
discolored

10. MEDICAL HISTORY
Medications and relevant medical conditions
If necessary the patients physician(s) can be contacted
for clarification

11. following classification may be
helpful:
•any disorders that necessitate the use of antibiotic
premedication
•any use of steroids or anticoagulants
•any previous allergic responses to medication or
dental materials
1.Conditions affecting the treatment
methodology
•previous radiation therapy
•hemorrhagicdisorders
•extremes of age
•terminal illness
2.Conditions affecting the treatment
plan

12. •periodontitis may be modified by diabetes,
menopause, pregnancy, or the use of anticonvulsant
drugs
•in cases of hiatal hernia, bulimia, or anorexia
nervosa, teeth may be eroded by regurgitated
stomach acid
•Certain drugs generate side effects that mimic
temporomandibulardisorders (TMDs) or reduce
salivary flow
3.Systemic conditions with oral
manifestations.
•patients who are suspected or confirmed carriers of
hepatitis B, acquired immunodeficiency syndrome, or
syphilis)
•In current scenario corona is added to this list
4. Possible risk factors to the dentist and
auxiliary personnel

14. Periodontitis in diabetic
patient
Previous radiation therapy

15. Dental offices practice "universal precautions" to ensure appropriate
infection control. This means that full infection control is taken for every
patient; no additional measures are needed when treating known carriers

16. DENTAL HISTORY
Clinicianshouldbecautiouswhencommentingbeforeathorough
examinationiscompleted.
withadequateexperience,acliniciancanoftenassessprimarytreatment
needsduringtheinitialappointment.
whensuchaassessmentisrequestedforlegalproceedings,thepatient
shouldbereferredtoaspecialistfamiliarwiththe“usualcustomary”
standardofcare

17. ORAL SURGICAL HISTORY
.
Informationaboutmissingteethandanycomplicationsthatmayhave
occurredduringtoothremoval
Specialevaluationdatacollectionprocedures-prosthodonticscare
subsequenttoorthognathicsurgery
Beforeanytreatmentisundertaken,theprosthodonticcomponentof
theproposaltreatmentshouldbefullyco-ordinatedwithsurgical
component.

18. The patients oral hygiene is assessed, current
plaque control measures are discussed, as are
previously received oral hygiene instructions.
The frequency of any previous debridements
should be recorded
Dates nature of any previous periodontal surgery
should be noted.
PERIODONTAL HISTORY

19. RESTORATIVE HISTORY
Simple composites resin or dental amalgam fillings or may involve
crowns and extensive FPDs.
The age of previous existing restorations can help the prognosis and
probable longevity of any future fixed prosthesis.
Occlusal analysis should be an integral part of the assessment of a
prosthodontic dentition.
If restorative treatment needs are anticipated , they should be
undertaken by the restorative dentist.
Occlusal adjustment (reshaping of the occlusal surfaces of the teeth)
may be needed to promote long-term positional stability of the teeth
and reduce or eliminate parafunctional activity.

20. ENDODONTIIC HISTORY
The findings should be reviewed periodically so that peri-apical health
can be monitored, any recurring lesions promptly detected.
Defective
endodontics has
led to recurrence
of
a periapical
lesion.
Retreatment will
be required.

21. ORTHODONTIC HISTORY
As the crown/root ratio is affected,
future prosthodontic treatment and its
prognosis may also be affected.
Restorative treatment can often be
simplified by minor tooth movement.
When a patient is contemplating
orthodontic treatment, considerable
time can be saved if minor tooth
movement (for restorative reasons) is
incorporated from the start.
Thus good communication between the
restorative dentist and the orthodontist
may prove very helpful
Apical root resorption
subsequent to orthodontic
treatment.

22. REMOVABLE PROSTHODONTIC HISTORY
The patients experiences with removable prostheses
must be carefully evaluated
a RPD may not have been worn for a variety of reasons,
and the patient may not even have mentioned its
existence
Listening to the patients comments about previously
unsuccessful in assessing whether future treatment will
be more successful.

23. 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.

24. 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.

25. EXAMINATION
An examination consist of the clinician’s use of sight,touch
, and hearingto detect conditions outside the normal range.
To avoid mistakes, it is critical to record what is actually
observed rather than to make diagnostic comments about
the condition. For example, "swelling," "redness," and
"bleeding on probing of gingival tissue" should be recorded
rather than "gingival inflammation" (which implies a
diagnosis).

26. 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.

27. EXTRAORAL EXAMINATION
FACIAL
ASYMMETRY
CERVICAL
LYMPHNODES
TMJ’S
MUSCLES OF
MASTICATION
(palpated)

28. TEMPEROMANDIBULAR
JOINT’S
Permits a comparison between the relative timing of left and
right condylar movements during the opening stroke.
ASYNCHRONIOUSMOVEMENT:Anteriordiskdisplacementthat
preventsoneofthecondylesfrommakingabnormaltranslatory
movements.
Auricularpalpationwithlightanteriorpressurehelpsidentify
potentialdisordersintheposteriorattachmentofthedisk.

29. The joints are palpated as the patient
opens and closes to detect signs
of dysfunction.
Tenderness or pain on
movement, is noted and
can be indicative of
inflammatory changes in
the retrodiscal tissues
,which are highly vascular
and innervated
Clicking in the TMJ is
often notecible through
auricular palpation but
may be difficult to detect
when palpating directly
over the lateral pole of
the condylar process,
because the overlying
tissue can “muffel” the
click , placement of the
fingertips on the mandible
will help to identify even
a minimal click

30. Average opening >50mm
Restricted opening<35mm (intracapsular changes in the joints)
Midline deviation :normal is 12mm
Mouth opening

32. MUSCLES OF MASTICATION
Bilaterally and simultaneously with light pressure
Allows the patient to compare and report any
differences between the left and right sides
MILD
MODERATE
SEVERE
CLASSIFY THE
DISCOMFORT AS
PALPATE FOR SIGNS OF
TENDERNESS
MASSETER
TEMPORAL
MUSCLES
POSTURAL
MUSCLES

34. MASSETER
palpated extraorally by placing the fingers
over the lateral surfaces of the rami of the mandible.

35. TEMPORALIS
fingers are placed over the patient’s temples to feel the
temporalis muscles.

36. MEDIAL PTERYGOID
index finger is used to touch the medial pterygoid muscle on the
inner surface of the ramus

37. TRAPEZIUS
trapezius muscle is felt at the base of the
skull, high on the neck

38. STERNOCLIEDOMASTOID
grasped between the thumb and forefingers on the side of the
neck. The muscle can be accentuated by a slight turn of the
patient’s head.

39. If there is evidence of significant asynchronous movement or
TMJ dysfunction, a systematic sequence for comprehensive
muscle palpation should be followed as described by Solberg
and Krogh-Poulsen and Olsson."
Each palpation site is given a numerical score based onthe
patient's response

40. LIPS
Visibility during normal and
exaggerated smiling.
(especially in margin
placement of certain metal
ceramic crowns)
Missing teeth, diastemas
and fractured or poorly
restored teeth will disrupt
harmony of the negative
space and require
correction.
NEGATIVE SPACE”-When
the patient laughs, the
jaws open slightly and a
dark space is often visible
between the maxillary and
mandibular teeth

41. 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 will depend on the length and mobility of the
upper lip and the length of the alveolar process.

42. 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 properly evaluated during
treatment planning only if objective indices, rather
than vague assessments, are used.

43. PERIODONTAL EXAMINITION
Status of bacterial accumulation
Response of the host tissues and the degree of
irreversible damage.
Long term periodontal health is essential to
successful fixed prosthodontic treatment.
Existing periodontal disease must be corrected.

44. Gingiva
The gingiva should be lightly dried before examination
so that moisture does not obscure subtle changes or
detail.
Color, texture, size, contour, consistency, and position
are noted and recorded
The gingiva is then carefully palpated to express any
exudate or pus that may be present in the sulcular area.

45. Methods of visualising mucogingival junction
width of the band of attached keratinized gingiva
around each tooth
•measure surface band of keratinized tissue in an apicocoronal
dimension with a periodontal probe and subtracting the
measurement of the sulcus depth.
Measurement by visual examination
•gently depress the marginal gingiva with the side of a periodontal
probe or explorer
•effect of the instrument will be seen to end abruptly, indicating the
transition from tightly bound gingiva to more flexible mucosa.
Injecting anestheticsolution into the non keratinized
mucosa close to the MGJ
•mucosa balloon slightly
(done only if the other methods do not provide the desired
information)

46. Periodontium
Measurement of depth (in millimeters) -periodontal
pockets and healthy gingival sulci on all surfaces of
each tooth.
Probe is inserted essentially parallel to the tooth and
is "walked" circumferentially through the sulcus in
firm but gentle steps, determining the measurement
when the probe is in contact with the apical portion
of the sulcus
most reliable
and useful
diagnostic tool

47. PERIODONTAL
EXAMINATION
TOOTH MOBILITY /
MALPOSITION
OPEN/DEFICIENT
CONTACT AREAS
INCONSISTENT
MARGINAL RIDGE
HEIGHTS
MISSING/ IMPACTED
TEETH
INCONSISTENT
MARGINAL RIDGE
HEIGHTS
MISSING/IMPACTED
TEETH
AREAS OF
INADEQUATE
ATTACHED
KERATINSED GINGIVA
GINGIVAL RECESSION
FURCATION
INVOLVEMENTS
MALPOSITIONED
FRENUM
ATTACHMENTS
any sudden change in the
attachment level can be detected
probe may also be angled slightly
(5 to 10 degrees) in the
interproximal areas to reveal the
topography of an existing lesion
Probing depths (usually six per
tooth) are recorded on a
periodontal chart

49. Clinical attachment levels
Determine the amount of periodontal
destruction that has occurred
measure of periodontal destruction at
a site, rather than current disease
activity, and it may be considered the
diagnostic "gold standard" for
periodontitis
more detailed and
accurate information
regarding the
prognosis of an
individual tooth
essential when rendering a diagnosis of
periodontitis (loss of connective tissue
attachment)
The clinical attachment level (CAL or AL) is determined by measuring the
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 and/or the cementoenameljunction (CEJ).

50. It should be documented in the initial periodontal examination.
an effective research tool.

51. When the free margin of
the gingiva is located on
the clinical crown and the
level of the epithelial
attachment is at the CEJ,
there is no loss of
attachment, and recession
is noted as a negative
number.
When the level of the
epithelial attachment is on
root structure and the free
margin of the gingiva is at
the CEJ, the attachment
loss equals the probing
depth, and the recession is
0.
In a situation in which there is increased periodontal destruction
and recession, the loss of attachment measurement equals the
probing depth plus the measurement of recession.

52. DENTAL CHARTING
PRESENCE / ABSENCE OF
TEETH
DENTAL CARIES
FRACTURES
RESTORATION WEAR
FACETING AND ABRASIONS
MALFORMATIONS
EROSIONS
impact on the position of adjacent teeth
carefully inspect the adjacent proximal wall,
even if caries is not apparent radiographically.
Condition and type of the existing restorations
are noted (e.g., amalgam, cast gold,
composite resin, all-ceramic)
wear facets is indicative of sliding contact
sustained over time and thus may indicate
parafunctional activity
Fracture lines in teeth may require fixed
prosthodontic intervention, although minor
hairline cracks in walls that are not subject
to excessive loading can often go untreated
and simply be observed at recall
appointments
Open contacts and areas where food impaction
occurs must also be identified

53. An accurate
charting of
the state of
the dentition
will reveal
important
information
about the
condition of
the teeth and
will facilitate
treatment
planning.

54. OCCLUSAL EXAMINATION
Askthepatienttomakeafew
simpleopeningandclosing
movements while carefully
observingtheopeningandclosing
strokes.
Theobjectiveistodetermineto
1.whatextentthepatient'socclusion
differsfromtheideal
2.howwellthepatienthasadapted
tothisdifference.
INITIAL
TOOTH
CONTACT
TOOTH
ALIGNMENT
ECCENTRIC
CONTACTS
JAW
MANEUREABILITY

55. INITIAL TOOTH CONTACT
The relationship of teeth in both centric relation and the
intercuspal position should be assessed.
If all teeth come together simultaneously at the end of terminal
hinge closure, the centric relation position (CR) of the patient is
said to coincide with the maximum intercuspation (MI)
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.

56. SLIDE FROM CR TO MI
If initial contact occurs between two posterior teeth (usually
molars), the subsequent movement from the initial contact to
the MI position is carefully observed and its direction noted.
Presence, direction, and estimated magnitude of the slide are
recorded, and the teeth on which initial contact occurs are
identified.
Any such discrepancy between CR and MI should be evaluated in
the context of other signs and symptoms that may be present
(e.g., elevated muscle tone previously observed during the
extraoral examination, mobility on the teeth where initial
contact occurs, wear facets on the teeth involved in the slide).

57. GENERAL ALIGNMENT
The teeth are evaluated for
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

58. •will affect tooth preparation design or in severe cases, may
result in a need for minor tooth movement before restorative
treatment.
TIPPED TEETH
•often overlooked clinically but will often complicate FPD design
and fabrication.
SUPRAERUPTED TEETH
•A tooth may have drifted into the space previously occupied by
the tooth in need of treatment because a large filling was
previously lost.
•Such changes in alignment can seriously complicate or preclude
fabrication of a cast restoration for the damaged tooth and may
even necessitate its extraction
DRIFTED TEETH

59. LATERAL AND PROTRUSIVE CONTACTS
Excursive contacts on posterior teeth may be undesirable
under certain circumstances
The degree of vertical and horizontal overlap of the teeth
is noted
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.
Then guided into lateral excursive movements, and the
presence or absence of contacts on the nonworking side
and then the working side is noted.
Such tooth contact in eccentric movements can be verified
with a thin mylar strip (shim stock).

60. Teeth that are subject to
excessive
loading may develop varying
degrees of mobility.
Tooth movement (fremitus)
should be identified
by palpation
Eccentric tooth contact can be
tested with thin Mylar shim stock.
If a heavy contact is suspected, a finger placed against the
buccal or labial surface while the patient lightly taps the
teeth together will locate fremitus in MI
Any posterior cusps that hold the shim
stock will be evident

61. MANEUVERABILITY
Ease with which the patient moves the
jaw and the way it can be guided through
hinge closure and excursive movements
should be assessed (good guide to
neuromuscular and masticatory function)
If the patient has developed a pattern of
protective reflexes, manipulating the jaw
will be difficult.
The patient's restricted maneuverability is
recorded.

62. DIAGNOSTIC AIDS
RADIOGRAPHS VITALITY TEST
DIAGNOSTIC
CASTS
PERIODONTAL
PROBE.

63. Radiographic examination
Essential information to supplement the
clinical examination.
Detailed knowledge of the extent of bone
support and the root morphology of each
standing tooth is essential
use of digital radiography reduce radiation
exposure
most information with a minimal need for
repeat films and by using appropriate
protection

64. •Radiation exposure
guidelines
recommend limiting
the number of
radiographs to only
those that will result
in potential changes
in treatment
decisions
•full periapical series
is normally required
for new patients-
comprehensive fixed
prosthodontic
treatment plan can
be developed.

65. RADIOGRAPHIC EXAMINATION
presence or absence of teeth
assessing third molars and impactions
evaluating the bone before implant placement
screening edentulous arches for buried root tips.
do not
provide a
sufficiently
detailed
view for
assessing
bone
support,
root
morphology,
caries, or
periapical
pathology.

66. Special radiographs may be
needed for the assessment
of TMJ disorders.
A transcranial 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.
However, interpretation
may be difficult

67. More information
can be obtained
from serial
tomography,
arthrography, CT
scanning
More sophisticated
techniques permit
the generation of
computer-assisted
images of clinician
determined cross-
sections. A, A CT
scan. B, An MRI
showing the soft
tissue in greater
detail

68. VITALITY TEST
Before any restorative treatment, pulpal health
must be assessed, usually by measuring the response
to percussion and thermal or electrical stimulation.
diagnosis of nonvitality can be confirmed by
preparing a test cavity without the administration of
local anesthetic.
Vitality tests, however, assess only the afferent
nerve supply.
Misdiagnosis can occur if the nerve supply is
damaged but the blood supply is intact.
Careful inspection of radiographs is therefore an
essential aid in the examination of such teeth.

69. Differential diagnosis
When the history and examination are
completed, a differential diagnosis is
made.
The practitioner should determine the
most likely causes of the observed
condition(s) and record them in order of
probability.
A definitive diagnosis can usually be
developed after such supporting evidence
has been assembled.

70. Diagnosis
A typical diagnosis will condense the information
obtained during the clinical history taking and
examination.
Not all the patients
seeking fixed
prosthodontic
treatment will
present diagnostic
problems
Diagnostic errors
are possible,
especially when a
patient complains
if pain or
symptoms of
occlusal
dysfunction.
A logical and
systematic
approach to
diagnosis will help
avoid mistakes

71. PROGNOSIS
•age of
patient
•lowered
resistance of
the oral
environment
General
factors
•Forces
applied to a
given tooth
•access for
oral hygiene
measures
Local
factors
F
A
C
T
O
R
S
estimation of the likely course of a disease
young person with
periodontal disease will
have a more guarded
prognosis than an older
person with the same
disease experience.
But disease has followed
a more virulent course
because of the generally
less-developed systemic
resistance; these facts
should be reflected in
treatment planning.

72. General factors
Such conditions also affect the
overall prognosis.
Overall caries
rate
Systemic
problems
Patients age
and overall
health
Patients
previous
dental history
indicates future risk to the patient
if the condition is left untreated.
Important variables
1.patient's
understanding
2.comprehensio
n of plaque-
control
measures
3.physical
ability to
perform those
tasks.
Diabetics are prone to a
higher incidence of
periodontal pathology, and
special precautionary
measures may be indicated
before treatment begins.

73. Bite forces
Some patients are capable of an
extremely high bite force, whereas others
are not.
If an elevated muscle tone of
hypertrophied elevator muscles is
identified during the extraoral
examination and multiple intraoral wear
facets are observed, loading of the teeth
will be considerably higher than in the
dentition of a frail 90-year-old who tires
easily when asked to close.

74. Local factors
Fixed prostheses function in a hostile environment: the moist oral environment
is subject to constant changes in temperature and acidity and considerable load
fluctuation.
Vertical overlap of
anterior teeth
Favorable/unfavoura
ble loading
Impactions adjacent
to molars
serious threat in a younger individual in
whom additional growth can be
anticipated, but it may be of lesser
concern in an older individual.
In the presence of favourable loading, minor
tooth mobility is less of a concern than in the
presence of unfavorable directed or high load.
direct impact on the load distribution in the dentition
and thus can have an impact on the prognosis.

75. DIAGNOSTIC CASTS AND
RELATED PROCEDURES
Accurate diagnostic casts transferred to
semi adjustable articulator are essential
in planning fixed prosthodontic
treatment.
Permits static and dynamic relationships
of the teeth to be examined without
interference from protective
neuromuscular reflexes
unencumbered views from all directions
reveal aspects of the occlusion not
always easily detectable intraorally
(e.g., the relationship of the lingual
cusps in the occluded position).

76. maxillary cast has been transferred with a
facebow
a centric relation (CR) interocclusalrecord
has been used for articulation of the
mandibular cast
condylar elements have been
appropriately set (such as with protrusive
and/or excursive interocclusalrecords)
reproducing the patient's movements with
reasonable accuracy is possible
If the casts have
been articulated
in CR, assessing
both the CR and
the MI position is
possible,
because any
slide can then be
reproduced
•On an articulator,
occlusocervical dimension
readily assessed in the
occluded position and
throughout the entire
range of mandibular
movement
•Alignment and angulation
of proposed abutment
teeth are easier to
evaluate on casts than
intraorally
ANALYSIS OF
THE
OCCLUSAL
PLANE AND
THE
OCCLUSION
REHEARSAL
OF TOOTH
PREPARATION
DIAGNOSTIC
WAXING
PROCEDURES

77. EVALUATION
Although it is apparently a simple
procedure, diagnostic cast
fabrication is often mishandled.
minor inaccuracies can lead to
serious diagnostic errors.
Questionable impressions and
casts should be discarded and the
process repeated
Voids in the impression create
nodules on the poured
cast(prevent proper articulation
and effectively render useless a
subsequent occlusal analysis or
other diagnostic procedure.

78. INTEROCCLUSAL RECORDS
CENTRIC RELATION RECORDS are used to
replicate on the articulator.
LATERAL OCCLUSAL RECORDS are used to
the condylar guidance of the articulator.
Identify the deflective contacts.
A distinction must be made between
mounting for diagnosis and for
treatment.

79. The attachment of casts to an articulator
for diagnosis will be done with the condyles
in the centric relation position.
For restoration of a significant portion of
the occlusion , it may also be done with the
condyles in the centric relation position.

80. Treatment Planning for
Single-Tooth Restorations
Using cast metal, ceramic, and metal-ceramic
restorations, large areas of missing coronal tooth
structure can be replaced while the remainder is
preserved and protected.
The successful use of these restorations is based
on thoughtful treatment planning, which is
manifested by choosing a restorative material and
design that are suited to the needs of the patient.
In a time when production and efficiency are
heavily stressed, it should be restated that the
needs of the patient take precedence over the
convenience of the dentist.
function
esthetics

81. Factors affecting selection of the
material and design of the restoration
•If remaining tooth structure must gain strength and protection from the
restoration, cast metal or ceramic is indicated over amalgam or composite
resin
Destruction of tooth structure
•If the tooth to be restored with a cemented restoration is in a highly visible
area, or if the patient is highly discriminating, the estheticeffect of the
restoration must be considered(partial coverage /full coverage restoration is
required in such an area, the use of ceramic in some form is indicated.)
•Metal-ceramic crowns can be used for single-unit anterior or posterior
crowns, as well as for FPD retainers.
•All-ceramic crowns are most commonly used on incisors(can be used on
posterior teeth when an adequate amount of tooth structure has been
removed and the patient is willing to accept the possibility of more frequent
replacement.)
Esthetics

82. •use of a cemented restoration demands the institution and
maintenance of a good plaque-control program to increase the chances
for success of the restoration
PLAQUE CONTROL
•someone must pay for the treatment. That may be a government
agency, a branch of the military, an insurance company, and/or the
patient
•If the patient is to pay, the dentist should provide good advice and
then allow the patient to make the choice.
•A conscientious dentist must walk a fine ethical line. On the one hand,
a dentist should not preemptthe choice by selecting a less-than-
optimum restoration just because he or she thinks that
•the patient cannot afford the optimum treatment. On the other hand,
a dentist should be sensitive enough to the individual patient’s
situation to offer a
•sound alternative to the optimum treatment plan and not apply
pressure.
FINANCES

83. A comparison of resistance
to removal forces for four
types of crowns (P =
.05).1,2 MOD, mesio-
occlusodistal
•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.
•It does become a special
concern for short teeth and
RPD abutments.
RETENTION

84. One type
can be
better suited
for a
particular
application
than the
other, or in
some cases
either may
be suitable.
•inserted as a soft (ie,
plastic) mass into the
cavity preparation,
where it will harden
•retained by mechanical
undercuts or adhesion.
Plastic
restoration
•made of cast metal,
metal-ceramic, or all-
ceramic material, is
fabricated outside of the
operatory and is lutedor
bonded to the patient’s
tooth at a subsequent
appointment
Cemented
restoration

85. INTRA CORONAL
RESTORATIONS
When sufficient coronal
tooth structure exists to
retain and protect a
restoration under the
anticipated stresses of
mastication
crown of the tooth and
the restoration itself are
dependent on the
strength of the
remaining tooth
structure to provide
structural integrity.
EXTRA CORONAL
RESTORATIONS
If insufficient coronal
tooth structure exists to
retain the restoration
within the crown of the
tooth, an extracoronal
restoration, or crown, is
needed.
where there are
extensive areas of
defective axial tooth
structure or if there is a
need to modify contours
to refine occlusion or
improve esthetics

86. Glass ionomer
Small lesions where extensions can be kept minimal and
where preparation retention will be minimal
Enhanced by the release of fluoride by the material
Tunnel preparation and glass
ionomer can be used to restore an
incipient lesion on the proximal
surface of a posterior tooth
Glass ionomer can be used
to restore gingival abrasion
or erosion
INTRA CORONAL RESTORATIONS

87. Root caries with glass ionomer
cement (caries in geriatric and
periodontal patients.)
Rampant caries can be
brought under control with
glass ionomeras interim
treatment restoration
Restoration of root An occlusal
approach may be precluded by the
presence of an otherwise acceptable
crown, or a conventional restoration
at such an apical level might require
the destruction of an unacceptable
amount of tooth structure.
In addition, handpiece access may be
too restricted to create the needed
retention for a small amalgam
restoration.

88. Composite resin
can be used for minor to moderate lesions in esthetically
critical areas and in the restoration of incisal angles assisted
by acid etching, a tooth that has received a Class IV resin
restoration ultimately will require a crown.

89. Composite resin in posterior teeth
Sufficient abrasion resistance to prevent occlusal wear has
been a problem.
Unless the resin is carefully applied in small increments,
polymerization shrinkage will lead to leakage and ultimately
to failure.
Use restricted to small occlusal and mesio occlusal
restorations on first premolars.
An innovative approach to the prevention of root caries at the
margins of restorations that extend from enamel to
cementum is the application of a slurry of unfilled resin and
sodium fluoride combined with laser energy.
significantly increased resistance to acid and mechanical
destruction
topical fluoride in combination with laser energy provided
resistance to enamel caries

90. Composite Resin Inlay
To combat the problems of
shrinkage and leakage
accomplished in the dental office,
using a fast-setting gypsum cast, or
in a dental laboratory.
Resultant bench-polymerized inlay
will have greater hardness, and
the thin layer of resin used for
affixing it to tooth structure will
be less susceptible to significant
shrinkage at the margin than a
restoration that is bulk cured in
situ.

91. Simple Amalgam
The simple amalgam, without pins or other means of
auxiliary retention, for decades has been the standard
one-to three-surface restoration for minor-to
moderate-sized lesions in esthetically noncritical areas
Approximately 71 million or more simple amalgam
restorations are placed annually.
They are best used where more than half of the coronal
dentin is intact.

92. Tooth preparation size for
incipient lesions has
diminished in recent years
“extension for prevention”
Less destructive
preparations has been
augmented by the
development of smaller
instruments and stronger
amalgams.
Even a minimal preparation
for an amalgam restoration
significantly weakens the
structural integrity of the
tooth

93. Complex amalgam
Amalgam augmented by pins or other auxiliary means of retention can be
used to restore teeth with moderate to severe lesions in which less than
half of the coronal dentin remains.
Employed as a definitive restoration when a crown is contraindicated
because of limited finances or poor oral hygiene.
Restoration of teeth with missing cusps or endodontically treated
premolars and molars—teeth that ordinarily would be restored with
mesio-occlusodistal (MOD) onlays or other extracoronal restorations.
(amalgam is used to replace or overlay the cusp to provide the
protection of occlusal coverage)
Ideally a crown should be constructed over the pin-retained amalgam,
using it as a core, or foundation restoration

94. Metal inlay
Teeth with low esthetic requirements and
small-to moderate sized lesions
Usually made of softer gold alloys,also can be
fabricated of etchable base metal alloys if a
bonding effect is desired.
preparation isthmus -narrow to minimize
stress in the surrounding tooth structure.
Premolars should have one intact marginal
ridge to preserve structural integrity and
minimize the possibility of coronal fracture.
Additional bulk of tooth structure in a molar
permits the use in an MOD configuration.
not recommended for incipient lesions

95. Ceramic inlay
Restore teeth with small to moderate sized lesions that permit a
narrow preparation isthmus in an area of the mouth where the
esthetic demand is high.
Premolars should have one intact marginal ridge
MOD ceramic inlays can be used in molars
can be etched to enhance bonding, (structural integrity of the tooth
cusps may be stabilized by bonding.)
Relatively large size of the cavity preparation required for this
restoration
precludes its use in the treatment of incipient lesions
.

96. Mesio occluso distal onlay
moderately large lesions on premolars and molars with
intact facial and lingual surfaces
wide isthmus and up to one missing cusp on a molar.
If a cast metal restoration is needed on a premolar with
both marginal ridges compromised, it should include
occlusalcoverage to protect the remaining tooth
structure.
can be considered an extracoronalrestoration because of
the occlusalcoverage that overlays and protects the
tooth cusps.
Does not have the necessary resistance to be used as a
FPD retainer.
Ordinarily fabricated of a gold alloy, this restoration
design has been used with cast glass and other types of
ceramics. Ceramic MOD onlaysshould be used very
cautiously.
Without generous occlusal thickness, these restorations are susceptible to
fracture.

97. Partial coverage crown
This is a crown that leaves one or more axial
surfaces uncovered
Therefore, it can be used 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 FPDs.
If tooth destruction is not excessive, a
partial coverage crown with a minimally
extended preparation and carefully finished
margins can satisfy moderate esthetic
demands in the maxillary arch.
EXTRA CORONAL RESTORATIONS

98. All metal crowns
to restore teeth with multiple defective axial
surfaces
maximum retention possible in any given
situation(restricted to situations where there
are no esthetic expectations)
second molars, some mandibular first molars,
and occasionally mandibular second
premolars.
less tooth structure must be removed for its
preparation than for crowns with a ceramic
component
fabrication is the simplest of any crown, this
restoration should remain among those
designs considered in planning single-tooth
restorations on molars as well as posterior
FPDs.
All metal full crown

99. Metal ceramic crown
Used to restore teeth with multiple
defective axial surfaces
Capable of providing maximum retention,
but it also will meet high esthetic
requirements.
It can be used as a FPD retainer where full
coverage and a good cosmetic result must be
combined
Metal ceramic crown
on premolar

100. All ceramic crowns
When full coverage and maximum esthetics must be
combined, an all ceramic crown is the treatment of
choice
All-ceramic crowns are not as resistant to fracture as
metal-ceramic crowns, so their use must be
restricted to situations likely to produce low to
moderate stress.
They are usually used for incisors, although cast glass
ceramics are also employed in the restoration of
posterior teeth.
Preparations for this type of restoration on premolars
and molars require the removal of large quantities of
tooth structure

101. Ceramic veneer
Because all-ceramic and metal-ceramic crowns
require the removal of such large quantities of
tooth structure, there has been considerable
interest in less destructive alternatives.
The ceramic veneer has emerged as a means of
producing an esthetic result on otherwise intact
anterior teeth that are marred by severe staining
or developmental defects restricted to the facial
surface of the tooth
This restoration also can be used to restore
moderate incisal chipping and small proximal
lesions. The use of a veneer requires only
minimal tooth preparation and therefore offers
an alternative to crowns that is attractive to the
patient and dentist alike.
Ceramic veneer on
maxillary incisor

102. Restoration longevity
Restorations are in a hostile biologic
environment, submerged in water.
The question of longevity is an
important one to consider when
choosing treatment for a patient.
The more destructive the
preparation required for the
restoration, the greater the
potential risk for the tooth and
ultimately the greater expense.
“How long will
my restoration
last?”
Cast
restorations
Amalgam
resrorations
Composite
restorations

103. Treatment Plan For The
Replacement Of Missing Teeth
The need to replace missing teeth is obvious to the patient
when the edentulous space is in the anterior segment of the
mouth, but it is equally important in the posterior region.
It is tempting to think of the dental arch as a static entity,
but that is certainly not the case.
It is in a state of dynamic equilibrium,
with the teeth supporting each other

104. When a tooth is lost, the
structural integrity of the dental
arch is disrupted, and there is a
subsequent realignment of teeth
as a new state of equilibrium is
achieved
Teeth adjacent to or opposing the
edentulous space frequently move
into it
Adjacent teeth, especially
those distal to the space, may
drift bodily, although a tilting
movement is a far more
common occurrence.

105. In severe cases, this may necessitate the
devitalizationof the supereruptedopposing
tooth to permit enough shortening to
correct the plane of occlusion; in extreme
cases, extraction of the opposing tooth may
be required.
If an opposing tooth intrudes severely into
the edentulous space, it is not enough just
to replace the missing tooth
To restore the mouth to complete
function, free of interferences, it is often
necessary to restore the tooth opposing
the edentulous space

106. Selection of type of prosthesis
PROSTHESIS TYPES
FOR MISSING TEETH
1.RPD
2.Tooth-supported FPD
3.Implant-supported FPD
FACTORS AFFECTING
SELECTION
1.Biomechanical
2.Periodontal
3.Esthetic
4.Financial factors
5.Patient’s wishes
It is not uncommon to combine two types in
the same arch, such as a RPD and a tooth-
supported FPD.
Combining teeth and implants in the
support of the same FPD, however, is not
recommended
In treatment planning,
there is one principle that
should be kept in mind:
treatment simplification

107. •There are many times when certain treatments are
technically possible but too complex.
•It is important to narrow the possibilities and present a
recommendation that will serve the patient’s needs and
still be reasonable to accomplish.
•At such times, the restorative dentist, or
prosthodontist, is the one who should manage the
sequencing and referral to other specialists.
•He or she will be finishing the treatment and should act
as the quarterback.
•The restorative dentist must communicate and be open
to suggestions but should not allow someone else to
dictate the restorative phase of the treatment, which
may result in carrying out a treatment plan that seems
unfeasible.
•As the clinician who is providing the restoration, the
restorative dentist is the one the patient will return to if
it fails; therefore, he or she must be comfortable with
the planned treatment.

108. REMOVABLE PARTIAL DENTURES
Edentulous spaces greater than two posterior teeth, anterior
spaces greater than four incisors, or spaces that include a canine
and two other contiguous teeth (ie, central incisor, lateral incisor,
and canine; lateral incisor, canine, and first premolar; or the
canine and both premolars).
An edentulous space with no distal abutment (cantilever FPD can
be used, but this solution should be approached cautiously.)
Multiple edentulous spaces, each of which may be restorable with
a FPD, nonetheless may call for the use of a RPD because of the
expense and technical complexity.
Bilateral edentulous spaces with more than two teeth missing on
one side also may call for the use of a removable prosthesis instead
of two fixed prostheses
INDICATIONS

109. The requirements of an abutment for a RPD are not as stringent as
those for a FPD.
Tipped teeth adjoining edentulous spaces and prospective abutments
with divergent alignments may lend themselves more readily to use as
removable rather than FPD abutments.
Periodontallyweakened primary abutments may serve better in
retaining a well-designed RPD than in bearing the load of FPD. It is also
possible to design the partial denture framework so that retentive
clasps will be placed on teeth other than those adjacent to the
edentulous space.
Short teeth or those with short clinical crowns usually are not good
FPD abutments for anything other than a single ponticprosthesis.
An insufficient number of abutments may also be a reason for
selecting a removable rather than a FPD.
If there has been a severe loss of tissue in the edentulous ridge, a RPD
can more easily be used to restore the space both functionally and
esthetically.

110. For successful RPD treatment, the patient should
demonstrate acceptable oral hygiene and show
signs of being a reliable recall candidate.
Patients of advanced age who are on fixed incomes
or have systemic health problems may require
special treatment simplification efforts, either to
cut down on the amount of appointment time
required to restore the mouth or to make the
treatment affordable.
Cajoling patients of limited means into
overinvesting their resources is not in their best
interest.
A large tongue is a good reason to avoid a
removable prosthesis if at all possible, as is a lack
of muscular coordination.
An unfavorableattitude toward a RPD also makes
it a poor choice.

111. Conventional tooth supported
FPD
When a missing tooth is to be replaced, a FPD is
preferred by the majority of patients.
The usual configuration for a FPD uses an abutment tooth
on each end of the edentulous space to support the
prosthesis.
If the abutment teeth are periodontally sound, the
edentulous span is short and straight, and the retainers
are well designed and executed, the FPD can be
expected to provide a long life of function for the
patient.

112. FACTORS FAVOURING THE
OPTION OF FPD
Teeth to use as abutments
Retainer designs to use
no gross soft tissue defect in the edentulous ridge.
If there is, it may be possible to augment the ridge with grafts
Reserved for patients who are both highly motivated and able
to afford this special procedure
Dry mouth creates a poor environment for any crown.
Margins of the retainers will be at great risk from recurrent
caries-limit life span of FPD
If the patient does not meet these criteria, a RPD should be
considered.

113. Resin Bonded Tooth Supported
FPD
•Conservative restoration
•Reserved for use on defect-free abutments
in situations where there is a single missing
tooth, usually an incisor or premolar.
•A single molar can be replaced by this type of
prosthesis if the patient’s muscles of
mastication are not too well developed, thus
assuring that a minimum load will be placed
on the retainers.
•Requires an abutment both mesial and
distal to the edentulous space.

114. Utilizes a standard ponticform,
accommodating an edentulous ridge with
moderate resorptionand no gross soft
tissue defects.
Requires a shallow preparation that is
restricted to enamel, the resin-bonded
FPD is especially useful in younger patient
whose immature teeth with large pulps
are poor candidates for endodontic free
abutment preparations.
Tilted abutments can be accommodated
only if there is enough tooth structure to
allow a change in the normal alignment of
axial reduction.

115. Limited by the need to restrict most of the reduction to enamel.
Rarely can a mesiodistaldifference in abutment inclination
greater than 15 degrees be accommodated.
There can be little or no difference in the inclination of the
abutments faciolingually.
The resin-bonded prosthesis cannot be used for replacing missing
anterior teeth where there is a deep vertical overlap.
Reduction deep into the underlying dentin of the abutment teeth will
be required in this situation, so a conventional FPD should be
employed.
For periodontal splints, it should be used with extreme care in
those situations. Preparations will demand additional resistance
features, such as long, well-defined grooves.
Abutment mobility has been shown to be a serious hazard in the
successful use of this type of restoration.

116. Implant Supported
FPD
FPDs supported by implants are ideally suited for use where there
are insufficient numbers of abutment teeth or inadequate strength
in the abutments to support a conventional FPD and when patient
attitude and/or a combination of intraoral factors make a RPD a
poor choice.
Implant-supported FPDs can be employed in the replacement of
teeth when there is no distal abutment.
Span length is limited only by the availability of alveolar bone with
satisfactory density and thickness in a broad, flat ridge
configuration that will permit implant placement.

117. A single tooth can be replaced by a single implant,
saving defect-free adjacent teeth from the destructive
effects of retainer crown preparations.
span length of two to six teeth can be replaced by
multiple implants, either as single unit restorations or
as implant-supported FPDs.
an entire arch can be replaced by an implant-supported
complete prosthesis

118. The retainers used for most implant systems require a
great degree of abutment alignment precision, as do the
retainers for a tooth-supported FPD.
If implants are placed by someone other than the
restorative dentist, implant/abutment alignment
demands close coordination between surgeon and
restorative dentist.
The abutments should be positioned so that the occlusal
forces will be as nearly vertical to the implants as
possible to prevent destructive lateral forces.
Implants should be better able than natural teeth to
survive in a dry mouth.
Better choice for FPD abutments if prospective tooth
abutments would require endodontic therapy with or
without dowel cores, periodontal surgery, and possibly
root resections to support a long span, complex, and
expensive prosthesis.

119. No prosthetic treatment
If a patient presents with a long-standing edentulous
space into which there has been little or no drifting or
elongation of the adjacent or opposing teeth, the
question of replacement should be left to the patient’s
wishes. If the patient perceives no functional, occlusal,
or estheticimpairment, it would be a dubious service to
place a prosthesis.
This in no way contradicts the recommendation that a
missing tooth routinely should be replaced.
The teeth adjoining an edentulous space usually move,
but they do not always move.
When meeting the occasional patient who has beaten
the odds, the dentist should recognize it for what it is,
congratulate the patient for being fortunate, and tend
to his or her other needs.

120. Case presentation
In cases in which the choice between FPD and a RPD is not
clear cut, two or more treatment options should be presented
to the patient along with their advantages and disadvantages.
The dentist is in the best position to evaluate the physical
and biologic factors present, while the patient’s feelings
should carry considerable weight on matters of esthetics and
finances.
Both dentist and patient must agree on the definitive
treatment plan. If the patient understands and is willing to
accept the risks associated with the dentist’s second-choice
treatment, it is prudent to make a notation to that effect and
have it signed by the patient.
If the restorative dentist is convinced that a particular type
of treatment desired by the patient is absolutely wrong for a
given situation, an attempt should be made to educate the
patient by explaining the reasons behind this opinion.
If the patient remains unconvinced, the patient should be
referred to someone else.

121. Abutment evaluation
Every restoration must be able to withstand the
constant occlusal forces to which it is subjected.
This is of particular significance when designing and
fabricating a FPD because the forces that would
normally be absorbed by the missing tooth are
transmitted, through the pontic, connectors, and
retainers, to the abutment teeth.
Abutment teeth are therefore called upon to withstand
the forces normally directed to the missing teeth in
addition to those usually applied to the abutments.

122. If a tooth adjacent to an edentulous space needs a crown
because of damage to the tooth, the restoration usually
can double as a FPD retainer.
If several abutments in one arch require crowns, there is
a strong argument for the selection of a FPD rather than
a RPD.
Whenever possible, an abutment should be a vital tooth.
However, a tooth that has been endodontically treated
and is asymptomatic, with radiographic evidence of a
good seal and complete obturation of the canal, can be
used as an abutment.
However, the tooth must have some sound, surviving
coronal tooth structure to ensure longevity. Even then,
some compensation must be made for the coronal tooth
structure that has been lost.
This can be accomplished through the use of a dowel
core or a pin-retained amalgam or composite resin core.

123. Teeth that have been pulp capped in the
process of preparation should not be used
as FPD abutments unless they are
endodontically
treatedThe supporting tissues surrounding
the abutment teeth must be healthy and
free from inflammation before any
prosthesis can be contemplated.
Abutment teeth should not exhibit
mobility because they will be carrying an
extra load.
ROOTS AND THEIR SUPPORTING
TISSUES EVALUATED FOR
1.CROWN ROOT
RATIO
2.ROOT
CONFIGURATION
3.PERIODONTAL
LIGAMENT AREA

124. 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.
As the level of the alveolar bone moves apically, the lever arm of
the portion out of bone increases, and the chance for harmful
lateral forces increases.
Optimum crown-root ratio for a tooth to be used as a FPD abutment
is 2:3; a ratio of 1:1 is the maximum ratio that is acceptable for a
prospective abutment under normal circumstances

125. If the occlusion opposing a proposed FPD is
composed of artificial teeth, occlusal force will
be diminished, with less stress on the abutment
teeth.
The occlusal force exerted against prosthetic
appliances has been shown to be considerably
less than that against natural teeth
•26 lbs
RPD
•54.5 lbs
FPD
•150 lbs
Natural teeth
root surface area of these teeth is
similar, the root
configuration of the maxillary
premolar
(a)with its greater faciolingual
dimension, makes it a superior
abutment
(b) maxillary central incisor-circular
in cross section.
abutment tooth with a less-than-desirable crownroot ratio is more likely to
successfully support a FPD if the opposing occlusion is composed of mobile,
periodontally involved teeth than if the opposing teeth are periodontally
sound.

126. The molar with
divergent roots (a) will
be a better abutment
tooth than one whose
roots are fused (b).
Root configuration
Important part of the assessment of
an abutment’s suitability from a
periodontal standpoint.
Roots that are broader labiolingually
than they are mesiodistallyare
preferable to roots that are round in
cross section.
Multirootedposterior teeth with
widely separated roots will offer
better periodontal support than roots
that converge, fuse, or generally
present a conical configuration.
The tooth with conical roots can be
used as an abutment for a short-span
FPD if all other factors are optimal.
A single-rooted tooth with evidence
of irregular configuration or with
some curvature in the apical third of
the root is preferable to the tooth
that has a nearly perfect taper.

127. Periodontal ligament area
Larger teeth have a greater surface area and are better
able to bear added stress.
Actual values are not as significant as the relative
values within a given mouth and the ratios between the
various teeth in one arch.
When supporting bone has been lost because of
periodontal disease, the involved teeth have a lessened
capacity to serve as abutments.
Millimeter per millimeter, the loss of periodontal
support from root resorption is only one-third to one-
half as critical as the loss of alveolar crestal bone
planned treatment should take this into account
Length of the pontic span that can be successfully
restored is limited in part by the abutment teeth and
their ability to accept the additional load.

128. Tylman -
two
abutment
teeth could
support two
pontics.
Ante’s Law by Johnston
et al-root surface area
of the abutment teeth
had to equal or surpass
that of the teeth being
replaced with pontics.

129. The 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).
The combined root surface
area of the first premolar and
the second
molar abutments (A1p +
A2m) is approximately equal
to that of the teeth being
replaced (A2p + A1m).
According to this
premise, one missing
tooth can be successfully
replaced if the abutment
teeth are healthy
If two teeth are
missing, a FPD
probably can replace
the missing teeth, but
the limit is being
approached

130. combined root surface area of the canine and second molar
(Ac + A2m) is exceeded by that of the teeth being replaced
(A1p + A2p + A1m)
FPD would be a poor choice in this situation.
When the root surface area of the teeth to be replaced
by pontics surpasses that of the abutment teeth, a
generally unacceptable situation exists

131. FPDs to replace more than 2
teeth
most common examples being anterior FPDs replacing the four
incisors.
Canine to second molar FPDs also are possible (if all other
conditions are ideal) in the maxillary arch, but not as often in
the mandibular arch
Biomechanical factors and material failure play an important
role in the potential for failure of long-span restorations.
Failures from abnormal stress have been attributed to leverage
and torque rather than overload
Abutment teeth can be maintained free of inflammation in the
face of mobility if the patients are well motivated and highly
proficient in plaque removal.
Crowns that anchor rigid prostheses to mobile teeth do require
greater retention than do crowns attached to relatively
immobile abutments

132. What is the impact of the success of
this type of treatment on FPDs for the
average patient?
The successful restoration of mouths with severe
periodontal disease does have significance in everyday
practice.
It emphasizes the extreme importance of carefully
evaluating the strengths and weaknesses of the
remaining dentition on an individual basis.
This should not be a signal for every dentist with a
handpiece to start using severely periodontallyinvolved
teeth as abutments.
successful treatments that have been cited are the
work of well-trained and highly skilled clinicians on
selected, highly motivated patients.

133. Biomechanical considerations
In addition to the increased load placed on the periodontal
ligament by a long-span FPD, longer spans are less rigid.
Bending or deflection varies directly with the cube of the length
and inversely with the cube of the occlusogingival thickness of
the pontic.
Longer pontic spans also have the potential for producing more
torquing forces on the FPD, especially on the weaker abutment.
To minimize flexing caused by long and/or thin spans, pontic
designs with a greater occlusogingival dimension should be
selected.
The prosthesis may also be fabricated of an alloy with a higher
yield strength, such as nickel-chromium

134. 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).
Compared with a FPD having a single-tooth
ponticspan a two-tooth ponticspan will bend
8 times as much
A three-tooth pontic
will bend 27 times as
much as a single
pontic

135. There is one unit of
deflection (x) for a pontic
with a given thickness
(t).
Fig
There will be eight
times as much
deflection (8x) if the
thickness is
decreased by one-half
(t/2).
A ponticwith a given occlusogingivaldimension will bend eight
times as much if the ponticthickness is halved
Therefore, a long-span FPD on short mandibular teeth could
have disappointing results.

136. Multiple grooves
All FPDs, long or short, flex to some extent.
Because of the forces being applied through the pontics
to the abutment teeth, the forces on castings serving as
retainers for FPDs are different in magnitude and
direction from those applied to single restorations.
The dislodging forces on a FPD retainer tend to act in a
mesiodistal direction, as opposed to the more common
faciolingual direction of forces on a single restoration.
Preparations should be modified accordingly to produce
greater resistance and structural durability.
Multiple grooves, including some on the facial and
lingual surfaces, are commonly employed for this
purpose
The walls of
facial and
lingual
grooves
counteract
mesiodistal
torque
resulting from
force applied
to the pontic.

137. Double abutments/ secondary
abutments
Double abutments are sometimes used as a means of
overcoming problems created by unfavorable crown-root
ratios and long spans.
At least as much root surface area and as favorable a
crown root ratio as the primary (adjacent to the
edentulous space) abutment it is intended to bolster.
retainers on secondary must be at least as retentive as
the retainers on the primary abutments. When the
pontic flexes, tensile forces will be applied to the
retainers on the secondary abutments
sufficient crown length and space between adjacent
abutments to prevent impingement on the gingiva under
the connector.
The retainers on
secondary
abutments will
be placed in
tension
when the
pontics flex,
with the primary
abutments
acting as
fulcrums.

138. Arch curvature
When ponticslie outside the interabutmentaxis
line, the ponticsact as a lever arm, which can
produce a torquingmovement.
This is a common problem in replacing all four
maxillary incisors with a FPD, and it is most
pronounced in the arch that is pointed in the
anterior.
Some measure must be taken to offset the
torque.
best be accomplished by gaining additional
retention in the opposite direction from the
lever arm and at a distance from the
interabutmentaxis equal to the length of the
lever arm
The first premolars sometimes are used as
secondary abutments for a maxillary four-pontic
canine-to-canine FPD. Because of the tensile
forces that will be applied to the premolar
retainers, they must have excellent retention
Secondary
retention (R)
must extend a
distance from
the primary
interabutment
axis equal to the
distance that
the pontic lever
arm (P) extends
in the opposite
direction.

139. Special problems
Pier abutments
Rigid connectors (eg, solder joints) between
pontics and retainers are the preferred way of
fabricating most FPDs.
A FPD with the pontic rigidly fixed to the
retainers provides desirable strength and
stability to the prosthesis while minimizing the
stresses associated with the restoration.
However, a completely rigid restoration is not
indicated for all situations requiring a fixed
prosthesis. An edentulous space can occur on
both sides of a tooth, creating a lone,
freestanding pier abutment
.
In this frequently
occurring situation,
the maxillary first
premolar
and molar are
missing, leaving the
second premolar as
a pier abutment.

140. The amount of faciolingual
movement (in μm) for each tooth in
the
maxillary arch
The direction of movement indicated
by arrows, varies considerably from
the anterior to the posterior
segment of the arch
Physiologic tooth movement, arch position of the abutments, and a
disparity in the retentive capacity of the retainers can make a rigid
five unit FPD a less-than-ideal treatment plan
Studies in periodontometry have shown that the faciolingual movement ranges
from 56 to 108 μm,16 and intrusion is 28 μm Teeth in different segments of the
arch move in different directions. Because of the curvature of the arch, the
faciolingual movement of an anterior tooth occurs at a considerable angle to
the faciolingual movement of a molar

141. NON RIGID CONNECTOR
Use is restricted to a short-span FPD replacing
one tooth.
There must be equal
distribution of occlusal
forces on all parts of
the FPD.
prospective
abutment
teeth with
significant
mobility.
Long span
FPD
magnification of force
created by a is too
destructive to the
abutment tooth under the
soldered retainer.
These movements of measurable
magnitude and in divergent directions can
create stresses in a long-span prosthesis
that will be transferred to the abutments.
Because of the distance through which
movement occurs, the independent
direction and magnitude of movements
of the abutment teeth, and the
tendency of the prosthesis to flex, stress
can be concentrated around the
abutment teeth as well as between
retainers and abutment preparations

142. forces are transmitted to the terminal retainers as a
result of the middle abutment acting as a fulcrum,
causing failure of the weaker retainer.
prosthesis bends rather than rocks.
Tension between the terminal retainers and their
respective abutments, rather than a pier fulcrum, is the
mechanism of failure.
Intrusion of the abutments under the loading could lead
to failure between any retainer and its respective
abutment.
loosened casting will leak around the margin, and caries
is likely to become extensive before discovery.

143. A nonrigid connector on the
middle abutment isolates
force to the
segment of the FPD to
which it is applied.
NEED FOR A NON RIGID
CONNECTOR
The retention on an anterior tooth is
usually less than that of a posterior
tooth because of its generally smaller
dimensions.
Because there are limits to increasing
a retainer’s capacity to withstand
displacing forces, some means must
be used to neutralize the effects of
those forces.
The use of a nonrigid connector has
been recommended to reduce this
hazard.

144. In spite of an apparently close fit, the movement in a non rigid
connector is enough to prevent the transfer of stress from the
segment being loaded to the rest of the FPD ( The nonrigid
connector is a broken-stress mechanical union of retainer and
pontic instead of the usual rigid connector)
The most commonly used nonrigid design consists of a T shaped
key that is attached to the pontic and a dovetail keyway placed
within a retainer
A nonrigid FPD transfers shear stress to supporting bone rather
than concentrating it in the connectors.
It appears to minimize mesiodistal torquing of the abutments while
permitting them to move independently
A rigid FPD distributes the load more evenly than a nonrigid design,
making it preferable for teeth with decreased periodontal
attachment.
If the posterior abutment and pontic are either opposed by a RPD
or unopposed, and if the three anterior units are opposed by
natural teeth, the key and the posterior units that are subjected
to little or no occlusal forces may supererupt.

145. The location of the stress-breaking
device in the five-unit pier-abutment
restoration is usually placed on the
middle abutment because placement
on either of the terminal abutments
could result in the pontic acting as a
lever arm.
The keyway of the connector should be
placed within the normal distal
contours of the pier abutment, and the
key should be placed on the mesial side
of the distal pontic.
The long axes of the posterior teeth
usually lean slightly in a mesial
direction, and vertically applied
occlusal forces produce further
movement in this direction.
Nearly 98% of posterior teeth tilt
mesially when subjected to occlusal
forces.
If a nonrigid connector is
placed on the distal side of the
retainer on
a middle abutment, movement
in a mesial direction will seat
the key into the keyway

146. Placement of the keyway on the mesial side, however,
causes the key to be unseated during mesial movements
In time, this could produce a pathologic mobility in the
canine or failure of the canine retainer.

147. When a mandibular molar
tilts mesially, there is a
discrepancy between its
long axis and that of the
premolar.
Tilted molar abutments
A problem that occurs with some
frequency is a mandibular second
molar abutment that has tilted
mesially into the space formerly
occupied by the first molar.
It is impossible to prepare the
abutment teeth for a FPD along the
long axes of the respective teeth
and achieve a common path of
insertion

148. If third molar is present?!
There is further complication
It usually will have drifted and tilted
with the second molar.
Because the path of insertion for the
FPD will be dictated by the smaller
premolar abutment, it is probable
that the path of insertion will be
nearly parallel to the former long
axis of the molar abutment before it
tilted mesially.
As a result, the mesial surface of
the tipped third molar will encroach
upon the path of insertion of the
FPD, thereby preventing it from
seating completely
This FPD will not
seat because the
tooth distal to the
FPD intrudes on
the path of
insertion (arrow).

149. If the encroachment is slight, the
problem can be remedied by
restoring or recontouring the
mesial surface of the third molar.
Overtapered second molar
preparation must have its
retention bolstered by the
addition of facial and lingual
grooves.
If the tilting is severe -treatment of choice is the uprightingof the molar by
orthodontic treatment.
1.place abutment tooth in a better position for preparation
2.distribution of forces under occlusalloading
3.eliminate bony defects along the mesial surface of the root.
average treatment time
required is 3
months
Third molar, if present, is often
removed to facilitate the distal
movement of the second molar

150. Immediately upon removal of appliance-teeth are prepared& provisional FPD is
fabricated to prevent post treatment relapse
second molar will arc occlusallyas it moves distally; therefore, it must be watched
closely and ground out of occlusion to allow it to continue moving
followed by the use of an open coil spring to complete the uprightingand bring the
tooth into the best possible alignment for fabrication of the fixed restoration
helical uprightingspring is inserted into a tube on the banded molar and activated by
hooking it over the wire on the anterior segment
Both premolars and the canine are banded and tied to a passive stabilizing wire
Uprighting is best accomplished through the use of a fixed appliance

151. If orthodontic correction is not possible,
or if it is possible to achieve only a partial
correction, a FPD can still be made.
long axis of the prospective abutments
should converge by no more than 25 to 30
degrees.
molar that has tipped mesially will
actually exhibit less stress in the alveolar
bone, along the mesial surface of its
mesial root, with a FPD than without it.
There will be an increase in stress along
the premolar, however. A proximal half
crown sometimes can be used as a
retainer on the distal abutment
If there is a severe marginal
ridge height discrepancy
between the distal of the second
molar and the mesial of the third
molar as a result of tipping, the
proximal half crown is
contraindicated.
It is simply a three-quarter crown that has been rotated 90 degrees so that the
distal surface is uncovered.
This retainer can be used only if the distal surface itself is untouched by caries or
decalcification and if there is a very low incidence of proximal caries throughout
the mouth.

152. Telescopic crowns
A telescope crown and coping can also be
used as a retainer on the distal abutment
Full crown preparation with heavy
reduction is made to follow the long axis
of the tilted molar.
An inner coping is made to fit the tooth
preparation, and the proximal half crown
that will serve as the retainer for the
FPD is fitted over the coping
Allows for total coverage of the clinical
crown while compensating for the
discrepancy between the paths of
insertion of the abutments.
marginal adaptation for this restoration
is provided by the coping.
extensive facial and/or lingual
restorations on
the tilted molar would call for
the use of a telescope crown.

153. The presence of a dowel
core or a disto-occlusal
amalgam on the
premolar would favor
placement of a nonrigid
connector on that tooth
The nonrigid connector is another
solution to the problem of the tilted
fixed partial denture abutment
A full crown preparation is done on the
molar, with its path of insertion
parallel with the long axis of that
tilted tooth.
A box form is placed in the distal
surface of the premolar to
accommodate a keyway in the distal of
the premolar crown.
It is tempting to place the connector
on the mesial aspect of the tipped
molar, but this could lead to even
greater tipping of the tooth.
A nonrigid connector for the tipped
molar abutment is most useful when
the molar exhibits a marked lingual as
well as mesial inclination

154. Preparing a tooth with a combined mesial and lingual
inclination as an abutment for a routine FPD can lead to
a drastically over-tapered preparation with no
retention.
Because telescope crowns and non rigid connectors both
require tooth preparations that are more destructive
than normal
selection of one of these would be influenced by the
nature of previous destruction of the prospective
abutment teeth.

155. Canine replacement FPDs
The prospective abutments are the lateral
incisor, usually the weakest tooth in the
entire arch, and the first premolar, the
weakest posterior tooth.
A FPD replacing a maxillary canine is
subjected to more stresses than that
replacing a mandibular canine because
forces are transmitted outward (labially) on
the maxillary arch, against the inside of the
curve (its weakest point)
Any FPD replacing a canine should be
considered a complex FPD.
No FPD replacing a canine should replace
more than one additional tooth.
A FPD replacing a maxillary
canine is subjected to
more damaging stresses
than that replacing a
mandibular canine because
the
forces are directed outward
and the pontic lies farther
outside the
interabutment axis.

156. On the mandibular canine, the forces are directed inward
(lingually), against
the outside of the curve (its strongest point)
An edentulous space created by the loss of a canine and any two
contiguous teeth is best restored with a RPD.

157. CANTILEVER FPDS
Abutment or abutments
at one end only, with
the other end of the
ponticremaining
unattached.
potentially destructive
design with the lever
arm created by the
pontic, and it is
frequently misused.
Generally, cantilever
FPDs should replace only
one toothand have at
least two abutments.
In the routine three-unit FPD, force
that is applied to the pontic is
distributed equally to the abutment
teeth
If there is only one pontic and it is
near the interabutment axis line, less
leverage is applied to the abutment
teeth and to the retainers than with a
cantilever.

158. Pontic acts as a lever that tends to be
depressed under forces with a strong
occlusal vector
Lengthy root
Favorable
configuration
Long clinical
crowns
Good crown
root ratio
Healthy
periodontium
Prospective
abutment teeth for
cantilever FPDs
no occlusalcontact on the ponticin either centric or lateral excursions

159. Canine must be used as an abutment, and it can
serve in the role of solo abutment only if it has a
long root and good bone support.
A rest on the mesial of the ponticagainst a rest
preparation in an inlay or other metallic
restoration on the distal of the central incisor to
prevent rotation of the ponticand abutment.
The mesial aspect of the ponticcan be slightly
wrapped around the distal portion of the
uninvolved central incisor to stabilize the pontic
faciolingually.
The root configuration of a central incisor makes
it an undesirable cantilever abutment.
Cantilever FPD
replacing a
maxillary lateral
incisor, using the
canine as the
abutment

160. This scheme will work best if occlusal contact is limited to the distal
fossa.
Full veneer retainers are required on both the second premolar and
first molar (excellent bone support)

161. Cantilever FPDs can also be
used to replace molars when
there is no distal abutment
present.
When used judiciously, it is
possible to avoid the insertion
of a unilateral RPD.
Most commonly, this type of
FPD is used to replace a first
molar, although occasionally it
is used to replace a second
molar to prevent
supereruption of opposing
teeth.
Forces on a full-size
molar cantilever pontic
place great stress on
mesial abutment

162. Cantilever FPD replacing
a mandibular first molar
.
Pontic should be kept as small
as possible, more nearly
representing a premolar than
a molar(minimize the
leverage effect)
There should be light occlusal
contact with absolutely no
contact in any excursion.
The pontic should possess
maximum occlusogingival
height to ensure a rigid
prosthesis.
A posterior cantilever ponticplaces maximum demands on the retentive
capacity of the retainer.

163. use reserved for those situations in which there is
adequate clinical crown length on the abutment teeth
to permit preparations of maximum length and
retention
The success of cantilevers in the restoration of the
periodontally compromised dentition is probably due at
least in part to the fact that periodontally involved
abutments do have extremely long clinical crowns.
While cantilever FPDs appear to be a conservative
restoration, the potential for damage to the abutment
teeth requires that they be used sparingly using both
premolars as abutment teeth.

164. Preliminary
assessment
Emergency
treatment of
presenting symptoms
Oral surgery
Orthodontic
treatment
Definitive
periodontal
treatment
caries control and
replacement of
existing restorations
Defintitiveocclusal
treatment
Fixed
prosthodontics
Removable
prosthodontics
Follow up care
sequence in the treatment of a patient with extensive dental disease
including missing teeth , retained roots , caries and defective
restorations.

165. understanding of
special patient
concerns
relating to
previous care
and expectations
about future
treatment
HISTORY AND CLINICAL
EXAMINATION
must provide
sufficient data for
the practionerto
formulate a
successful treatment
plan
If too hastily
accomplished!!
CONCLUSION
•details may be missed
•problems during treatment
•difficult or impossible to make
corrections.
•Overall outcome and prognosis may
be adversely affected
Diagnosis is a summation of the observed problems and their underlying
etiologies. The overall prognosis is influenced by general and local factors.

166. Related articles
Wright KW, YettramAL
Reactive force
distributions for teeth
when loaded singly
and when used as
fixed partial denture
abutments.
J ProsthetDent. 1979;42(4):411-
416. doi:10.1016/0022-
3913(79)90142-2
A finite element model was devised to examine mechanical responses of the
periodontium to loads applied to the model in vertical, oblique, and horizontal
directions for an individual tooth having varied alveolar levels, splinted teeth,
and a cantilever type of fixed partial denture

168. Knowledge and attitude of patients
regarding choice of selecting of fixed
partial dentures and implant.
A questionnaire-based study was conducted to evaluate the
knowledge and attitude of patients regarding choice of selecting FPD
or implant.
A total of 50 patients participated in this survey and successfully
completed. This study highlights the knowledge and attitude of
patients regarding choice of selecting FPD or a dental implant.
38% of patient prefer to replace missing tooth for esthetics and 66%
patients choose implant as a treatment of choice.
About 48% of patient feels that FPD is less time consuming than
implant because of the time duration and also because implant is a
surgical procedure. Conclusion: From our study, we conclude that
majority of patients choose implant as a treatment of choice. Some
patient feels that FPD is less time consuming than implant because of
the time duration and also because implant is a surgical procedure.

169. Meta-analysis of fixed partial
denture survival: Prostheses
and abutments
A systematic review of the English language literature since 1960
identified eight studies that met the presetinclusion criteria.
Estimated annual survival proportions were back-calculated based on
the Kaplan-Meier model and these proportions were combined
through a fixed effects model meta-analysis.
The probabilities and corresponding 95% confidence intervals at 5, 10,
and 15 years for the three categories of survival are reported.
For the aggregate population represented by the limited longitudinal
studies available, this metaanalysisindicated that less than 15% of fixed
partial dentures were removed or in need of replacement at 10 years;
whereas, nearly one third were removed or in need of replacement at 15
years. Less than 5% of abutments were removed at 10 years

171. All-ceramic restorations in
different indications
A case series
Daniel Edelhoffand Oliver Brix
The Journal of the American Dental Association. 2011 Apr
1;142:14S-9S.
The authors describe five clinical cases
involving different indications to illustrate the use of different
ceramic materials and combinations of materials.
They describe the collaboration between the dentist and
dental technician for single-tooth restorations and for
complex cases, including all stages of the restorative
procedures from treatment planning with an analytic
wax-up to the selection of appropriate materials, tooth
preparation and cementation.

175. All-Ceramic versus Metal-Ceramic
Tooth Supported Single
Crowns with a Minimum Follow-Up
Time of 3 Years; Survival
and Complications: A Systematic
Literature Review
Ayda L, Imen K, Mounir C, Dalenda H and Hassen H
Biomed J Sci & Tech Res
The research revealed 501 titles and led to a final analysis of 31 full text
articles. Only 6 studies met the inclusion criteria and
reported on 215 metal-ceramic and 501 all-ceramic TSSCs.

178. Questionable abutments:
General considerations,
changing trends in treatment
planning and
available options
D. Krishna Prasad, ChethanHegde, AnshulBardia, D. AnupamaPrasad
The past few decades have witnessed acceleration in
advancements in materials, techniques and concepts that
have been well-researched and scientifically accepted.
While root canal therapy saves roots, sound post
endodontic restoration saves crowns. Combination of
these procedures (endodontic-periodontic-prosthodontic)
have been able to successfully salvaged more teeth and
restored its form and function in recent times.

180. Different techniques for
management of pier abutment:
Reports of three cases with
review of literature
Puja Hazari, SurabhiSomkuwar, Naveen S. Yadav,
Sunil Kumar Mishra
Arch Med Health Sci2016;4:89-92.
Pontic are considered as heartthrob of abutments since under occlusal load
maximum stresses are concentrated on them.
Selection of the right type of connector can make a real difference
between success and failure.

183. REFERENCES
Tylmanstheory and practice of fixed prosthodontic–eigthedition
Contemporary fixed prosthodontic; Stephen.F. Rosenstiel–third
edition.
Fundamentals of fixed prosthodontic; Herbert.T. Shillingburg–third
edition
Wright KW, YettramAL. Reactive force distributions for teeth when
loaded singly and when used as fixed partial denture abutments. J
ProsthetDent. 1979;42(4):411-416. doi:10.1016/0022-3913(79)90142-2
AydaL, ImenK, MounirC, DalendaH, HassenH. All-Ceramic versus
Metal-Ceramic Tooth Supported Single Crowns with a Minimum Follow-
Up Time of 3 Years; Survival and Complications: A Systematic Literature
Review. Biomed J Sci& Tech Res 1(7)-2017. BJSTR. MS.ID.000563.
Prasad DK, HegdeC, BardiaA, Prasad DA. Questionable abutments:
General considerations, changing trends in treatment planning and
available options. J InterdiscipDentistry 2013;3:12-7.
HazariP, SomkuwarS, YadavNS, Mishra SK. Different techniques for
management of pier abutment: Reports of three cases with review of
literature. Arch Med Health Sci2016;4:89-92.

EdelhoffD, Brix O. All-ceramic restorations in different indications: a
case series. The Journal of the American Dental Association. 2011 Apr
1;142:14S-9S.