Sem 20 - dig and trmt planing in FPD.pptx

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1. Diagnosis and treatment planning in FPD 1

2. CONTENTS Introduction Definitions History recording Examination Diagnostic casts Importance of radiographs Treatment planning and its considerations Summary Conclusion References 2

3. INTRODUCTION 3

4. Diagnosis Is the determination of the nature of the disease PROGNOSIS Is a forecast as to the probable result of a disease or a course of therapy TREATMENT PLAN Is the sequence of procedures planned for the treatment of a patient after diagnosis (GPT 9) 4

5. Fixed prosthodontics is concerned with the replacement and/or restoration of teeth by artificial substitutes that are not readily removed from the mouth (GPT-9) 5

6. Periodontal Therapy Endodontic Therapy (RCT) Removal of existing restorations Caries control Dental & medical history Clinical examination, Radiographic films Dx Casts, Dx photographs Dx Wax-up, Aesthetic evaluation Crown lengthening/Implant surgery Gnathologic technique Long-term provisional restorations Permanent restorations Recall every 6 months Fluoride supplements Reinforce oral hygiene Improve diet Phase I Diagnosis Phase II Disease Control Phase III Restorative Phase IV Maintenance Diagnosis and Treatment Plan by Phases 6

7. DIAGNOSIS Proper diagnosis in fixed prosthodontics begins with a thorough patient interview which includes both the medical and the dental history. There are five elements to a good diagnostic workup in preparation for fixed prosthodontic treatment. History Tmj evaluation Intraoral examination Diagnostic cast Radiographic examination. 7

8. Name Age/Sex Occupation Registration number Address/Phone number Personal details 8

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10. Chief Complaint: The accuracy and significance of the patient’s primary reason or reasons for seeking treatment should be analyzed first Four categories: Comfort (pain, sensitivity, swelling) Function (difficulty in mastication or speech) Social (bad taste or odor ) Appeareance (fractured or unattractive teeth or restorations, discoloration 10

11. Medical history: Miller’s 3 methods: 1.Conditions affecting treatment methodology 2.Systemic conditions with oral manifestations 3.Possible risk to the dentist /auxiliary Vending machine method Direct interview Both 11

12. HISTORY Infectious diseases : A history of infectious diseases such as Hepatitis, AIDS etc must be known so that protection can be provided for other patients as well as office personnel. Allergic reaction : Previous reactions to any drug therapy if present should be mentioned. Attention should be given especially to local anaesthetics , antibiotics and dental materials especially impression materials and Nickel containing alloys Cardiovascular problems : Patient should be sufficiently pre-medicated with antibiotics ( Amoxycillin 2 grams orally 1 hour before the procedure) prior to fixed prosthodontic therapy. 12

13. Diabetes: No patient with uncontrolled diabetes should be treated until it is brought under control. Epilepsy : If present should be known. Steps should be taken to control anxiety of the patient. Long, fatiguing appointments should be avoided to minimize the possibility of precipitating a seizure. Xerostomia : Prolonged presence of xerostomia or drymouth is conducive to greater caries activity and is therefore extremely hostile to the margins of cast metal or ceramic restorations. 13

14. Dental history: Plaque control Restorative history Endodontic history Orthodontic history Radiographic history TMJ dysfunction history 14

15. TMJ EVALUATION Assessment of TMJ should be done. Healthy TMJ functions quietly with no evidence of clicking, crepitation or limitation of movement on opening, closing or moving laterally. 15

16. 16 Examination includes : Analysis Of Mandibular Movements Palpation Auscultation Two types of examination :- preauricula r ( 8 – 13 mm ahead of tragus) intraauricular Preauricular examination is performed at 7o’ clock & 12 o’ clock position Intraauricular is performed only at 12 o‘clock position.

17. HABITS : such as clenching the teeth and playing with the bite during the course of daily routine may result in fatigue and muscle spasm. Most of the times they will have a square- jowled appearance with masseter muscles that are overdeveloped from hyper activity. A brief palpation of the masseter , temporalis , medial and lateral pterygoid muscles may reveal tenderness if such habits are present. 17

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20. Requires the clinician’s tactile sense, sight and hearing; knowledge and experience ” The eyes see what the mind knows.” examination 20

21. GENERAL EXAMINATION General appearance Gait Weight Skin color Vital signs-pulse, blood pressure, respiratory rate, temperature EXTRA ORAL EXAMINATION Facial symmetry Profile Palpation of: Lymph nodes TMJ Muscles of mastication Lips 21

22. Tooth visibility during normal/exaggerated smile observed More than 25% patients do not expose gingival third of upper central incisors (Crispin 1981) Missing teeth,diastemas,fractured teeth affect “ negative space” (Lombardi 1973) 22

23. INTRAORAL EXAMINATION Oral Hygiene Examination : The quality of home care is a limiting factor in fixed prosthodontic treatment. If the patient is unable to maintain adequate oral hygiene they are not candidates for fixed prosthodontic treatment. 23

24. Periodontal Examination : Examination of the gingival and periodontal tissues surrounding the teeth should be included in the clinical examination. This should include Long term periodontal health is essential for the success of fixed prosthodontic treatment. If any periodontal therapy is indicated it should be performed prior to beginning of the treatment. Assessment of the quality and quantity of attached gingiva Depth of periodontal pockets measured with periodontal probe The degree of tooth mobility Degree of recession of surrounding tissues 24

25. Examination of Tooth Structure Examination and charting of the current condition of the teeth will aid in diagnosis and treatment planning process for fixed prosthodontics . Carious lesion : Determine the rate and extend of carious lesions. Caries must be restored before actually beginning with fixed prosthodontic treatment. Erosion and Abrasion : Areas with erosion and abrasion must be noted and corrected 25

26. Existing Restorations : All existing restorations must be examined. Some existing restorations may need to be replaced. This would also necessitate root canal therapy. Recurrent Caries : All existing restorations need to be checked thoroughly with an explorer to examine the margins for areas of recurrent decay Occlusal Wear : Examination of patients occlusion including degree and extend of occlusal wear is necessary prior to fixed prosthodontic treatment. Exposed dentine or cementum : Note areas of exposed dentine and cementum and whether or not they are sensitive to the patient. Extension of crown preparation may be necessary in order to cover these areas and protect them. 26

27. Occlusal examination Patient’s occlusion must be evaluated to determine if it is healthy enough to allow the fabrication of such restorations. If the occlusion is within normal limits then all treatment should be designed to maintain that occlusal relationship Horizontal/vertical overlap of the teeth Occlusal plane Vertical dimension of occlusion Missing/ supraerupted teeth Non working interferences evaluated Group function/canine guided occlusion 27

28. MOBILITY INDEX FOR TEETH Miller’s index: Grade I slightly more than normal(.5-1mm) Grade II moderately more than normal(1-2mm) Grade III severe mobility facio lingually and/or mesiodistally combined with vertical displacement (>2mm) 28

29. Fremitus (movement on palpation) indicates tooth contact during lateral excursions . Mobility is tested by exerting horizontal force on the tooth between the handles of two instruments. 29

30. Articulated diagnostic cast can provide a great deal of information for diagnosing problems and arriving at a treatment plan. They allow unobstructed view of the edentulous spaces An accurate assessment of the span length Determination of Occluso -gingival dimension Determination of curvature of arch in the edentulous region View of the true inclination, mesiodistal drifting, rotation and faciolingual displacement of the abutment teeth DIAGNOSTIC CAST 30

31. Gauging of the length of the abutment for determining which preparation designs will provide adequate retention and resistance Clear view of the supraerupted tooth, and hence the amount of correction can be determined 31

32. A current full mouth series of radiograph is required for evaluation of areas not seen clinically. Radiograph can help to evaluate the following areas RADIOGRAPHIC EXAMINATION Caries Presence of periapical lesions Existence and quality of previous endodontic treatments Degree of bone loss Root morphology, Crown-root ratio Impacted teeth, Residual roots Periodontal ligament and surrounding bone Presence of existing restorations and its marginal fit and contour 32

33. Bite wing radiograph OPG Full mouth radiographic series 33

34. Examination of the edentulous area: Siebert’s classification(1983) of ridge defects: Class I Loss of facio -lingual ridge width with normal apico -coronal height Class II Loss of ridge height ,with normal width Class III Loss of both ridge width and height 34

35. Class N “Normal” classification with minimal deformity Abrams et al: Class I 32.4% Class II 2.9% Class III 55.9%; mostly in the anterior region (91%) 35

36. An accurate charting of the state of the dentition is very important and will reveal important clinical findings in the patient ;saves a lot of time. 36

37. VITALITY TESTING Done to assess pulpal health before any restorative treatment Thermal stimulation Electric stimulation Test cavity preparation 37

38. LACTOBACILLUS COUNT Hadley(1933) Estimation of the number of acidogenic / aciduric bacteria in saliva by counting colonies on tomato peptone agar 0-1000  none/little caries activity 1000-5000  slight 5000-10000  moderate >10000  severe/marked 38

39. DIAGNOSIS AND PROGNOSIS 39

40. After a careful review of all the available information, a definitive diagnosis is made A logical and systematic approach to diagnosis will help avoid mistakes Diagnosis— 28yr old male,no significant medical history and normal vital signs;chief complaint:mesiolingual cusp fracture #30. Teeth #1,#16,#17,#32 missing Caries #6 mesial,#7 distal Generalized gingivitis in 4 posterior quadrants Recession on teeth #31 Radiographic evidence of periapical pathology #30 #30 tests nonvital 40

41. PROGNOSIS General factors age caries rate plaque control systemic diseases Local factors Tooth mobility Root angulation Root morphology Crown/root ratio 41

42. Each criterion is evaluated, and a checkmark is placed in the appropriate box. In instances in which a patient’s diagnostic criteria overlap two or more classes, the more complex class is the selected diagnosis Guidelines for the Use of PDI Classification System for Partial Edentulism and Complete Dentition 42

43. TREATMENT PLANNING 43

44. The treatment plan is a sequence of procedure that will restore the mouth to a healthy, functional occlusion. During the treatment plan presentation, the cost of the treatment, the time involved, and home care should be discussed. Treatment Planning For Replacement Of Missing Teeth 44

45. Sequence of treatment procedures before fixed prosthodontics ( Rosenstiel ): Relief of symptoms (chief complaint) Removal of etiologic factors (caries excavation,calculus removal) Repair of damage Maintenance of dental health 45

46. Considerations in treatment planning: ( Tylman ) I. Patient’s desires, expectations and needs: Desires of the patient take priority yet Dentist should not deliver substandard care claiming that the patient wanted it! II. Systemic and emotional health: Elderly/debilitated patients conservative care removable prosthesis 46

47. Antibiotic prophylaxis patients----as much treatment covered per appointment as possible to reduce the frequency of dentist-induced bacteremias Bruxism patients----overall prognosis poor Medications----side effects like xerostomia AIDS patients-----universal precautions Antisialagogues : Methantheline bromide( Banthine )50mg Propantheline (Pro- Banthine ) 15mg Given 1Hr prior to appointment 47

48. III. Periodontal factors : Goals of periodontal therapy for prosthodontic patient  Resolve inflammation Establish gingival architecture Attached gingiva adequate Reduce pocket depths Adequate oral hygiene 48

49. IV. Material Of Choice Partial veneer crowns Restores tooth with one or more axial surfaces with half or more of the coronal tooth structure remaining. Retainers for short span FPDs Good esthetic demands met Full metal crowns Used to restore teeth with multiple defective axial surfaces Esthetics not good due to metal display Used on posterior teeth only 49

50. Metal ceramic crown Restores teeth with multiple defective axial surfaces Well met high esthetic requirements Used where full coverage and a good cosmetic coverage is desired 50

51. All ceramic crowns Used when full coverage and maximum esthetics must be combined Not as resistant to fracture as metal ceramic crowns Restricted to areas with low to moderate stresses Not conservative tooth preparation Ceramic veneer crowns Produce a very cosmetic result Used on stained/developmentally defective facial surfaces of the teeth, moderate incisal chipping and small proximal lesions 51

52. Conservative/adhesive retainers Require minimal tooth preparation(etching) Indicated for anterior teeth as cannot accept loads Eg.Maryland bridges,Virginia bridges Telescopic retainers Used when the path of insertion of FPD does not coincide with long axis of the abutment tooth. 52

53. V.Biologic width Combined connective tissue-epithelial attachment from alveolar crest to base of gingival sulcus (Maynard/Wilson 1979) 1mm connective tissue+1mm junctional epithelium ( Garguilo et al 1961) 1.07mm connective tissue + .97mm junctional epithelium = 2.04mm biologic width (Glickman) 53

54. Tooth preparation must terminate 2mm coronal to alveolar crest else Pockets Osseous Defects Inflammation 54

55. To avoid violating biologic width Crown lengthening procedures Surgical methods Ortho- perio extrusion 55

56. VI. Esthetic concerns Drifting of teeth into edentulous areas Reduces pontic space Diastema Excessive mesiodistal width for pontic may be very helpful to plan contours before actual tooth preparation. 56

57. Diagnostic waxing It is a blue print for fixed restorative care. 57

58. Orthodontic treatment as an adjunct to fixed restorative therapy Closure of a diastema orthodontically Mesially tilted molar uprighted with a coil spring before fixed prosthodontic treatment 58

59. Residual ridge defects : Class I defects  Abram’s Roll technique Class II/III defects interpositional or onlay grafts Roll and pouch technique Interpositional or onlay grafts 59

60. In large class III defects Surgery is recommended with grafts Gingival/pink porcelain Gingival prosthesis made of silicone gingival porcelain 60

61. VII. Endodontic considerations: Endodontically treated tooth with sufficient tooth structure  restored with cast crowns If insufficient tooth structure  coronoradicular stabilization with a post and core Intentional RCT  supraerupted / malaligned tooth to improve arch relationship Pulpless tooth with short roots or non-negotiable canals  poor prognosis for post placement; 61

62. VIII. Abutment selection: 1.Crown root ratio 2.Root configuration 3.Periodontal Ligament Area 62

63. Teeth must have adequate occlusocervical crown length to achieve sufficient retention. If short clinical crowns Unsatisfactory retention Unless full – coverage preparations are used or Additional length is achieved through periodontal surgery 1.Crown root ratio 63

64. The optimum crown- root ratio for tooth to be utilized as a fixed partial denture abutment is 2:3 ( shillingburg ) 1:2 ( dykema 1962) 1:1 is the minimum acceptable ratio Grossmann and Sadan gathered data from literature and concluded that since there are no definitive guidelines for establishing an optimal crown to root ratio, prosthesis has a good prognosis even if the ratio is 1:1. Later on this became the gold standard for prosthesis designing. 64

65. 2.Root Configuration Teeth with short, blunted, conical roots Poorest support Roots that are broader labiolingually are preferable to roots which are round in cross section Long irregularly shaped roots, divergent multiple roots Best prognosis 65

66. 3. Periodontal Ligament Area “Abutment teeth should have a combined pericemental area equal to or greater in pericemental area than the tooth to be replaced” ANTE’S LAW (Irwin H. Ante Toronto, Ontario Canada 1926) 66

67. Dimensions of root surface area(mm 2 ) MAXILLA Boyd(1958) Jepsen (1963) Central 204.5 204 Lateral 177.3 179 Cuspid 266.5 273 First bicuspid 219.7 234 Second bicuspid 216.7 220 First molar 454.8 433 Second molar 416.9 431 MANDIBLE Central 162.2 154 Lateral 174.8 168 Cuspid 272.2 268 First bicuspid 196.9 180 Second bicuspid 204.3 207 First molar 450.3 431 Second molar 399.7 426 67

68. Factors modifying Ante’s law: Bone loss from periodontal disease Tipping of teeth Less than favourable opposing arch relationships producing increasing loads Endodontically restored abutments with resected roots Arch form situations creating greater leverage factors Tooth mobility after osseous surgery (increase abutments used for support) Migration of teeth decreasing mesio distal length of edentulous area (decrease abutments used for support) 68

69. No Common path of insertion If long axes of teeth diverge more than 25 degrees, tooth preparation becomes difficult (Reynolds 1968) Mesially tilted molars: Solution to the problem Mesial half crowns Non rigid attachments Telescopic prosthesis Orthodontic therapy 69

70. Telescopic crowns Advantages:- Increased Retention Paralleling of the severely tilted abutment Full arch Periodontal Splinting in multiple smaller segments Protection to the abutment tooth (Cemented Coping) Superstructures can be easily removed 70

71. Uprighting is also an option 71

72. PIER ABUTMENTS: P ier abutments produce unfavourable leverage forces and an unseating effect on terminal retainers ( Shillingburg 1973) Solution : Non rigid connector ( Kornfeld 1974) Cantilevered pontic 72

73. NON RIGID CONNECTOR Tenon -mortise connector Split pontic connector Cross-pin and wing connector 73

74. (A)Split pontic connector . Mesial segment with distal shoe is cemented first. ( B ) Distal segment is cemented next. (A) Tenon -mortise connector . Three-unit FPD containing mortise is cemented first. (B) Other FPD component containing tenon is cemented next. 74

75. Cross-pin and wing connector. Distal retainer and wing cemented first (B) Retainer pontic segment seated finally (C) Final cementation of cross-pin and wing. 75

76. Classic FPD design is a lateral incisor cantilever pontic supported by a strong canine. 76

77. Abutment Selection For Cantilever Fpd When a cantilever pontic is employed to replace a missing tooth, forces applied to the pontic have an entirely different effect on the abutment teeth. The pontic acts as a lever to be depressed under forces with a strong occlusal vector. Vertical force causes the component to rotate Weak crowns of natural vital or non vital teeth are subjected to excessive pressure– need additional support Terminal free end pontic is best supported by two or more abutment teeth which adjoin it Because of the forces exerted, the abutment, casting, soldered joints and cements should be strong 77

78. IX.Margin placement: Gingiva healthiest when margins 1-2mm above gingival crest (Glickman 1972) but Sub-gingival margins justified if: 78 Caries,erosion,restorations extend subgingivally Proximal contact area extends to gingival crest Additional retention needed PFM margin to be hidden behind the labio gingival crest Recession Root sensitivity Modification of axial contour is indicated

79. X. Pontic design Ovate and modified ridge lap pontics -high esthetic zone areas Conical and sanitary pontics -non esthetic zones Sanitary pontic Modified ridge lap pontic 79

80. XI Patient education and recall visits Dental floss Proxa brushes Gum massage 80

81. Xii Canine Replacement FPD FPDs replacing canines can be difficult because the canine often lies outside the inter abutment axis. The prospective abutments are the lateral incisor, usually the weakest tooth in the entire arch and the first premolar, the weakest posterior tooth. 81

82. A FPD replacing a maxillary canine is subjected to more stresses than that replacing a mandibular canine since the forces are transmitted outwards ( Labially ) on the maxillary arch against the inside of the curve (weakest point). An edentulous space created by the loss of a canine and any two contiguous teeth is best restored with a RPD. 82

83. Implant supported fixed prosthesis 83

84. Main indications: Need for long span FPD with questionable prognosis Unfavourable number and location of potential natural abutments Single tooth loss that would necessitate preparation of minimally restored teeth for FPD Some contraindications: Acute/terminal illness Pregnancy Uncontrolled metabolic disease Radiation to the implant site Improper patient motivation Unrealistic patient expectation Lack of operator experience Inability to restore with a prosthesis 84

85. Clinical Evaluation Flabby excess tissue Bony ridges Sharp underlying osseous formations Undercuts that may limit implant placement Width of posterior bony area Radiographic Evaluation Panoramic films most important However,bone width in anterior region may be seen with cephalometric film Specialized CT Scan determines maxillary sinus location and inferior alveolar canal 85

86. The concept of crown implant ratio is entirely different and should not be confused with the crown root ratio. In the anatomical crown implant ratio, the fulcrum is between the implant shoulder and crown-abutment complex whereas in the clinical crown implant ratio, the fulcrum is at the most coronal bone to implant contact . 86

87. According to Misch , the implant doesn’t rotate around a central two-third portion of the root as in the crown root ratio. He also suggested that the length of the implant has no relation with the implant mobility and resistance to the lateral forces. Thus, the data retrieved in this review clearly explains that the crown implant ratio between 0.5 and 2 show a favorable prognosis and can be maintained successfully if other prosthetic principles are equally taken into consideration. Increased CIR is not associated with bone loss or prosthetic failure if the forces are well distributed and cannot be considered as risk factor for biological complications around dental implants & implant failure 87

88. DIAGNOSTIC CASTS Proposed fixture installation sites checked for proper alignment,direction,location and relation to remaining dentition Waxing helps determine most esthetic placement of the teeth to be restored After waxing,resin template made to guide the surgeon during implant placement 88

89. BONE SOUNDING Helps in judging the soft tissue thickness at the implant site 89

90. Biologic width in teeth and implants S= sulcus depth .5-1mm JE=1.5-2mm CT=1-2mm 90

91. CONCLUSION Once successful, fixed prosthesis can transform an unhealthy unattractive dentition with poor function into a comfortable healthy occlusion capable of giving years of further service while greatly enhancing esthetics 91

92. REFERENCES Contemporary fixed prosthodontics 3 rd edition Rosensteil SF, Land MF, Fujimoto J Contemporary fixed prosthodontics 4 th edition Rosensteil SF, Land MF, Fujimoto J Tylman’s Theory and practice of fixed prosthodontics 8 th edition Malone William F.P, Koth David.L Fundamentals of fixed prosthodontics.3 rd edition Shillingburg HT, Hobo S. Robert E.Penny and Jan H. Krall Crown root ratio:Its significance in restorative dentistry. J Prosthet Dent 1979;42;34-37 92