DIAGNOSIS AND

TREATMENT PLANNING IN
FIXED PARTIAL DENTURE.

DIAGNOSIS:
GPT7determinationofthenatureofa
disease.
thesystemicmethodofidentifyinga
diseaseprocessonthebasisofdata
obtainedfromtheinterviewand
examination.

Diagnosticprocedures:
1.
2.
3.
4.
5.

Medicalanddentalhistory.
Visualanddigitalexamination
Clinicalandlaboratorydiagnosticaids
Radiographs
Diagnosticcasts.

Personaldetails

Name,
Age
sex
Addressandphoneno
Occupation,
Maritalandfinancialstatus

Chiefcomplain
Itfallsinoneofthefollowingcategories
Comfort-pain,sensitivity,swelling.
Function-difficultyinmasticationorspeech.
Social-badtasteorodour
Appearance-fracturedorunattractivetooth
orrestoration,discoloration

Medicalhistory
1.Infectiousdisease
2.Allergicreactions
3.Reactionstodentalmaterials
4.Hypertension
5.Diabetes
6.Xerostomia
7.CVSdisorders
8.Bleedingdisorders
6

1.Infectiousdisease
AIDS,
HEPATITIS.

2.Allergicreactions
Drugs:shouldbeprominentlymarkedonthe
patientsrecordinredink.
aspirin,
iodine,
localanesthetic,
penicillinorotherantibiotics
Eugenol,mercury,
8

3.Reactionstodentalmaterials
Impressionmaterials
Alloys:Nickel
Palladium

4.Hypertension
Nopatientswithuncontrolledhypertensionshould
betreated.
Patientwithsystolicreadingabove160mmofHg
oradiastolicreadingabove95shouldbereferred
tophysicianfortreatmentandevaluation.
Patientswithhistoryofhypertensionorcoronary
arterydiseaseshouldnotbegivenepinephrineas
itincreasesheartrateandelevatesbloodpressure
10

5.Diabetes
Diabetics are more prone for abscess
formationandperiodontalbreakdown.

11

Poorlycontrolleddiabetes
resultsintohyperglycemia.
These patients poorly tolerate stress of a
dental appointment and can fall into
diabeticcoma.

12

Controlleddiabetic
ifmissesamealorhasnoteatenforseveral
hoursmaygointohypoglycemicshock.
Dentaltreatmentshouldnotinterferewith
patientsdietaryroutine

13

6.Xerostomia
Causes
1. Largedosageofradiationinoralregion
2. Autoimmunediseases:Sjogrenssyndrome
Rheumatoidarthritis
Lupuserythromatosus
Scleroderma
3.Drugs:Anticholinergics
Anorectics
Antihypertensives
Antihistamines

14

7.CVSdisorders
Prostheticheartvalve
Rheumaticheartdisease
Congenitalheartmalformations
Mitralvalveprolapse
Allshouldbepremedicatedwithamoxycillin
15

Presenceofpacemaker
itcontraindicateselectrosurgical
softtissuedilatationforimpression
procedures.

16

8.Bleedingdisorders

17

ClassificationofMedicalhistory
Conditionsaffectingthetreatment
methodology
Conditionsaffectingthetreatmentplan
systemicconditionswithoral
manifestations.
possibleriskfactorstothedentistand
auxiliarypersonnel
18

Drughistoryandmedication
currentlybeingtaken
Phenytoin:
appropriatemeasurestobetakenineventof
seizure
Shouldcontrolanxiety
Long fatiguing appointments should be
avoided.
19

Anticoagulant
Coumadin( in patients with prosthetic
heart valves).
Evenminorbleedingcanbeserious

20

Dentalhistory
1.
2.
3.
4.
5.
6.
7.
8.

Periodontalhistory
Restorativehistory.
Endodontichistory
Orthodontichistory
Removableprosthodontichistory
Oralsurgicalhistory.
Radiographichistory.
TMJdysfunctionhistory
21

1.Periodontalhistory
oralhygieneisassessed
currentplaquecontrolmeasuresare
discussed
previouslyreceivedoralhygiene
instructionsdiscussed
frequencyofanypriordebridements
datesandnatureofanypriorperiodontal
surgerynoted
22

2.Restorativehistory.
ageofexistingrestorationscanhelp
establishtheprognosisandprobable
longevityofanyfuturefixedprostheses

23

3.Endodontichistory
endodonticallytreatedteethtobeidentified
withradiographs

24

4.Orthodontichistory
Root resorption (detected on radiographs)
maybeattributabletopreviousorthodontic
treatment and have implications for future
prosthodontictreatment

25

5.Removableprosthodontic
history
patientsexperienceswithremovable
prosthesismustbecarefullyevaluated
patient may not have volunteered its
existence.

26

6.Oralsurgicalhistory
complicationsthatmayhaveoccurred
duringtoothremoval
forpatientswhorequireprosthodonticcare
subsequenttoorthognathicsurgery;special
evaluationanddatacollectionprocedureare
alsonecessary

27

7.Radiographichistory
Previousradiographsmayprovehelpfulin
judgingtheprogressofdentaldisease

28

8.TMJdysfunctionhistory
Ascreeningquestionnairewillefficiently
identifytheseproblems.
Thepatientshouldbequestionedregarding
anyprevioustreatmentforjoint
dysfunction.(E.g.occlusalappliances,
medications,exercises)

29

Habits
Bruxismetc.

30

Examination
General
Headandneck
intraoral

31

Generalexamination

Generalappearance
Weight
Gait
Skincolorforsignsofanemiaorjaundice.
Vitalsignsrespiration,pulse,temperature,
andbloodpressure
32

Headandneckexamination

Special attention is given to facial

asymmetry because small deviations form
normal may hint at serious underlying
conditions.

33

 Evaluationofsize,shape,andsymmetryof
theheadandneck.
Profile
Retrognathic,
Mesiognathic
Prognathic
34

Skinandhair
Lymphnodeenlargements
Cutaneousulcerations
Scars
Exophyticgrowth.
Anomalouspigmentation

35

TMJjoints:

1.
2.
3.
4.

Lookfor;
Tenderness
clicking
painonmovement
Maximumjawopening(lessthan40mmindicates
restriction)
5. anydeviationfrommidlineisalsorecorded.
6. Maximum lateral movement is measured
(normalisabout12mm).
36

Musclesofmastication:
patientaskedtoreportanydiscomfortand
toclassifyitasmild,moderate,orsevere.
masseterandtemporalmuscles,aswellas
otherrelevantposturalmusclesarepalpated
Palpationisbestaccomplishedbilaterally
andsimultaneously.

37

Lips.
Observethepatientfortoothexposureduring
normalandexaggeratedsmilingformargin
placementofmentalceramiccrowns
Theextentofthesmilewilldependonthelength
andmobilityoftheupperlipandthelengthof
alveolarprocess
Morethan25%donotshowthegingivalthirdof
themaxillarycentralincisorsduringan
exaggeratedsmile
38

 negativespace;Whenthepatientlaughs,
thejawsopenslightlyandadarkspaceis
visiblebetweenthemaxillaryand
mandibularteeth.
diastema

39

Intraoralexamination
1.
2.
3.
4.
5.
6.

Generaloralhygiene
Lips.
Tongue
Floorofthemouth
Cheeks
Palate

40

7.Examinationofteeth.
8.Examinationandevaluationofprevious
restorations.
9.Periodontalexamination.
10.Occlusalexamination.
11.Lateralandprotrusivecontacts.
12.Centricrelation.

41

 Screeningformalignancy
Generaloralhygiene
Amountofplaque.
Areasofplaqueconcentration.
Qualityandquantityofsaliva

intraoralexamination

42

Lips
examinedforsignsofearlymalignant
neoplasticdiseaseorprecancerouslesions.
anylesionpresentfortwoweeksormore
shouldbeconsideredneoplasticuntil
provedotherwise

43

Tongue
asarule,lesionsoftonguearetraumaticin
origin.
Local
and
systemic
pathological
involvementsmaybepresent.
carcinoma,tuberculosis,syphilis,pernicious
anemia,herpes,and gossitis of vitamin
deficiencies.
44

Floorofthemouth
canshowcysticlesions.

45

Buccalmucosa
leukoplakia
lichenplanus
andareasofchronicirritation.

46

Palate
localizedlesionfrom
trauma
herpes
necrotizingulcerativegingivitis
hyperkeratosis
systemiclesions
oftuberculosisor
syphiliscanbeseen
47

Examinationofteeth
Caries: Localizedorwidespread
Amount
Wearfacets:
Localized/generalized
Decalcifications
Erosion
Abrasion
Occlusalattrition
Hypersensitiveexposedrootsurfaces
Fractures
48

Examinationandevaluationof
previousrestorations

49

Periodontalexamination.

50

Gingiva
mirrorofsystemicdisease.
Anemia,
leukemia,
polycythemiaand
addisons'sdiseaseusuallyhaveoral
manifestationsaffectingthegingivaltissues
51

 lightlydriedbeforeexamination
Color,
texture,
size,
contour,
consistency,andpositionarenotedand
recorded.
palpated to express any exudates or
pusthatmaybepresentinthesulcular
area.
52

HealthyGingiva
pink,
stippled,and
firmlyboundtotheunderlyingconnective
tissue.
Thegingivalmarginisknifeedged,and
sharplypointedpapillaefillthe
interproximalspaces
53

widthofthebandofkeratinzed
attachedGingiva
Canbeexaminedby
withthesideofaperiodontalprobeor
explorer
Injectinganestheticssolution

54

 Mandibular third molars frequently do not

have attached gingiva around the distal
segment. Such tooth make poor abutment
candidate.
Prospects
of
chronic
inflammation occurring in response to any
minute marginal irregularity in the crown
arequitehigh.
55

Periodontium
probeisinsertedparalleltothetoothand
walkedcircumferentiallythroughthe
sulcusinfirmbutgentlesteps,alwaysin
contactwiththebaseoftheapicalportion
ofthesulcus

56

Occlusalexamination.

Angleclassification,
occlusalplane,
verticaldimensionofocclusion,
anymissing,
supraerupted,
rotated,teeth,
interceptiveocclusalcontacts,
evidenceofbruxism.
Toothalignment,
eccentriccontacts

57

Existenceandamountofanterior
guidance
Restorationofanteriorteethmustduplicate
existing guidance or, in some patients,
replace that which has been lost through
wearortrauma.

58

Lateral and protrusive

contacts.
The presence or absence of tooth contact in
eccentric movements can be verified with a thin
Mylarstrip.Toothmovement(fremitus)shouldbe
identified by palpation. If heavy contact is
suspected, a finger placed against the buccal or
labial surface while the patient lightly taps the
teethtogetherwilllocateit.
59

Centricrelation.
Therelationshipofteethinbothcentricand
intercuspalpositionshouldbeassessed.Ifa
slidefromCRtoIPispresent,itshorizontal
and vertical components can be estimated
andanotemadeofanylateraldeviation.

60

Edentulousridge.
Siebertgroupedridgedeformitiesintothreecategories.
Class132.4%ofdefects
Lossoffaciolingualridgewidth,withnormalapicocoronal
height.

Class22.9%ofdefects
Lossofridgeheightwithnormalwidth

Class355.9%ofdefects.
Lossofbothridgewidthandheight.

61

62

Abutmentevaluation.
Preferably abutment tooth should be a vital
tooth
Endodonticallytreatedtoothcanbeusedif,its
asymptomatic and with radiographic evidence
of good seal and complete obturation of the
canal.
Pulp capped teeth should never be used as an
abutment.
Surroundingtissueshouldbehealthyandfree
frominflammationbeforeanyprosthesiscanbe
63
contemplated

Rootsandsupportingtissues
shouldbeevaluatedforthree
factors
Crownrootratio
Rootconfiguration
Periodontalligamentarea.

64

Crownrootratio
This is a measure of the length of tooth
occlusal to the alveolar crest of bone
comparedwiththelengthofrootembedded
inthebone.
As the length above the bone increases the
chances of harmful lateral forces is
increased.
65

 Optimumratio2:3
Minimum acceptable 1:1This ratio is
adequate when opposing occlusion is
artificialteethorperiodontalweakteeth.
Naturalteethexertforcesof
150.0lb,
26.0forRPD,and
54.5lbforFPD.
66

Rootconfiguration
Preferencefor:
Longerrootsarebetter,
flatrootsarebetterthanconicalrootsas
theyoffermoreresistance;
multirootedteetharepreferredtosingle
rootedteeth.

67

 Widelyseparatedrootspreferredthanthose,
whichconvergeorfuse.
Apicalcurvatureorirregularconfiguration
preferredthanuniformtaperinanterior
teeth

68

Periodontalligamentarea
This is the area of periodontal ligament
attachment of the root to the bone of
prospectiveabutmentteeth.
Larger teeth have a greater surface area ad
arebetterabletobearaddedstress.

69

 The actual values are not as significant as

therelativevalueswithinagivenmouthand
the ratios between the various teeth in one
arch.
The loss of periodontal support from root
resorption is only one third to one half as
criticalasthelossofalveolarcrestalbone.
70


Tylman-two abutment teeth could support
twopontics.
Antes law. The root surface area of the
abutmentteeth had to equalorsurpassthat
of the teeth being replaced with pontics.
(Johnsonetal)

71

 Fixed partial denture with short pontic

spanshaveabetterprognosisthandothose
withexcessivelylongspans.

72

Rootsurfacearea/pericementalarea
FactorsmodifyingANTESlaw
a)Boneloss
b)Mesialordistaltippingorchangesinaxial
inclination-increase
c)Migration-decreasethenoofabutments
d)increasedocclusalload-increasethenoof
abutments.
e)rootresection.-Increasethenoofabutment.
f)greaterleveragefactors-increase
g)Toothmobilityafterosseoussurgeryincrease
73

FPDreplacingmorethantwo
teeth
Replacementof4incisors
CaninetosecondmolarFPDinthe
maxillaryarch

74

Teethwithverypoorperiodontal
supportcanbeusedassuccessful
abutmentsprovided
1) Stabilization of mobile teeth by
splintingtopreventincreaseinmobility.
2)Patientshouldbehighlyproficientin
plaqueremovalandwellmotivated.

75

 3) Crowns should be more retentive on

theabutments.
4)Highskillisneeded
Low failure rate of less than 8% was
reportedintimespanof6years.

76

Radiographicexamination

14periapicaland4bitewingisessential
AnIntraoralradiographicexaminationreveals
1)Remainingbonesupport
2) Root number and morphology; and root proximity.
Short,long,slender,broad,bifurcated,fused,dilacerated
3) Quality of supporting bone, trabecular patterns,
andreactionstofunctionalchanges.
4) Width of the periodontal ligament spaces and
evidenceoftraumafromocclusion.
77

 5. Areas of vertical and horizontal osseous

resorptionandfurcationinvasions.
6. Axial inclination of teeth (degree of non
parallelismifpresent)

7. Continuity and integrity of the lamina

dura.

78

 8. Pulpal morphology and previous Endodontic

treatmentwithorwithoutpostandcores.
9. Presence of apical disease, root resorption,
orrootfractures.
10.Retainedrootfragments,radiolucentareas,
calcifications,foreignbodiesorimpactedteeth.

79

11.Presenceofcariouslesions,theconditionof
existing restorations, and the proximity of
cariesandrestorationstothedentalpulp.
12.Proximityofcariouslesionsandrestorations
tothealveolarcrest.
13.Calculusdeposits
14. Oral roentegenographic manifestations of
systemicdisease.
15.Thicknessofsofttissuesinedentulousarea
as outline of tissue can be traced in some
radiographs
80

Diagnostictools
1.
2.
3.
4.

Transillumination
Percussion
Pulpalvitalitytest
Laboratorytests
Examinationofthetmj

81

Diagnosticcast
They are the reproductions of the patients
maxillary and mandibular arches .they are
needed as the source of information in
reachingthediagnosis.
Theymustbeaccuratereproductionsofthe
maxillary and mandibular arches, made
fromdistortionfreealginateimpressions.
They should be mounted on a semi
adjustablearticulator
82

 Advantages
1.Unobstructedviewoftheedentulousspaces
2.Accurate assessment the span length and
occluso-gingivaldimension
3.To determine curvature of arch in the
edentulous region-it can be predicted
whetherponticwillactasleverarmonthe
abutmentteeth.
83

4.Lengthofabutmentcanbedeterminedandproperdesign
selectionforadequateresistanceandretention.
5.Trueinclinationofabutmentisevident
6. Mesiodistal drifting, rotation, and faciolingual
displacementofprospectiveabutmentcanalsobeseen.
7.Evaluationofwearfacets;number,sizeandlocation
8.Occlusaldiscrepanciescanbeevaluated.
9. Evaluation of discrepancy in occlusal plane and super
eruptedteeth.

84

10.Diagnosticwaxup;
Whenponticsareneededforspaces,which
are wider or narrower than the teeth that
would normally occupy the edentulous
space.
Doneinivorywax-allowsforpatientstosee
allthecompromisesthatwillbenecessary.

85

Diagnosticcastmodification
Proposedtreatmentprocedurescanbe
rehearsedonthestonecastpriortomaking
anyirreversiblechangesinthepatients
mouth

86

orthognathicprocedures
orthodonticprocedures
Modifyingtheocclusalscheme
Trialtoothpreparation

87

Treatmentplanning
objectives;

Correctionofexistingdisease.

Preventionoffuturedisease.
Restorationoffunction.
Improvementoffunction

88

Selectionoftypeofprosthesis

Removablepartialdenture
Toothsupportedfixedpartialdenture
Resinbondedfixedpartialdenture
Implantsupportedfixedpartialdenture

89

Factorsinfluencingtheselection
1.
2.
3.
4.
5.
6.
7.
8.

Spanlength
Spanconfiguration
Abutmentalignment
Abutmentcondition
Occlusion
Periodontalcondition
Ridgeform
Generalfeatures
90

Spanlength
RPD-isadvisedwhen
posteriorspanslongerthanteeth
Anteriorspanlongerthan4incisor
Canine+2ormorecontiguousteeth.
FPD-posteriorspan;2orfewer
Incisors;4orfewer
RBFPD-singletooth;possiblefor2incisors
Implantsingletooth;2to6unitspan.
91

Spanconfiguration.
RPD- when there is no distal abutment; multiple
orbilateraledentulousspacesarepresent.
FPD distal abutment is usually present,
sometimesacantileveredponticcanbeused
RBFPD-abutments present mesial and distal to
pontic
Implant-no distal abutment; pier in 3+-pontic
span; all abutments at ends and as piers of long
span.
92

Abutmentalignment
RPD-tippedabutmentcanbetolerated;
widelydivergentabutmentalignment
FPD less than 25-degree inclination
can be accommodated by preparation
modification

93

 RBFPD-less then 15 degree inclination

mesiodistally; should be in same
faciolingualplane;preparationarenoteasily
modifiedbecauseofminimalreduction.
Implant- need for implant /abutment
alignment requires close coordination
betweensurgeonandrestorativedentist.

94

Abutmentcondition.
RPD-givenin
shortclinicalcrowns;
insufficientabutments:
therequirementsofabutmentforRPDarenot
as stringent as those for a fixed partial
dentureabutment.

95

 FPD-good if abutment needs crowns;

nonvital teeth can be used if there is
sufficientcoronaltoothstructure
RBFPD- defect free abutments; incisor,
premolarsreplacements
Implant defect free abutments requiring
norestoration.
96

Occlusion.
RPD-moreadaptabletoirregularitiesin
ahealthyopposingnaturaldentition.
FPD-favorable loading (magnitude,
direction,frequency,duration)

97

 RBFPD- cannot be used for incisor

replacement in presence of deep vertical
overlap.
Implant occlusal forces must be as nearly
vertical as possible to prevent unfavorable
lateralloadingofimplants.

98

Periodontalcondition
RPD- can use alternate (secondary
abutments) when primary abutments are
weakened.
FPD- good alveolar bone support; crown
root ratio 1:1 or better; no mobility;
favorable root morphology; provides rigid
stabilization.
99

 RBFPD-no mobility (mobility is a

serious hazard.); periodontal splints
(with auxiliary resistance in tooth
preparation)
Implantdensebone

100

Ridgeform
RPD-canbegiveneveningrosstissueloss
inresidualridge.
FPD-moderate resorption; no gross soft
tissuedefects.
RBFPD-moderate resorption; no gross soft
tissuedefects.
Implant-broadflatridge

101

Generalfeatures.
RPD

-drymouthpoorrpdrisk
Limitedpatientfinances
Acceptableoralhygiene.
Reliablerecallcandidate
Treatmentsimplification
Advancedage
Systemichealthproblems
More adaptable to dentition in transition to
edentulousstate.
102

Generalfeatures.FPD

Drymouthhighcariesriskwithfpd
Musculardiscordination
Mandibulartori
Palatalsofttissuelesion
Largetongue
Exaggeratedgagreflex
UnfavorableattitudetowardRPD
Patientcantcopewithaging,toothloss.
Favorableopposingocclusion
Mustbewithindentistsskill

103

Generalfeatures.RBFPD
Wellsuitedforyoungpatients
Canbeusedforreplacingmolarsif
masticatorymusclesarenottoowell
developed

104

Generalfeatures.Implant
Abletosurviveindrymouth
May be better choice if teeth will require
extensive treatment and will still be weak,
questionableabutment;unfavorableattitude
towedRPD;mustbewithindentistsskill.

105

Biomechanicalconsiderationsin
treatmentplanning

106

Spanlength
Bending or deflection varies
directly with the cube of the
length.Comparedwithafixed
partialdenturehavingasingle
toothponticspan,atwo-tooth
pontic span will bend 8 times
asmuch.Athreetoothpontic
willbend27timesasmuchas
asinglepontic.
107

 ReplacingthreeposteriorteethwithanFPD
rarely has a favorable prognosis, especially
in the mandibular arch. In long span FPD
pontics and connectors should be made as
bulkyaspossibletoensureoptimumrigidity
withoutjeopardizinggingivalhealth.

108

Occlusogingivaldimension.
Bendingordeflectionvaries
inversely with the cube of
the
Occlusogingival
thickness of the pontic
pontic with a given
Occlusogingival dimension
will bend eight times as
muchIftheponticthickness
ishalved.
109

 Long span on short mandibular teeth has

disappointingresults.
Prosthesis with higher yield strength alloy
such as nickel chromium should be
selected.

110

Dislodgingforces
Single restorations. -On buccolingual
direction.
FPD-mesiodistaldirection.
Preparations
should
be
modified
accordingly to produce greater resistance
andstructuraldurability..
111

Multiplegrooves,including
someonthebuccaland
lingualsurface,are
commonlyemployedfor
thispurpose

112

Secondaryabutments.
Criteriaforselection
1.Musthaveatleastasmuchrootsurfaceareaandas
favorable crown root ratio as the primary
(adjacent to edentulous space) abutment it is
intended to bloster.E.g. canine can be used as a
secondary abutment to a first premolar primary
abutment, but it would be unwise to use a lateral
incisor as a secondary abutment to a canine
primaryabutment.
113

114

2.The retainers on secondary abutment must

beatleastasretentiveastheretainersonthe
primaryabutments.Whentheponticflexes,
tensileforceswillbeappliedtotheretainers
onthesecondaryabutment.
3.Sufficientcrownlengthandspacebetween
adjacentabutmentstopreventimpingement
onthegingivaundertheconnector.
115

Archcurvature
Becauseofthecurvatureofthearch,forces
directedagainstamaxillaryincisorspontic
willtendtotiptheabutmentteeth.Tipping
forcesmustberesistedbymeansoftwo
abutmentteethateachendofalongspan
anteriorFPD

116

Pierabutments
An edentulous space occurring on both
sidesofatoothcreatesalone,freestanding
pierabutment.

117

 Physiologic tooth movement, arch position of the

abutments,andadisparityintheretentivecapacity
of the retainers can make a rigid five unit FPD a
lessthanidealplanoftreatment.
Studies have shown that faciolingual movement
ranges from 56 to 108 micro m and intrusions 28
micrometer.
Teeth in different segment move in different
directions.
118

 Theoretically -Middle abutment can act as

fulcrum, causing failure of the weaker
retainer.
Photoelastic stress analysis shows tat
prosthesisbendsandnotrocks.
Standleeandcaputo-tensionbetweenthe
terminalretainersandtheirrespective
abutmentsisthemechanismoffailure.
119

Useofnon-rigidconnector.
The nonrigid connector is a broken-stress
mechanical union of retainer and pontic,
insteadoftheusualrigidconnector.
Mostcommonlyuseddesign-Tshapedkey
thatisattachedtothepontic,andadovetail
keywayplacedwithinaretainer.

120

 Prosthesiswithnon-rigidconnectorsshould
not be used if prospective abutment teeth
exhibit significant mobility. There must be
equal distribution of occlusal forces on all
partsofthefixedpartialdenture.

121

 A non-rigid FPD transfers shear stress to

supportingboneratherthanconcentratingitinthe
connectors. It appears to minimize mesiodistal
torquing of the abutments while permitting them
tomoveindependently.
a rigid fixed partial denture distributes the load
more evenly than a non-rigid design, making it
preferable for teeth with decreased periodontal
attachment.
122

Locationofstressbreaking
device
Placedonthemiddleabutment.Keyway-withinthe
distalcontoursofthepierabutment.Key-isplaced
onthemesialsideofthedistalpontic.
Long axes of posterior teeth lean in mesial
direction, and vertically applied forces further
producemovementmesially.Thismesialmovement
seatsthekeyintothekeywaymoresolidly.
123

Tiltedmolarabutments
Ifthirdmolaristiltedwiththesecondmolarthemesialsurfaceofthetippedthirdmolar
will encroach upon the path of insertion of
theFPD,therebypreventingitfromseating
completely.

124

Whenencroachmentisslight
restoring or recontouring the mesial surface
ofthethirdmolar.

125

Inseveretilting
orthodontic treatment for up righting the
molar, up righting also helps to eliminate
bonydefectsalongthemesialsurfaceofthe
root. Average treatment time required is 3
months.
Thirdmolarisremovedtofacilitatedistal
movementofsecondmolar.
126

Whenpartialcorrectionis
achieved.
Fixed partial denture can still be made, as
the prospective abutment should converge
bynomorethan25to30degrees.

127

 Photoelastic and finite element analysis

have shown that a molar, which has tipped
mesially, will actually exhibit less stress in
the alveolar bone, along the mesial surface
ofitsmesialroot,withaFPDthanwithout
it.Therewillbeanincreaseinstressalong
thepremolar,however.
128

Proximalhalfcrown.
Distalsurfaceisuncovered.
Isindicatedonlyif
Distalsurfaceisuntouchedbycaries
orDecalcification
Lowincidenceofproximalcaries
Shouldbeabletokeeptheareaexceptionally
clean.
129

Telescopecrown
Afullcrownpreparationwithheavyreduction
ismadetofollowthelongaxisofthetilted
molar. An inner coping is made to fit the
tooth preparation, and the proximal half
crownthatwillserveastheretainerforthe
fixed partial denture is fitted over the
coping. The marginal adaptation for this
restorationisprovidedbythecoping.
130

Nonrigidconnector.
Thistypeofconnectorismostusefulwhen
themolarexhibitsamarkedlingualaswell
asmesialinclination.Preparingatoothwith
a combined mesial and lingual inclination
for abutment will result in drastically
overtapperedpreparation.

131

 A full crown preparation is done on the

molar; with its path of insertion parallel
withthelongaxisofthattiltedtooth.abox
is placed in the distal surface of the
premolar to accommodate a keyway in the
distal of the premolar crown. Placing the
connectoronthemesialaspectofthetipped
molar couldleadto even greater tippingof
thetooth.
132

CaninereplacementFPD.
Canine lies outside the interabutment axis
andsoFPDreplacingthemaredifficult.
The prospective abutment lateral incisor
andpremolararetheweakestteethinentire
archandposteriorteenrespectively.

133

 FPDreplacingmaxillarycanineissubjected
to more stresses than that replacing a
mandibular canine, since forces are
transmitted outward (labially) on the
maxillary arch, against the inside of the
curve

134

 On the mandibular canine the forces are

directed inward (lingually), against the
outsideofthecurve(itsstrongestpoint).
No fixed partial denture replacing a canine
should replace more than one additional
tooth. Such edentulous spaces should be
restoredwitharemovablepartialdenture.
135

Replacementofasinglemissing
tooth.
Unless bone support has been weakened by
advanced periodontal disease, a single missing
tooth can almost always be replaced by a threeunit fixed partial denture having one mesial and
one distal abutment tooth .an exception is when
the FPD is replacing a maxillary or mandibular
canine. Under these circumstances the small
anteriorabutmenttoothneedstobesplintedtothe
centralincisortopreventlateraldriftoftheFPD.
136

Cantileveredfixedpartial
denture.
FPDS in which only one side of the pontic is
attached to a retainer are referred to as
cantilevered.anexamplewouldbealateralincisor
pontic attached only to an extra coronal metal
ceramic retainer on the canine. Their use remain
popular because some of the difficulties
encountered in making a three unit fpd are
lessened. Also many clinicians are reluctant to
prepareanintactcentralincisor,preferringinstead
touseacantilever.
137

 Prospective abutment teeth for cantilever FPD

shouldbeevaluatedfor
a. Lengthyrootswithafavorableconfiguration
b. Longclinicalcrowns
c. Goodcrownrootratio
d. HealthyPeriodontium.
CantileverFPDshouldreplaceonlyonetoothand
haveatleasttwoabutments.
138

Cantileverforreplacementfora
maxillarylateralincisor

Caninecanactassoleabutment
Shouldhavelongroot
Goodbonesupport
No occlusal contact on the pontic in either
centricorlateralexcursions.
Arestpreparationonthedistalofthe
centralincisortopreventrotationofthe
ponticandabutment.
139

Replacementofmissingfirst
premolar
Occlusal contact should be limited to the
distalfossa
Full veneer retainers prepared on second
premolarandfirstmolar.
Excellentbonesupportshouldbepresent.
Preferred when first molar has to be
restoredanyway.
140

Replacementofmolarwhenthere
isnodistalabutment.
Mostoftenusedforthereplacementoffirst
molar. Used to prevent supraeruption of
opposingteeth.
To minimize the leverage effect the pontic
should be kept as small as possible, more
representingapremolarthanamolar.

141

 Lightcontactshouldbepresent
Absolutely no contact in excursions. Pontic should
posses maximum Occlusogingival height to ensure a
rigidprosthesis.
Posterior cantilever puts maximum demands on the
retainer capacity of the retainer. therefore adequate
crownlengthontheabutmenttoothshouldbepresent
to permit preparations of maximum length and
retention.

142

 Thesuccessofcantileversintherestoration
of theperiodontally compromised dentition
is probably due at least in part to the fact
that periodontally involved abutments do
haveextremelylongclinicalcrowns.

143

 Long-term prognosis of the single abutment

cantileverispoor.Forcesarebesttoleratedbythe
periodontalsupportingstructureswhendirectedin
thelongaxesoftheteeth.Acantileverwillinduce
lateralforcesonthesupportingtissues,whichmay
beharmfulandleadtotipping,rotation,ordrifting
of the abutment. Laboratory analysis has
confirmed the potential harmful nature of such
fixedpartialdentures.
144

Replacingmultipleanteriorteeth

145

Mandibularincisors
Thefourmandibularincisorscanusuallybe
replaced by a simple fixed partial denture
with retainers on each canine. It is not
usually necessary to include the first
premolars. If a lone incisor remains, it is
often best removed because its retention
will unnecessarily complicate the design
and fabrication of the fpd and can
jeopardizethelong-termresult.
146

Mandibularincisors
Smallsizetoothmakespoorabutmentchoice
Pulpalexposureduringpreparation-selectivetooth
removaltobedone
Over contoured restorations on these teeth make
plaquecontroldifficult
Compromised esthetics from too thin a ceramic
veneer.

147

Maxillaryincisors
twoabutmentteethateachendofalong
spananteriorFPD
Becauseofthecurvatureofthearch,forces
directed against a maxillary incisors pontic
will tend to tip the abutment teeth. Tipping
forces must be resisted by means of two
abutment teeth at each end of a long span
anteriorFPD
148

Othertreatmentconsiderations

149

Marginplacement
The concept of placing margins in caries
immuneareaisnotuniversallyaccepted.
Therecommendationthatallgingivalfinish
lines be developed within the gingival
crevicehasbeenchallenged.

150

 The gingiva is healthiest when margins are

placed well above (i.e. 1 to 2 mm) the
gingival crest, and intracrevicular margin
placement is not the universal solution to
dentalcaries.

151

Indicationsforintracrevicular
gingivalmargin.
Esthetics
Retentionrequirements
Location of caries or preexisting
restorations
Rootsensitivity
Areasofcervicalerosionorrootfracture.
152

 Crown margins when placed subgingivally,

shouldbelocatedatthebaseofthegingival
sulcus, which is the level reached when a
thin blunt probe is positioned without
pressureintothegingivalsulcus.

153

 Marginsofthe preparation arenotusually placed

at the crest of the marginal gingiva, regardless of
how precise the margins of the restoration.
Microscopically, the margin is rough and an
excellentsitetoharborbacteria.Sincethemargin
of the gingiva rapidly collects plaque, this is the
siteofrecurrentdecay.ifdecaydoesnotresult,the
plaque causes periodontal disease at this most
criticalareawhichisnotselfcleansing.
154

 Supragingivalmarginismoresusceptibleto
cementdissolution.
If periodontal therapy has been performed
and the gingiva has receded, the
preparations should end at the
cemntoenameljunction.

155

Biologicwidth
A band of soft tissue attachment between
the base of the gingival sulcus and the
alveolar crest that is composed of
approximately 1mm of junctional
epithelium (attachment epithelium) and 1
mm of connective tissue fibers. This
dentogingivalattachment,referredtoasthe
biologic
width,
has
significant
implicationsintreatmentplanning.
156

 Toavoidencroachingonthebiologicwidth,
thetoothpreparationmustterminateatleast
2mmcoronaltothealveolarcrest

157

Severingthenaturaldentogingival
attachmentwillproduce
1.Chronic gingival inflammation, pocket
formation
2.Osseousdefectsinthebone
3.Fibrousconnectivetissue
4.Epitheliumremodelinattempttoreestablish
physiologicattachment.
158

Electivecrownlengtheningtobe
donewith
Controlledostectomy
Apicallypositionedflaps

159

Pontic
Tissuecontact(differentviews).
the pontic should exert no pressure on the
ridge.
Contacttobehadwiththefilmofsalivaon
theridge.
Ponticshouldnotcontactthetissueatall.

160

 Excessive contact has been sited as the

reasonoffailureofFPD.
Theareaofcontactshouldbeassmall.
Portionofpontictouchingtheridgeshould
beasconvexaspossible.

161

 If contact is there at gingivofacial angle

than their there must be no space between
pontic and soft tissue on the facial side of
theridge.
Pontic should contact only the attached
keratinzed gingiva. If it extends beyond
mucogingivaljunctionanulcerwillform.
162

 Appearance zone: these are areas of high

visibility and pontics placed in this zone
must produce the illusion of being teeth
withoutcompromisingcredibility.
Non-appearance zone; pontics placed in
these zones like in mandibular posterior
replacements are there to prevent drifting
andrestorefunctionofteeth.
163

 Pontics should be in straight line to prevent any

torquingoftheretainersandabutments.
Pontics can be slightly narrower than the natural
tooth
Itcanalsobenarrowattheexpenseofthelingual
surface in an effort to avoid the formation of an
uncleable, overhanging shelf in the pontic
overlying the lingual aspect of the ridge.
Narrowingtheponticdoesnotalterplaqueindex

164

Ponticdesigns
Saddle
Pontic looks most like tooth, replacing all the
contoursofthemissingtooth.Ridgelap:acontact
with the ridge that extends beyond the midline of
the edentulous ridge or a sharp angle at the
linguogingival aspect of the tissue contact
constitutesaridgelap.
This design is impossible to clean causes tissue
inflammationanditshouldnotbeused.
165

Modifiedridgelap.
Thisdesignwiththeporcelainveneeristhe
most commonly used pontic design in the
appearance zone for both maxillary and
mandibularFPD.
Thisdesigngivesillusionoftooth.Itposses
allornearlyallconvexsurfacesforeaseof
cleaning.
166

 There may be slight faciolingual concavity

onthefacialsideoftheridge,whichcanbe
cleaned and tolerated by the tissue as long
asthetissuecontactisnarrowmesiodistally
andfaciolingually.
Ridge contact must not extend lingually
than the midline of the edentulous ridge,
evenonposteriorteeth.
167

 Wheneverpossible,thecontourofthe
tissue-contactingareaoftheponticshould
beconvex,evenifasmallamountofsoft
tissueontheridgemustbesurgically
removedtofacilitateit.

168

HYGIENIC
These pontics have no contact with the
edentulous ridge. Also called as sanitary
pontic
Usedinthenonappearancezone,particularly
for replacing mandibular first molar .it
restores occlusal function and stabilizes
adjacentandopposingteeth.

169

 Can be made entirely of metal, as there is

noestheticfunction.
Occlusogingival thickness of the pontic
shouldbenolessthan3mm.
Thereshouldbeadequatespaceunderitto
facilitatecleaning.
Undersurfaceoftheponticisround.Itis
alsocalledfishbelly.
170

 Alternativedesign:undersurfaceismadeintheformof
a concave archway mesiodistally. The undersurface of
the pontic is convex faciolingually. Advantages; added
bulk for strength in the connectors, and access for
cleaning is good. Stress is reduced significantly in the
connectors,anddeflectionisdiminishedinthecenterof
the pontic, with less gold used. Esthetic version of this
pontic can be made by veneering with porcelain those
parts of the pontic that are likely to be visible. This
design has been called an arc-fixed partial denture a
modifiedsanitaryponticorsimpleaperelpontic.
171

Conical.
It is rounded and
cleanable.Tipissmallin
relation to the overall
sizeofthepontic.
Itisusedoverthinridges
in the non-appearance
zone.
172

Ovate.
It is the round end design currently in use where
esthetics is a primary concern. The tissue
contacting segment of the ovate pontic is bluntly
rounded, and it is set into a concavity in the
ridge .it is easily flossed. The concavity can be
created by placement of a provisional FPD with
the pontic extending one quarter of the way into
the extraction socket immediately after tooth
extraction.Itcanalsobecreatedsurgically.
173

 This pontic works well with a broad, flat

ridge, giving the appearance that it is
growingfromtheridge.

174

Prefabricatedponticfacings

Metalceramicpontics.
Metal-ceramic pontics have the greatest esthetic
potential as prosthetic replacement s for missing
teeth.Theyarestrongersinceporcelainisbonded
to the metal substrate rather than cemented to it.
They are easier to use because the backing is
custommadeforaspace.
175

 Ponticmodification:
Pink porcelain can be added to simulate
interdental papilla though the shade rarely
matches.

176

Andrewsbridgesystem

Itutilizesfixedretainersthatareconnectedbe
a rectangular bar that follows the curve of
the ridge under it .the prosthesis consist of
teeth set in a patient-removable flange of
gingiva-colored acrylic resin that clips over
andisstabilizedbetherectangularbar.
.
177

 Flangeisthefoodandplaquetrapthatis
difficultclean.Inspiteofitsdrawbacks,it
stillmaybethebestwayofhandlingsome
largeridgedefects

178

Surgicalcorrection
Excellent esthetic results in class 1 defects
canbeobtainedbyconnectivetissueplastic
surgery in the form of a sub epithelial or
submucosalconnectivetissuegraft.
Considerationsintreatmentplanning

179

Considerationsintreatment
planning

180

Occlusion
Occlusal
restoration
with
fixed
prosthodonticsshouldresultin
1.Simultaneous equalized contact of all teeth
(anterior and posterior)in maximum
intercuspation (centric occlusion)at a
physiologicverticaldimensionofocclusion.
2.Physiologicplaneofocclusion.
181

3. A functional anterior guidance (vertical and

horizontaloverlapoftheanteriorteeth)thatwill
protect the posterior teeth from interceptive
occlusalcontactsineccentricpositions.
4. a comfortable ,unlocked arrangement of cusps,
fossae, grooves, and ridges that will not restrict
functionaljawmovements.
5.Axialloadingofallposteriorteeth.
182

6.Ananatomeicformtothecusps,fossae,marginal
ridges, and clucie ways that will minimize
interdental food impaction and contribute to
efficientcomminutionoffood.
7. Occlusal and proximal tooth contacts that will
lendlongtermstabilitytotheocclusalscheme.
8. An aesthetic and phonetic relationship of the
anteriorteeth.
9.Occlusalsurfacesfabricatedofamaterialthat
wearslikenaturalenamel.
183

Endodonticconsiderations.
When there is insufficient remaining tooth
structure to support an extra coronal
restoration, coronoradicular stabilization
withapostandcoreisindicated.

184

 Prognosisispoorforapulplesstoothwith
anextremelyshortrootorwithacanalthat
cannot be negotiated to place a post as an
abutment to an FPD or RPD, such tooth is
bettersuitedtosupportacompleteorpartial
overdenture. a pulp less tooth is
contraindicated as an abutment to a
cantileverFPD.
185

ElectiveEndodontictherapy.
Endodontictreatmentmaybenecessaryfor
a supraerupted or malaligned tooth to
improve the arch relationship with a post
and core while facilitating fabrication of a
cast restoration with a more favorable arch
positionandocclusion.
.
186

 WhileelectiveEndodontictherapycan
improvetheprognosisofabadlydamaged
tooth,itmaypresentmoreproblemsthanit
resolves.Teethwithaberrantrootcanal
morphologydonotofferafavorable
Endodonticprognosis,andintentional
devitalizationoftheseteethshouldbe
avoidedwheneverpractical
187

Factorsinfluencingabutment
selection.
1.
2.
3.
4.
5.
6.

Ageofthepatient
DMFratio
Edentulousspan
Poororalhygieneindividuals
Vitalityofabutment
Archpositionofabutment
188

7. Esthetics.
8. Lengthofnaturalcrown.
9. Opposingocclusion.
10. Longaxisofabutment.
11. Rootconfiguration
12. Mobility
13. Crown:rootratio
189

Crownform
tapered crown form interferes with preparation
parallelism,necessitating full coverage retainers to
improvetheirretentiveandestheticqualities.e.g.anterior
teeth that have poorly developed cingulum and short
proximal walls and mandibular premolars with poorly
developed lingual cusps and short proximal
surfaces.some incisors posses very thin highly
translucent incisal edges,making the se of partial
coverageretainersestheticallyunacceptable.

190

Degreeofmutilation
The size number and location of carious
lesions or restorations in tooth affect
whetherfullorpartialcoverageretainersare
indicated.or whether it is restorable or cab
beremoved.

191

Rootproximities
Theremustbeadequateclearancebetweenthe
rootsofproposesabutmentstopermitthe
developmentofphysiologicembrasuresinthe
completedprosthesis.malpositionedanteriorteeth
andthemesiobuccalrootsofthemaxillarymolars
oftenpresentunfavorablerootproximitieswhere
desiredembrasureformisnotpossible.selective
extractionorrootresectionproceduremaybethe
onlysolutiontotherootproximity
192

commonpathofinsertion
Abutment teeth for an FPD must be prepared with a
commonpathofinsertionforallretainerswhenarigid
designisemployed.
Evaluation of the diagnostic cast with dental surveyor
and radiographic evaluation to determine the most
favorablepathofinsertion.Ifthelongaxesoftheteeth
divergeorconvergefromparallelismbymorethan25
degrees,toothpreparationbecomesmoredifficult.

193

Biologicwidthembrasures
Theteethtouchinanareacalledaproximal
contact, the spaces below the contact are
known as embrasures .in health, the
embrasures are usually filled with tissue.
Embrasures protect the gingiva from food
impaction and deflect the food to massage
thegingivalsurface.
194

 Theproximalsurfacesofcrownsshould
taperawayfromthecontactareasonall
surfaces.Excessivelybroadproximal
contactareasandinadequatecontouronthe
cervicalareassuppressthegingival
papillae.Theseprominentpapillaetrapfood
debris,leadingtogingivalinflammation
195

Splinting
Itserves3purposes
1.To protect loose teeth from injury during
stabilization in a favorable occlusal
relationship
2.To distribute occlusal forces for teeth
weakenedbylossofperiodontalsupport
3.Topreventanaturaltoothfrommigrating.

196

 The number of teeth required to stabilize a

looseteethdependson
1.Thedegreeanddirectionofnobility
2.Theremainingbone
3.Locationofthemobiletooth
4.Designated function. i.e. whether it is to be
usedasanabutmenttooth.

197

Phonetics:
Thereplacementofmissingteethwithfixed
prosthesis generally provides sufficient
resistancetotheflowofairtoallownormal
speech sounds to be produced. However,
the design of certain pontics or the
existence of a large alveolar bone defect
may not allow pontics to help the patient
produce normal phonetics as well as a
removableprosthesisdoes,
198

Esthetics
UsuallyFPDprovidesthemostestheticmeansof
replacingmissingteeth.However,anintracoronal
attachment removable prosthesis is often
esthetically advantageous when there is large
defect in the edentulous ridge or when several
teeth are missing and diastemas are required. a
removableprosthesismayalsobeindicatedwhen
the use of a pontic produces large and unsightly
proximalembrasuresinafixedprosthesis.
199

Sequenceoftreatment

Treatmentofsymptoms
Stabilizationofdeterioratingconditions
Definitivetherapy
Followup

200

Treatmentofsymptoms:
discomfortcanbeduetooneormoreofthe
following,afracturedtoothorteeth,acute
pulpitis,acuteexacerbationofchronic
pulpitis,dentalabscess,anacute
pericoronitisorgingivitis,andmyofascial
paindysfunction.Treatmentisinstitute
withoutdelay.
201

Stabilizationofdeteriorating
conditions:
thesecondphaseoftreatmentinvolves
stabilizingconditionssuchasdentalcaries
orperiodontaldiseasebyremovingthe
etiologicfactores,increasingthepatients
resistanceorboth.

202

 Dentalcariestreatmentofcariouslesions
approachedinconventionalmannerandthe
teeth are restored with properly contoured
plastic material. Dietary advice, oral
hygienemeasures,andfluoridetreatment.

203

 Periodontal disease: the proper removal of plaque is

possible only if teeth are smooth and there contours allow
unimpeded access to the gingival sulci. Therefore the
followingareessential
Replacementofdefectiverestorations
Removalofcariouslesions
Recontouring of over contoured crowns (especially
nearfurcationareas)
Proper oral hygiene instruction adequately
implementedathome.

204

Definitivetherapy
Whenthestabilizationphasehasbeencompleted,
successfulelectivelong-termtreatmentaimedat
promotingdentalhealth,restoringfunction,and
improvingappearancecanbegin.Usuallyoral
surgicalproceduresarescheduledfirst,followed
byperiodontics,Endodontic,orthodontics,fixed
prosthodontics,andfinallyremovable
prosthodontic
205

Oralsurgery
Teeth with a hopeless prognosis, unerupted teeth,
andresidualrootsandroottipsshouldberemoved
early. All preprosthetic surgical procedures (e.g.,
ridge contouring) should be undertaken during
earlyphaseoftreatment.
Periodontics; pocket elimination, mucogingival
procedures, guided tissue regeneration, or root
resection.

206

Endodontics
ProphylacticEndodontictreatment

207

Orthodontics

Minororthodonticmovementisacommon
adjunct to fixed prosthodontics tooth can e
up righted, rotated, moved laterally,
intruded, or extruded to improve its
relationshipbeforeprosthodontictreatment.

208

Occlusaladjustment
Where extensive fixed prosthodontics is to
be provided, anaccurate andwell-tolerated
occlusal relationship may be obtainable
only if a discrepancy between intercuspal
position and centric relation is eliminated
first.

209

Anteriorrestorations.
In the event that both anterior and posterior teeth
are to be restored, the anterior teeth are usually
done first because they influence the border
movementsofthemandibleandthustheshapeof
the occlusal surfaces of the posterior teeth. If the
posterior teeth are restored first, a subsequent
changeinthelingualcontouroftheanteriorteeth
could require considerable adjustment of the
posteriorrestorations.
210

Posteriorrestorations.
Itisoftenadvantageoustorestoreopposing
posteriorsegmentsatthesametime.Itisusually
goodtocompleteonesideofthemouthbeforethe
othersideistreated;restoringallfourposterior
segmentsatthesametimemightleadto
considerablemorecomplicationsforthepatient
anddentist,includingfractureorbreakingof
provisionalrestorations,discomfortandbilateral
localanesthesia,anddifficultiesinconfirmingthe
accuracyofjawrelationshiprecordings.
211

4.Followup
A specific program of follow up care and
regular recall is n essential part of the
treatmentplan.Theaimistomonitordental
health, identify the signs of disease early,
and initiate prompt corrective measures as
necessary.
212