DIAGNOSIS & TREATMENT

PLANNING IN FIXED
PARTIAL DENTURE

RESHMA
II MDS
Introduction
Definitions
Diagnostic aids
a. Personal information
b. Patient evaluation
History
Examination
a. General
b. Extra And Intra Oral
c. Radiographic

CONTENTS
Treatment planning
1. Single – tooth restoration
2. Replacement of missing teeth
a. Selection of the type of prosthesis
b. Abutment evaluation
c. Biomechanical considerations
d. Special problems 
 Conclusion
Fixed prosthodontic treatment - offer
exceptional satisfaction for both patient
and the dentist.
Can transform an unhealthy, unattractive
dentition with poor function - comfortable,
healthy occlusion capable of giving years
of further service while greatly enhancing
esthetics.

INTRODUCTION
 DIAGNOSIS: The determination of the
nature of a disease.
 PROGNOSIS: A forecast as to the
probable result of a disease or a course of
therapy.
 TREATMENT PLAN: The sequence of
procedures planned for the treatment of a
patient after diagnosis.

DEFINITIONS
FIXED PARTIAL DENTURE - Any
dental prosthesis that is luted, screwed,
or mechanically attached or otherwise
securely retained to natural teeth, tooth
roots, and/or dental implants/abutments
that furnish the primary support for the
dental prosthesis and restoring teeth in a
partially edentulous arch; it cannot be
removed by the patient.
PHASE I a. Dental and medical history
DIAGNOSIS b. Clinical examination , radiographic films
c. Diagnostic casts , photographs
d. Aesthetic evaluation
PHASE II a. Periodontal therapy
DISEASE b. Endodontic therapy
CONTROL c. Caries control
d. Removal of existing restorations
PHASE III a. Crown lengthening/implant surgery
RESTORATIVE b. Provisional restorations
c. Cast restorations , RPD
PHASE IV a. Recall
MAINTENANCE b. Fluoride supplements
c. Improve diet
d. Reinforce oral hygiene

TREATMENT PLAN BY PHASES

PERSONAL INFORMATION
 Name
 Age
 Sex
 Address
 Contact No.
 Family history
 Socio-economic status

DIAGNOSTIC AIDS
Patient’sprimary 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/odor )
APPEAREANCE (fractured or unattractive
teeth or restorations, discoloration )

CHIEF COMPLANT
HISTORY –
Include all necessary information
concerning the reasons for seeking
treatment, along with any personal details
and past medical and dental experiences
that are pertinent.
Should include any medication the patient
is taking as well as all relevant medical
conditions.
 Any disorders that necessitate the use of
antibiotic premedication, any use of
steroids or anticoagulants and any
previous allergic responses to medication
or dental materials should be recorded.

MEDICAL HISTORY
Any conditions affecting the treatment
plan –
 various radiation therapy,
 hemorrhagic disorders …
Possible risk factors to the dentist and
auxiliary personnel,
e.g. Hepatitis B,
Aids or Syphilis.
 Periodontal History
 Restorative History
 Endodontic History
 Orthodontic History
 Removable Prosthodontic History
 Oral Surgical History
 Radiographic History
 TMJ Dysfunction History

DENTAL HISTORY
Oral hygiene is assessed,
Current plaque control measures are
discussed,
The frequency of any previous
debridement should be recorded.
Previous periodontal surgery should be
noted.

PERIODONTAL HISTORY
Simple composites resin or amalgam
fillings.
Crowns and extensive fixed partial
dentures.
Previous existing restorations can help the
prognosis and probable longevity of any
future fixed prosthesis.

RESTORATIVE HISTORY
The findings should be reviewed
periodically so that peri-apical health can
be monitored, any recurring lesions
promptly detected.

ENDODONTIC HISTORY
Bruxism was for long considered a major
cause of tooth wear.
Etiology – unclear and multifactorial.
Altered mastication observed – in people
who brux.
This may also be due to an attempt to
avoid premature occlusal contacts.

BRUXISM
Apicalroot resorption - subsequent to
orthodontic treatment.
As the crown/root ratio is affected, future
prosthodontic treatment and its prognosis
may also be affected.

ORTHODONTIC HISTORY
The patients experience with removable
prostheses must be carefully evaluated.

REMOVABLE PROSTHODONTIC
HISTORY
Missing teeth and any complications that
may have occurred during tooth removal
is obtained.

ORAL SURGICAL 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.

RADIOGRAPHIC HISTORY
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.

TMJ DYSFUNCTION HISTORY

GENERAL EXAMINATION
General appearance - Gait and weight
assessed.
Skin color : Anemia or jaundice.
Vital signs: Respiration, pulse,
temperature and blood pressure are
measured and recorded.
FacialAsymmetry
Cervical Lymph nodes
TMJ
Muscles Of Mastication
Mouth opening
Lips

EXTRAORAL EXAMINATION
Palpated bilaterally.
Tenderness, clicking or pain on movement
is noted and can be indicative of
inflammatory changes in the retrodiscal
tissues.

TEMPOROMANDIBULAR JOINTS
MUSCLES OF MASTICATION
Average opening > 50mm
Restricted opening < 35mm
Maximum lateral movement can be
measured - normal is about 12mm.

MOUTH OPENING
Observed for Tooth exposure during
normal and exaggerated smiling.

LIPS
The space between maxillary and
mandibular anteriors during normal smile.
Missing teeth, diastema and fractured or
poorly restored teeth affect negative
space and require correction.

NEGATIVE SPACE
Condition of the soft tissues , teeth and
supporting structures.
Lips, tongue, floor of the mouth, gingiva,
vestibule, cheeks, hard and soft palate.
Any abnormalities of the soft tissues –
noted.

INTRA ORAL EXAMINATION

Oral hygiene is observed.
The presence or absence of inflammation
should be noted along with gingival
architecture and stippling.
Pockets - location and depth examined.

GINGIVAL & PERIODONTAL

EXAMINATION
GRADE 0 – No overgrowth ; feather edge
gingival margin.
GRADE 1 – Blugging of gingival margin.
GRADE 2 – Moderate gingival overgrowth
( one third crown length )
GRADE 3 – Marked gingival overgrowth
( more than one third of crown )

GINGIVAL OVERGROWTH INDEX

GRADE Hyperplasia size coverage

0 No Normal No

1 Minimal <2 mm Cervical

third or
less
2 Moderate 2-4mm Middle 3rd

3 Severe >4mm Morethan

2/3rd
According to Angelopoulos and Goaz
 0 Normal gingiva , no inflammation , no
discoloration , no bleeding.

1 Mild inflammation , slight erythema ,

minimal superficial alterations, no
bleeding.

2 Moderate inflammation , erythema ,

bleeding on probing.

3 Severe inflammation, severe erythema

and swelling, tendency to spontaneous
bleeding, possible ulceration.

BLEEDING INDEX
GRADE I Incipient furcation

GRADE Cul de sac

II

GRADE Through and

III through furcation

GRADE Complete loss

IV

GLICKMAN’S CLASSIFICATION
The presence and location of caries -
noted.

EXAMINATION OF
TOOTH STRUCTURE
The initial clinical examination starts with
the clinician asking the patient to make a
few simple opening and closing
movements while carefully observing the
opening and closing strokes.
Special attention - Initial tooth contact

- Tooth alignment
- Eccentric contacts

OCCLUSAL EXAMINATION
BilaterallyBalanced Occlusion,
Unilaterally Balanced Occlusion
Mutually protected Occlusion

Bilateral Balanced Occlusion - earliest

proposed theory.
The bilateral, simultaneous, anterior, and
posterior occlusal contact of teeth in
centric and eccentric positions.

CONCEPTS OF OCCLUSION
In fixed prosthodontics - it proved to be
extremely difficult to accomplish, even
with great attention to detail and
sophisticated articulators.
High rates of failure resulted.
An increased rate of occlusal wear,
increased or accelerated periodontal
breakdown, and neuromuscular
disturbances were commonly observed.

BILATERAL BALANCED
OCCLUSION
Based on Schyler’s Concept.

Unilaterally balanced occlusion – all teeth

on working side to be in contact during
lateral excursion.
Teeth on non-working side to be free of
any contact.

UNILATERAL BALANCED
OCCLUSION
The group function of teeth on working
side distributes the occlusal load.
The absence of contact on the non-
working side prevents those teeth from
being subjected to destructive forces.
Advocated by Stuart and Stallard.
Centric relation coincides with the
maximum intercuspation position.
The six anterior maxillary teeth, together
with the six anterior mandibular teeth,
guide excursive movements of the
mandible, and no posterior occlusal
contacts occur during any lateral or
protrusive excursions. 

MUTUALLY PROTECTED
OCCLUSION
Uniform contact of all teeth around the
arch when the mandibular condylar
processes are in their most superior
position.
Stable posterior tooth contacts with
vertically directed resultant forces.
Centric relation coincide with maximum
intercuspation.

FEATURES OF MUTUALLY PROTECTED OCCLUSION

No contact of posterior teeth in lateral or
protrusive movement.
 Anterior tooth contacts harmonizing with
functional jaw movements.
Crowding, rotation, supra-eruption,
spacing, malocclusion, and vertical and
horizontal overlap.
Teeth adjacent to edentulous spaces often
have shifted position slightly.

GENERAL ALIGNMENT
Evaluate - Degree of bone loss
- Impacted teeth,
- residual roots
- Root morphology,
- crown-root ratio
- Presence of apical disease
- Caries
- Pulp chambers & canals
- Periodontal ligament and
surrounding bone
- Existing restorations

RADIOGRAPHIC EXAMINATION
Presence or absence of teeth.
Assessing third molars impactions.
Evaluating the bone before implant
placement.
Screening edentulous arches - root tips.

PANOROMIC RADIOGRAPHS
Transcranial exposure- reveal the lateral
third of the mandibular condyle and can
be used to detect structural and positional
changes.

Tomography
Arthrography
CT scanning
Magnetic resonance imaging

RADIOGRAPH’S FOR TMJ

DISORDERS
Pulpal health must be assessed -
percussion and thermal /electrical
stimulation.
A diagnosis of non-vitality - confirmed by
preparing a test cavity before the
administration of local anesthetia.

VITALITY TESTING
Purpose of study and treatment planning.
Articulated diagnostic casts are essential
in planning fixed prosthodontic treatment.

DIAGNOSTIC
CASTS
For diagnosing problems and arriving at a
treatment plan.
View of the edentulous spaces.
An accurate assessment of the span
length,
Occlusogingival dimension.

ADVANTAGES OF DIAGNOSTIC
CASTS
Curvature of the arch in the edentulous
region – determined.
To predict whether the pontic will act as a
lever arm on the abutment teeth.
Inclination of the abutment teeth will also
become evident.
Mesiodistal drifting, rotation and
faciolingual displacement of abutment
teeth - seen.
Evaluation of wear facets — number, size
and location is possible. 
Discrepancies in the occlusal plane –
articulated casts.
Supra-erupted tooth into the opposing
edentulous spaces.
Diagnostic wax-up can be carried out.
Dental procedure that need to be
accomplished before fixed prostheses can
be properly undertaken.

Reliefof symptoms.
Removal of etiological factors.
Repair of damage.
Maintenance of dental health.

MOUTH PREPARATION
 TREATMENT
PLANNING

SINGLE REPLACEMENT OF
TOOTH MISSING TEETH

Convent
Design
Selection Implant ional
of
of
restorati RPD support tooth FPD
material ed FPD support
on
ed
The selection of the material and design of
restoration - based on several factors –

Destruction of tooth structure

Esthetics
Plaque control
Financial considerations
Retention

SINGLE TOOTH
RESTORATIONS
 If the amount of destruction of the tooth
is such that the remaining tooth structure
must gain strength and protection from
the restoration.
Cast metal or ceramic is indicated over
amalgam or composite resin.

DESTRUCTION OF
TOOTH STRUCTURE
PARTIAL VENEER.
FULL VENEER.
METAL CERAMIC CROWNS

ESTHETICS
Maintenance of good plaque control
program to increase the chances for
success of the restoration.

 PLAQUE CONTROL
Full veneer crowns - most retentive.

RETENTION
Selection should not be less than optimum
just because the patient cannot afford.
Sound alternative to the preferred
treatment plan.

FINANCIAL CONSIDERATIONS
When sufficient coronal tooth structure
exists to retain and protect a restoration
under the anticipated stresses of
mastication - an intracoronal restoration
can be employed.

INTRA CORONAL
RESTORATION
GLASS IONOMER CEMENT
COMPOSITE RESIN
AMALGAM
METAL INLAY
CERAMIC INLAY
MOD ONLAY
Insufficientcoronal tooth.
Deflective axial tooth structure.
Modify contours to refine occlusion or
improve esthetics.

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

PARTIAL VENEER
CROWNS
Situation where there are no esthetic
expectations.

FULL METAL
Multiple defective axial surfaces
Full coverage and good cosmetic results
must be obtained.

METAL CERAMIC CROWN

Fullcoverage and maximum esthetics.
Restricted to situation likely to produce
low moderate stress .

ALL CERAMIC CROWN

Produces good cosmetic result.

CERAMIC VEENERS
Biomechanical factors
Periodontal factors
Esthetics
Financial factors
Patient’s desire

TREATMENT PLANNING FOR THE

REPLACEMENT OF MISSING TEETH
Should be a vital tooth – whenever
possible.

The roots and their supporting tissues

should be evaluated -
Crown-root ratio
Root configuration
Periodontal ligament area

ABUTMENT EVALUATION
Measure of the length of the tooth
occlusal to the alveolar crest of bone
compared with the length of the root
embedded in the bone.
Optimum -2:3
Minimum -1:1

CROWN ROOT RATIO

Broader labiolingually - preferable to roots
that are round in cross section.
Multirooted posterior teeth with widely
separated roots - better periodontal
support than roots that converge, fuse or
generally present a conical configuration.
Conical roots can be used -for short span.

ROOT
CONFIGURATION
A single rooted tooth - irregular
configurations /curvature in the apical
third is preferable to the tooth that has a
nearly perfect taper.
Larger teeth have a greater surface area
and better able to bear added stress.
ANTE’S LAW - the root surface area of the
abutment teeth had to equal or surpassed
that of the teeth being replaced with
pontics.

PERIODONTAL LIGAMENT
AREA
According to this –
One missing tooth can be successfully
replaced if abutment teeth are healthy.
If two teeth are missing, a FPD can
probably replace the missing teeth but the
limit is being approached.
When the root surface area of the teeth to
be replaced by pontics surpass that of the
abutment teeth , then a high risk or an
unacceptable situation exists.
FPD’s with short pontic spans have a
better prognosis than do those with
extremely long spans.
However, Nyman and Ericsson - have
demonstrated that even teeth with very
poor periodontal support can serve
successfully as FPD abutments in carefully
selected cases. 
Allfixed partial dentures, long or short
spanned bend and flex.
Bending or deflection varies directly with
the cube of the length and inversely with
the cube of occlusogingival thickness of
the pontic.

BIOMECHANICAL
CONSIDERATIONS
Compared with a fixed partial denture
having a single tooth pontic span, a two
tooth pontic span will bend - 8 times as
much.
A three tooth pontic will bend 27 times as
much as a single pontic.
Whenever possible – FPD’S designed as
simple as possible – with a single well
anchored retainer fixed rigidly at each end
of pontic.
Use of multiple splinted abutment teeth –
non –rigid connectors –makes procedure
difficult and often the result compromise
the long term prognosis.

SELECTION OF ABUTMENT
TEETH
ENDODONTICALLY TREATED
ABUTMENT –
Post and core foundation for
retention and strength.
Failure occurs – short roots/little
remaining coronal tooth structures.

ASSESSMENT OF
ABUTMENT TEETH
IDEAL.
Conservative preparation for strong
retentive restoration with optimum
esthetics.

UNRESTORED ABUTMENTS
Loss of permanent mandibular first molar
to caries – common.
If space ignored – second molar will tilt
mesially – difficult /impossible to make a
satisfactory fixed partial denture.

MESIALLY TILTED SECOND

MOLAR
As no longer allows for parallel paths of
insertion without interference from
adjacent teeth.
FPD – modified preparation designs /non-
rigid connector – up righting tilted
abutment – orthodontically.
Long term prognosis – single abutment
cantilever – poor.
Forces best tolerated by periodontal
supporting structures when directed –
long axes of teeth.

CANTILEVER FIXED PROSTHESES

Cantilever will include lateral forces on
supporting tissues – maybe harmful and
lead to tipping rotation/drifting of
abutment.
An edentulous space can occur on both
sides of a tooth, creating alone - pier
abutment.

SPECIAL PROBLEMS
- PIER ABUTMENTS
The retention on the smaller anterior
tooth is usually less than that of the
posterior tooth because of its smaller
dimensions.
The use of a non-rigid connector has been
recommended.
key way : Distal contours of pier
abutment.
Key: Mesial side of the distal pontic.
A FPD replacing maxillary canine is
subjected to more stress than that
replacing a mandibular canine since forces
are transmitted outward on the maxillary
arch.
So the support from secondary abutments
will have to be considered.
Best restored with Implants.

CANINE
REPLACEMENT FPD
When there are insufficient abutment
teeth, inadequate strength in abutments,
no distal abutment present.
 Span length limited by availability of
alveolar bone, with satisfactory density
and thickness in a broad flat ridge.
Single missing tooth – replaced by single
implant – therefore no destruction of
adjacent abutments.

IMPLANT SUPPORTED FPD

2 -6 missing teeth – replaced by multiple
implants either as single units or implant
supported FPD’s.
 Occlusal forces should be nearly vertical
to the implant as possible to prevent
lateral destructive forces.
Implants are better able than natural
teeth to survive in a “ Dry Mouth”
 Iftooth abutments require endodontic
therapy with or without dowel cores,
periodontal surgery & even possibly root
resection to support a long span complex
FPD - “ Implant may be a better choice”
CONCLUSION
Tylmans theory and practice of fixed
prosthodontics - eight edition

Contemporary fixed prosthodontic;

Stephen.F. Rosenstiel - third edition.

Fundamentals of fixed prosthodontic;

Herbert.T. Shillingburg –third edition

REFERENCES