Abutmnt evaluation /orthodontics courses in india

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

ContentsContents
 IntroductionIntroduction
 Diagnostic recordDiagnostic record
General informationGeneral information
Medical historyMedical history
Drug historyDrug history
Dental historyDental history
 Clinical examinationClinical examination
Extra oralExtra oral
Intra oralIntra oral
 Radiographic examinationRadiographic examination
 Pre treatment recordsPre treatment records
 PrognosisPrognosis
 Treatment planningTreatment planning
 ConclusionConclusion www.indiandentalacademy.com

INTRODUCTIONINTRODUCTION
Successful fixed prosthodontic therapySuccessful fixed prosthodontic therapy
begins with a thorough assessment of thebegins with a thorough assessment of the
patient’s physical and psychologicalpatient’s physical and psychological
condition and determining a treatment thatcondition and determining a treatment that
will satisfy the expectations of the patient.will satisfy the expectations of the patient.

Some key words used are :Some key words used are :
• ExaminationExamination: Scrutiny or investigation for the purpose: Scrutiny or investigation for the purpose
of making a diagnosis or assessment.of making a diagnosis or assessment.
• Diagnosis:Diagnosis: It is translation of data gathered by clinicalIt is translation of data gathered by clinical
and radiographic examination into an organized,and radiographic examination into an organized,
classified definition of condition present.classified definition of condition present.
• Treatment planningTreatment planning: Sequence of procedures planned: Sequence of procedures planned
for the treatment of the patient.for the treatment of the patient.
• PrognosisPrognosis: A forecast as to the probable result of a: A forecast as to the probable result of a
disease or a cause of therapy.disease or a cause of therapy.

To gain the necessary informationTo gain the necessary information
about the patient, dentist should:about the patient, dentist should:
(1) Conduct a thorough examination(1) Conduct a thorough examination
(2) Listen to all the patient has to say(2) Listen to all the patient has to say
(3) Be alert to things patient may leave unsaid(3) Be alert to things patient may leave unsaid
(4) Record details of information in an logical(4) Record details of information in an logical
sequencesequence

Diagnostic record for the fixedDiagnostic record for the fixed
partial denture patientpartial denture patient
It includes:It includes:
• General informationGeneral information
• Visual examinationVisual examination
• PalpationPalpation
• Still photographyStill photography
• Intraoral radiographyIntraoral radiography
• MeasurementsMeasurements
• Diagnostic castsDiagnostic casts

• Diagnostic casts are an integral part of theDiagnostic casts are an integral part of the
diagnostic procedures necessary to give thediagnostic procedures necessary to give the
dentist as complete a perspective as possible ofdentist as complete a perspective as possible of
the patient’s dental needs.the patient’s dental needs.
• These casts are used to evaluate soft tissueThese casts are used to evaluate soft tissue
contours, vestibular morphology frenalcontours, vestibular morphology frenal
attachments, bony contours (eg Tori), crownattachments, bony contours (eg Tori), crown
length, and morphology, teeth alignment andlength, and morphology, teeth alignment and
paths of insertion, available pontic space,paths of insertion, available pontic space,
existing restorations, esthetic factors and theexisting restorations, esthetic factors and the
occlusion.occlusion.
• www.indiandentalacademy.com

Data obtained must beData obtained must be
• easily retrievableeasily retrievable
• In a logical sequenceIn a logical sequence
• And should be kept confidentialAnd should be kept confidential
General information can be gathered by any of theGeneral information can be gathered by any of the
following 3 ways:following 3 ways:
I) Direct interrogation by the dentist:I) Direct interrogation by the dentist:
- It offers greatest latitude- It offers greatest latitude
- Questions asked are brief & general in nature- Questions asked are brief & general in nature
-Can be probing & overlapping on points,-Can be probing & overlapping on points,
dentist deems importantdentist deems important

--Helps in developing rapport with patient and toHelps in developing rapport with patient and to
evaluate patient attitude towards previous treatment.evaluate patient attitude towards previous treatment.
DisadvantagesDisadvantages
- Time consuming- Time consuming
- Relies heavily on skill & experience of dentist.- Relies heavily on skill & experience of dentist.
- It is easy to forget necessary questions to be posed.- It is easy to forget necessary questions to be posed.
(ii)(ii) A comprehensive questionnaire:A comprehensive questionnaire:
-It is quick & filled by patient in waiting room-It is quick & filled by patient in waiting room
Disadvantages:Disadvantages:
-Patient may not read it carefully-Patient may not read it carefully

-May overlook important information-May overlook important information
-May give it to companions to fill which lead to-May give it to companions to fill which lead to
errors.errors.
(iii)(iii) A combination of both:A combination of both:
-- Gives added advantage of bothGives added advantage of both
- Form filled by pt. can be verbally reviewed- Form filled by pt. can be verbally reviewed
- Any +ve/-ve response may be noted &- Any +ve/-ve response may be noted &
clarifiedclarified
-- chance to correlate between examination,chance to correlate between examination,
observation & pt.’s health historyobservation & pt.’s health history
- Any conflicting information may be thoroughly- Any conflicting information may be thoroughly
probedprobed

• GENDER:GENDER: Female pts. are more conscious ofFemale pts. are more conscious of
their appearance. Therefore importance given totheir appearance. Therefore importance given to
details such as lip support, visibility of teeth,details such as lip support, visibility of teeth,
cuspal contour, shade of teeth etc.cuspal contour, shade of teeth etc.

-postmenopausal women also pose psychologicalpostmenopausal women also pose psychological
problems with other problems like dry mouth, burningproblems with other problems like dry mouth, burning
mouth syndrome & general vague pain.mouth syndrome & general vague pain.
-- Male patientsMale patients tend to be more occupied with theirtend to be more occupied with their
work & are less concernedwork & are less concerned
-Expect comfort & functionExpect comfort & function
OCCUPATION: influences the degree of importance
of factors like esthetics, phonetics and general
appearance.

• For professionals, who are in intimate contact
with people in their public life, appearance and
retention of denture is more important than
masticatory efficiency.
• Public speakers, singers and musicians who
play wind instrument require perfect retention
and particular attention to shape and position of
teeth and palatal form and thickness.
In addition a question about the work hours will
allow the dentist to fix appointments at time
convenient for the patient.www.indiandentalacademy.com

• SOCIAL SETTING:SOCIAL SETTING: Knowledge of patient’sKnowledge of patient’s
social setting helps the dentist to understandsocial setting helps the dentist to understand
patient expectationspatient expectations
- It is also helpful to have patient identify close- It is also helpful to have patient identify close
friends and relatives whose judgment they valuefriends and relatives whose judgment they value
and if possible gain insight into their views.and if possible gain insight into their views.

• Other questions to be asked:Other questions to be asked:
- how the patient chose the particular dental
office.
-Was he referred by another dentist physician or by
other means?
- If referral is from another dentist, valuable
background information and specific items like
diagnostic casts / radiographs can be obtained.

Medical historyMedical history
A complete health history should include,
(1) Name of patient’s physician, including data
and reason for the last appointment.
(2) A record of the status of all major body
systems
(3) A record of all medications the patient is
currently taking and any change in that regime
within last six months.

(4) A record of any hospitalization
(5) A record of any complication that was a
result of previous dental treatment.
(6) A record of patients opinion of his / her
general health.
(7) Space to update health history whenever
patient is recalled.patient is recalled.

• Many systemic diseases might or might not haveMany systemic diseases might or might not have
local manifestations. But some have a directlocal manifestations. But some have a direct
relation to FDP success. Few such conditionsrelation to FDP success. Few such conditions
are:are:
(1) Debilitating diseases(1) Debilitating diseases: Patient with known: Patient with known
debilitating diseases like Diabetes, tuberculosis,debilitating diseases like Diabetes, tuberculosis,
blood dyscrasias etc should be under medicalblood dyscrasias etc should be under medical
control.control.

• These patients require extra instructions in oralThese patients require extra instructions in oral
hygiene, eating habits and tissue rest.hygiene, eating habits and tissue rest.
(a) Diabetes:(a) Diabetes: An uncontrolled diabetic or poorlyAn uncontrolled diabetic or poorly
controlled diabetics may pose problems of:controlled diabetics may pose problems of:
(i) Bacterial, viral and fungal infections –(i) Bacterial, viral and fungal infections –
including candidiasisincluding candidiasis

(ii) Xerostomia: It causes dry, atrophic oral(ii) Xerostomia: It causes dry, atrophic oral
mucosa accompanied by mucositis, ulcers,mucosa accompanied by mucositis, ulcers,
desquamation and opportunistic infection.desquamation and opportunistic infection.
• Inflammed depapillated, painful tongueInflammed depapillated, painful tongue
• Difficulty in lubricating, masticating, andDifficulty in lubricating, masticating, and
swallowing are the other complicationsswallowing are the other complications

(iii) Poor wound healing(iii) Poor wound healing
(iv) Burning mouth syndrome(iv) Burning mouth syndrome
(v) Insulin reaction in patients treated with insult.(v) Insulin reaction in patients treated with insult.
Precautions taken to prevent insulin shockPrecautions taken to prevent insulin shock
during dental appointments are dietaryduring dental appointments are dietary
instruction i.e. to eat normal meal, keepinstruction i.e. to eat normal meal, keep
appointments as short as possible and source ofappointments as short as possible and source of
sugar given to patient, in case of symptoms.sugar given to patient, in case of symptoms.

(b) Tuberculosis:(b) Tuberculosis:
- should find whether disease is active/ passive- should find whether disease is active/ passive
- immunity is usually low- immunity is usually low
- precaution to be taken while handling such- precaution to be taken while handling such
patients like sterilization, protective gear etc.patients like sterilization, protective gear etc.
(c) Blood dyscrasias:(c) Blood dyscrasias:
- proper history should be taken- proper history should be taken
- blood tests/ consultation prior to treatment- blood tests/ consultation prior to treatment
- these patients get easily bruised, so care- these patients get easily bruised, so care
should be taken while during crown preparationshould be taken while during crown preparation
and impression making.and impression making.

(2) Cardio vascular diseases:
-Patient with history of Rheumatic fever and
Rheumatic heart disease are susceptible to infective
endocarditis.
- Prophylactic antibiotic coverage for all dental
procedures
Artificial heart valves also warrant antibiotic
prophylaxes to prevent prosthetic valve endocarditis.

• Stress and anxiety related to dental visit may
precipitate angina and sudden death due to
cardiac arrhythmias and cardiac arrest.
• The following points have to be noted to
avoid emergencies in dental office:
• (i) Detection of the condition through history &
consultation with patient’s cardiologist.

(ii) Making patient free to talk about fears and relieving
them of the anxiety
(iii) Convenient short morning appointment
(iv) Premedication with diazepam 5-10 mg to
reduce apprehension
(v) Nitroglycerine tablets to be made available
in dental office and given sublingually if pain
starts.

(3) Diseases of joints:
 Particularly osteoarthritis presents a problem.
 Under the age of 45, men and women are
affected in the ratio of 2 : 1.
 It affects the weight bearing joints like, hips,
knee and spine and also the terminal joints of
fingers, less frequently affected are second row
of joints in fingers and TMJ.

Prosthetic consideration:
-When terminal joints fingers are arthritic it is difficult
to maintain oral hygiene.
- Osteoarthritis of TMJ presents problem in FDP
construction as mandibular movements are painful
and jaw relation records are difficult to record and
repeat.

(4) Diseases of skin:(4) Diseases of skin: DermatologicalDermatological
conditions like pemphigus that are extremelyconditions like pemphigus that are extremely
painful.painful.
(5) Neurological disorders:(5) Neurological disorders:
-Patient with Bell’s palsy and Parkinson’s-Patient with Bell’s palsy and Parkinson’s
disease etc. need special prosthetic treatmentdisease etc. need special prosthetic treatment
considerationsconsiderations

(6) Radiation treated patients:(6) Radiation treated patients: Patients treatedPatients treated
by radiation of head and neck tend to developby radiation of head and neck tend to develop
problems likeproblems like
i) Mucositisi) Mucositis
ii) Xerostomiaii) Xerostomia
iii) Loss of tasteiii) Loss of taste
iv) Constricture of muscles (trismus)iv) Constricture of muscles (trismus)
v) Secondary infections (Candidiasis)v) Secondary infections (Candidiasis)
- Dentist detects most oral malignancies.- Dentist detects most oral malignancies.
Malignancies are eradicated by surgery /Malignancies are eradicated by surgery /
radiation and subsequent treatment handled byradiation and subsequent treatment handled by
maxillofacial prosthodontist.maxillofacial prosthodontist.

• Before radiation treatment is started:Before radiation treatment is started:
1) Infections are treated1) Infections are treated
2) Extraction of all remaining teeth if CD is2) Extraction of all remaining teeth if CD is
plannedplanned
3) Xerostomia, mucositis and oral hygiene3) Xerostomia, mucositis and oral hygiene
managed.managed.

• Patient receiving chemotherapy for CancerPatient receiving chemotherapy for Cancer
show:show:
1) Mucositis1) Mucositis
2) Extensive bleeding following minor trauma2) Extensive bleeding following minor trauma
3) Xerostomia3) Xerostomia
4) Infection4) Infection
5) Poor healing5) Poor healing
• Oncologist consulted prior to any invasive dentalOncologist consulted prior to any invasive dental
procedure. Symptomatic relief for mucositis andprocedure. Symptomatic relief for mucositis and
xerostomia should be providedxerostomia should be provided

(7) Menopause:(7) Menopause: Occurs at around 45 years ageOccurs at around 45 years age
- Important changes in bodily function occurs.- Important changes in bodily function occurs.
- Majority undergo bone changes, generalized- Majority undergo bone changes, generalized
osteoporosis mental disturbances ranging fromosteoporosis mental disturbances ranging from
mild irritability to complete nervous breakdown,mild irritability to complete nervous breakdown,
hot flushes, burning palate, burning tongue,hot flushes, burning palate, burning tongue,
inability to adjust and vague areas of pain.inability to adjust and vague areas of pain.

(8) Hypo & Hyper thyroidism:(8) Hypo & Hyper thyroidism:
HyperthyroidismHyperthyroidism – Thyrotoxic crisis precipitated by– Thyrotoxic crisis precipitated by
stress, trauma, surgical procedures.stress, trauma, surgical procedures.
- Osteoporosis might develop.- Osteoporosis might develop.
HypothyroidsHypothyroids – may develop hypothyroid coma when– may develop hypothyroid coma when
exposed to stressful conditions.exposed to stressful conditions.
- Oral manifestations are increase tongue size and- Oral manifestations are increase tongue size and
gingival edema.gingival edema.

• (9) Allergies and Angionematic edema:(9) Allergies and Angionematic edema:
- H/o of allergy to any drugs, most commonly to- H/o of allergy to any drugs, most commonly to
lignocaine , allergy to nickel etclignocaine , allergy to nickel etc
- Angioneurotic edema is a no emergency,- Angioneurotic edema is a no emergency,
edematous swelling of lips, cheek etc afteredematous swelling of lips, cheek etc after
contact with an antigen like acrylic / metal.contact with an antigen like acrylic / metal.
- Emergency treatment :0.3 – 0.5 ml epinephrine- Emergency treatment :0.3 – 0.5 ml epinephrine
1 : 1000 1M, support respiration / obtain medical1 : 1000 1M, support respiration / obtain medical
assistance.assistance.

(10) Diseases of respiratory system: Asthma,(10) Diseases of respiratory system: Asthma,
COPD, pneumonia,TB etc.COPD, pneumonia,TB etc.
- usually patient is on medications, so physician- usually patient is on medications, so physician
should be consulted.should be consulted.
- short morning appointments- short morning appointments
- avoid NSAIDS- avoid NSAIDS
-Malaise in older patients is often indicative of an-Malaise in older patients is often indicative of an
impeding health crisis and should not beimpeding health crisis and should not be
ignored.ignored.
In diseases like AIDS, Hepatitis B &C and otherIn diseases like AIDS, Hepatitis B &C and other
communicable diseases universal precautionscommunicable diseases universal precautions
should be taken to avoid cross infection.should be taken to avoid cross infection.www.indiandentalacademy.com

Drug historyDrug history
• Value of knowing what medication the patientValue of knowing what medication the patient
takes is:takes is:
-It can be an indication of a systemic disease-It can be an indication of a systemic disease
and which could alter dental treatment.and which could alter dental treatment.
-Compatibility of the drugs prescribed during the-Compatibility of the drugs prescribed during the
course of dental treatment with those alreadycourse of dental treatment with those already
being taken.being taken.
• Dentists should be aware of the synergistic andDentists should be aware of the synergistic and
antagonistic` effects of drugs.antagonistic` effects of drugs.
• Effects of drugs that can influence the outcomeEffects of drugs that can influence the outcome
of prosthodontic treatment are listed below:of prosthodontic treatment are listed below:

(1) Xerostomia :(1) Xerostomia :
(a) Antihistamines Diphenylhydramine (Benadryl)(a) Antihistamines Diphenylhydramine (Benadryl)
(b) Glycopyrrolate, Propanthelin(b) Glycopyrrolate, Propanthelin
(c) Antihypertensives(c) Antihypertensives
(d) Nitroglycerin given in angina(d) Nitroglycerin given in angina
(e) Antipsychotic drugs(e) Antipsychotic drugs
(f) Antiparkinsonian agents(f) Antiparkinsonian agents
(g) Anti arrhythmic agents(g) Anti arrhythmic agents
(h) Tricyclic anti depressants – Imipramine,(h) Tricyclic anti depressants – Imipramine,
amitriptylinamitriptylin
(i) Antianxiety agents – diazepam, alprazolam(i) Antianxiety agents – diazepam, alprazolam

(j) Antisialogogues – atropine(j) Antisialogogues – atropine
(k) Decongestants – phenyl propanolamine(k) Decongestants – phenyl propanolamine
(2) Sialorrehea(2) Sialorrehea – increase salivation– increase salivation
(a) Adrenergic stimulating drugs – epinephrine(a) Adrenergic stimulating drugs – epinephrine
(b) Sialogogues – Pilocarpine, neostigmine(b) Sialogogues – Pilocarpine, neostigmine
(c) Cholinesterase inhibitors used in myasthenia(c) Cholinesterase inhibitors used in myasthenia
gravisgravis
(3) Dysphagia :(3) Dysphagia :
- Tricyclic antidepressants- Tricyclic antidepressants
- Antipsychotic drugs- Antipsychotic drugs
- All those that cause xerostomia also cause- All those that cause xerostomia also cause
dysphagiadysphagia www.indiandentalacademy.com

(4) Mucosal changes:
(a)Phenytoin – Edematous gingival tissues and
hyperplasia
(b) Digoxin
(c) Adrenal corticosteroids – atrophy of mucosa / skin
(5) Hypoglycemic shock- Insulin takers
(6) Nausea, vomiting
Aspirin – Used in Rheumatic conditions
Narcotic analgesic – codein, propoxyphene
Digitalis
Estrogens – In postmenopausal women

(7) Anti coagulants- Warfarin, Heparin
(8) Drug induced Parkinson like syndrome
with bizarre muscle movements including facial
muscles
(a) Antipsychotics – chlorpromazine, Haloperidol
(b) Tricyclic antidepressants
(c) Metoclopromide
(9) Altered taste sensation
Beta blockers – propanotol, Atenolol
ACE inhibitors – captopril enalopril

(10) Behavioural changes / confusion
Adrenal corticosteroids
• Antiparkinsonism agents
– Procyclidine, Benztropine, trihexphenedryl
tricyclic antidepressants, narcotic analgesics,
central nervous system depressing drugs
including alcohol
– Patient acceptance of prosthesis could be
affected.
• The updating of health history is very important.
• New medications, changes in treatment, and
surgery can have a significant effect on dental
treatment

• Family history:Family history:
- proper history can reveal inheritable diseases in- proper history can reveal inheritable diseases in
the familythe family
- it includes blood disorders, abnormality ofit includes blood disorders, abnormality of
bones, teeth, diabetes, hypertension etc.bones, teeth, diabetes, hypertension etc.
• Appraisal of General PhysicalAppraisal of General Physical
Characteristics:Characteristics:
The three main physical characteristics to beThe three main physical characteristics to be
looked for are :looked for are :
(1) The neuromuscular skills / motor skills(1) The neuromuscular skills / motor skills
(2) The general appearance(2) The general appearance
(3) The face(3) The face www.indiandentalacademy.com

I) Neuromuscular skillsI) Neuromuscular skills: Degree of: Degree of
coordination in a patient is the foremost factor tocoordination in a patient is the foremost factor to
be looked for:be looked for:
a) Facial movements:a) Facial movements: Bell’s palsy, nerveBell’s palsy, nerve
blocks or trigeminal neuralgia will result inblocks or trigeminal neuralgia will result in
hemiplegia / dyskinesia. Tremors or spasms arehemiplegia / dyskinesia. Tremors or spasms are
indicative of Parkinson’s disease, nervous habitsindicative of Parkinson’s disease, nervous habits
/ possible drug induced Tardive dyskinesia./ possible drug induced Tardive dyskinesia.

b) Speech:b) Speech: Fluency and quality of patient’sFluency and quality of patient’s
speech is judged during casual conversation.speech is judged during casual conversation.
II) Facial features:II) Facial features:
An observation of patient’s face to note theAn observation of patient’s face to note the
length, fullness, support of lips includinglength, fullness, support of lips including
pihiltrum, nasolabial fold, labiomental fold, labialpihiltrum, nasolabial fold, labiomental fold, labial
commisures and modiolus.commisures and modiolus.

• General Appearance:General Appearance: A patient with pleasingA patient with pleasing
countenance who has a zest for life is usually acountenance who has a zest for life is usually a
better prosthodontic risk than one who is tensebetter prosthodontic risk than one who is tense
and depressed about life in general.and depressed about life in general.
• Mental Attitude:Mental Attitude:
The international prosthodontic workshopThe international prosthodontic workshop
identified certain factors that produce anidentified certain factors that produce an
adaptive or maladaptive response.adaptive or maladaptive response.
Factors which produce an adaptive response:Factors which produce an adaptive response:
1) The acceptance of the dentist & confidence in1) The acceptance of the dentist & confidence in
the dentist.the dentist.
2) Previous favorable experience with authority2) Previous favorable experience with authority
figures.figures. www.indiandentalacademy.com

3) The capacity to cope favorably with change.3) The capacity to cope favorably with change.
4) Favorable physical condition.4) Favorable physical condition.
5) Realistic expectations of the patient.5) Realistic expectations of the patient.
6) Good learning capacity.6) Good learning capacity.
7)Desire of the patient to please the doctor.7)Desire of the patient to please the doctor.
8) Recognition by the patient of the limitations to8) Recognition by the patient of the limitations to
complete success.complete success.
9) Good physical coordination.9) Good physical coordination.
10) The therapeutic alliance of the patient with10) The therapeutic alliance of the patient with
the doctor.the doctor. www.indiandentalacademy.com

Factors which produce a maladaptive responseFactors which produce a maladaptive response
toFDP:toFDP:
1) Lack of trust in the dentist.1) Lack of trust in the dentist.
2) Poor communication between the dentist & his2) Poor communication between the dentist & his
patient.patient.
3) Negative previous experience.3) Negative previous experience.
4) Unrealistic expectations of the patient.4) Unrealistic expectations of the patient.
5) Resistance to change arising from severe5) Resistance to change arising from severe
anxiety or depression or hopelessness.anxiety or depression or hopelessness.
6) Low tolerance level for anxiety or pain.6) Low tolerance level for anxiety or pain.
7) High level of anxiety on the part of the patient.7) High level of anxiety on the part of the patient.
8) Inadequate tissue tolerance.8) Inadequate tissue tolerance.
9) Muscle in coordination.9) Muscle in coordination.

10) Chronic dissatisfaction10) Chronic dissatisfaction
11) The wish to fail. The patient wants attention11) The wish to fail. The patient wants attention
and needs a continuing relationship with theand needs a continuing relationship with the
dentist.dentist.
- Dr. Milus House classified mental attitude into 4- Dr. Milus House classified mental attitude into 4
types based on extensive clinical experience.types based on extensive clinical experience.
a) Philosophical patienta) Philosophical patient
b) Indifferent patientb) Indifferent patient
c) Critical patientc) Critical patient
d) Skeptical patientd) Skeptical patient

Dental historyDental history
• It includes:It includes:
1) Chief complaint:1) Chief complaint: It is a simple statement ofIt is a simple statement of
what prompted the patient to seek care. Itwhat prompted the patient to seek care. It
should be expressed clearly & concisely inshould be expressed clearly & concisely in
patient’s own words.patient’s own words.
2) Symptoms & duration of problem:2) Symptoms & duration of problem:
Information to be obtained.Information to be obtained.
(1) Beginning and severity of dental disease.(1) Beginning and severity of dental disease.
(2) Patients reaction to dental treatment(2) Patients reaction to dental treatment
(3) Opinion of the dentists who have performed(3) Opinion of the dentists who have performed
service for the patient.service for the patient.www.indiandentalacademy.com

Detailed information obtained:Detailed information obtained:
(1) Cause of loss of natural whether carious /(1) Cause of loss of natural whether carious /
periodontalperiodontal
(2) H/o difficult extraction – there might be more(2) H/o difficult extraction – there might be more
bone loss at that site.bone loss at that site.
(3) Order of tooth loss(3) Order of tooth loss
(4) Length of time patient has been edentulous(4) Length of time patient has been edentulous
(5) Any areas of jaw not healed might indicates(5) Any areas of jaw not healed might indicates
(a) In sufficient healing time(a) In sufficient healing time
(b) Incomplete elimination of pathological tissue(b) Incomplete elimination of pathological tissue
(c) Health state not conducive to bone(c) Health state not conducive to bone
regenerationregeneration

Diet and NutritionDiet and Nutrition
-The diet of the patient must be assessed-The diet of the patient must be assessed
-Any deficiencies of nutrients and essential-Any deficiencies of nutrients and essential
elements can have various manifestations e.g.elements can have various manifestations e.g.
Vitamin B can cause angular chelitis.Vitamin B can cause angular chelitis.
-Also seen in patient with decrease VD.-Also seen in patient with decrease VD.
• Iron deficiency anemia, protein and calciumIron deficiency anemia, protein and calcium
deficiency cause muscle weakness and bonedeficiency cause muscle weakness and bone
resorption in postmenopausal women andresorption in postmenopausal women and
elderly patients.elderly patients.

• Patients advised on a balanced diet.Patients advised on a balanced diet.
• Pt. should be asked about the habit of pan/betelPt. should be asked about the habit of pan/betel
nut chewing, smoking, drinking & bruxism whichnut chewing, smoking, drinking & bruxism which
have detrimental effect on health of oral tissues.have detrimental effect on health of oral tissues.

CLINICAL EXAMINATION &CLINICAL EXAMINATION &
EVALUATION:EVALUATION:
(I) Extra oral examination:(I) Extra oral examination:
• The head and neck region is examined for theThe head and neck region is examined for the
presence of any pathological condition relatingpresence of any pathological condition relating
to non dental or systemic conditionto non dental or systemic condition
(a) Face form:(a) Face form: Classification of the shape / formClassification of the shape / form
of the face put forward by Leon Williams is theof the face put forward by Leon Williams is the
simplest and most useful guide though notsimplest and most useful guide though not
scientifically correct.scientifically correct.
• Williams claims that the shape of upper CentralWilliams claims that the shape of upper Central
Incisor bears a definite relation with the shape ofIncisor bears a definite relation with the shape of
the face.the face. www.indiandentalacademy.com

Face formsFace forms

Face profile:Face profile: Can be early indicator of patientsCan be early indicator of patients
jaw classification – Normal, prognathic &jaw classification – Normal, prognathic &
retrognathic. The labial surface of central incisorretrognathic. The labial surface of central incisor
parallels the profile and vertical jaw relationsparallels the profile and vertical jaw relations
(increase or decrease VD) can be accurately(increase or decrease VD) can be accurately
determined.determined.

Facial profileFacial profile

Facial profilesFacial profiles

b)b) Lips:Lips: It includesIt includes
(1) Lip support(1) Lip support
(2) Lip thickness(2) Lip thickness
(3) Lip length(3) Lip length
(4) Lip fullness(4) Lip fullness
• Lips should be examined for cracking fissures atLips should be examined for cracking fissures at
corners and ulceration. It may be due tocorners and ulceration. It may be due to
candidal infection, vitamin deficiency, incompletecandidal infection, vitamin deficiency, incomplete
or over closureor over closure

 Lip support:Lip support: Lack of proper lip support can leadLack of proper lip support can lead
to a collapsed appearance and wrinklingto a collapsed appearance and wrinkling
 Lip thickness:Lip thickness: A thin lip presents specialA thin lip presents special
problems as a slight change in labiolingual toothproblems as a slight change in labiolingual tooth
position alters the drape of lip whereas a thick lipposition alters the drape of lip whereas a thick lip
gives more freedom to the dentist beforegives more freedom to the dentist before
obvious changes in lip contour manifest.obvious changes in lip contour manifest.

Lip supportLip support
BeforeBefore AfterAfter

 Lip length:Lip length: Long lips tend to hide the teeth thusLong lips tend to hide the teeth thus
presenting dentist with a temptation to restorepresenting dentist with a temptation to restore
teeth too long to make them visible.teeth too long to make them visible.
Short upper lip, will expose most of the toothShort upper lip, will expose most of the tooth
surface and even the tooth restorationsurface and even the tooth restoration
junction(margin of the restoration)junction(margin of the restoration)

C)TMJ: TMJ should be healthy before FDP isC)TMJ: TMJ should be healthy before FDP is
made.made.
Patient presenting with one / more of thePatient presenting with one / more of the
following symptoms are considered to befollowing symptoms are considered to be
suffering from TMJ disorder.suffering from TMJ disorder.
(1) Pain and tenderness in muscles of(1) Pain and tenderness in muscles of
mastication and TMJ.mastication and TMJ.
(2) Sounds during condylar movements(2) Sounds during condylar movements
(3) Limitations of mandibular movements(3) Limitations of mandibular movements
TMD can be either degenerative arthritisTMD can be either degenerative arthritis
related TMD or nonarthritic TMD.related TMD or nonarthritic TMD.

Reported by Patient Clinical findings
1) Joint noise (s) 1) Clicking, crepitation
2) Pain in face, jaw, ears, headache 2) Pain, tenderness with palpation of
masticatory muscles and TMJ
3) Pain on mouth opening 3) TM arthralgia
4) Difficulty in opening wide and
chewing
4) Impaired mandibular mobility
irregularity or deviation of opening,
locking of mandible

• Health of TMJ can be estimated by a simpleHealth of TMJ can be estimated by a simple
test:test:
1) Patient is asked to open mouth wide1) Patient is asked to open mouth wide
and relax, move jaw to left and relax, moveand relax, move jaw to left and relax, move
jaw to right and relax and finally move jawjaw to right and relax and finally move jaw
forward and relax.forward and relax.
2) A fingertip is placed on face over each condyle2) A fingertip is placed on face over each condyle
and patient instructed to open the mouthand patient instructed to open the mouth
slightly and move jaw sideways, then to openslightly and move jaw sideways, then to open
wide and close.wide and close.
If clicking / crepitus in joints is detected byIf clicking / crepitus in joints is detected by
finger and is accompanied by painful function,finger and is accompanied by painful function,
TMD is likely to be present.TMD is likely to be present.www.indiandentalacademy.com

• Prosthetic considerations:Prosthetic considerations:
 Unhealthy TMJ complicates jaw relation records.Unhealthy TMJ complicates jaw relation records.
 Centric relation depends on structural andCentric relation depends on structural and
functional harmony of osseous structures, intrafunctional harmony of osseous structures, intra
articular tissue and capsular ligaments. Difficultyarticular tissue and capsular ligaments. Difficulty
to give correct & repeatable centric relation andto give correct & repeatable centric relation and
centric occlusion.centric occlusion.
 Occlusal corrections often needed.Occlusal corrections often needed.

• Dentist’s treatment strategies will includeDentist’s treatment strategies will include
(1) General emphasis on rest for masticatory(1) General emphasis on rest for masticatory
systemsystem
(2) Elimination of gross occlusal discrepancies(2) Elimination of gross occlusal discrepancies
(3) Patient counseling regarding nature of TMD.(3) Patient counseling regarding nature of TMD.
- Symptomatic treatment for pain- Symptomatic treatment for pain

• Tone of facial muscles:Tone of facial muscles: Tone of facial tissueTone of facial tissue
may indicate limitations on what might be donemay indicate limitations on what might be done
to improve patient facial contour.to improve patient facial contour.
Only the inadequate support from the intra oralOnly the inadequate support from the intra oral
structures can be restored to the originalstructures can be restored to the original
positions. Care is taken to see that tone of skinpositions. Care is taken to see that tone of skin
is comparable through out the face.is comparable through out the face.

• Valuable diagnostic information can be obtainedValuable diagnostic information can be obtained
by means of:by means of:
• TransilluminationTransillumination
• PercussionPercussion
• Pulpal vitality testsPulpal vitality tests
• Laboratory testsLaboratory tests

TRANSILLUMINATIONTRANSILLUMINATION::
• It is a fine adjunct in the oral examination. ItIt is a fine adjunct in the oral examination. It
consists of the passage of light through tissuesconsists of the passage of light through tissues
by interposing the object to be examinedby interposing the object to be examined
between the light source and the examiner. Thebetween the light source and the examiner. The
extent of sub gingival calcareous deposits,extent of sub gingival calcareous deposits,
interproximal caries. The presence of opaqueinterproximal caries. The presence of opaque
foreign objects embedded in soft tissues etc. canforeign objects embedded in soft tissues etc. can
be evaluated.be evaluated.

• PERCUSSIONPERCUSSION
• Percussion is the tapping of teeth for indicationPercussion is the tapping of teeth for indication
of pulpal and periapical inflammation, with theof pulpal and periapical inflammation, with the
handle end of the mouth mirror.handle end of the mouth mirror.

– PULPAL VITALITY TESTSPULPAL VITALITY TESTS::
• Vitality of abutment (J) should always beVitality of abutment (J) should always be
checked for. Before any restorative treatment,checked for. Before any restorative treatment,
pulpal health must be assessed usually bypulpal health must be assessed usually by
measuring the response to percussion andmeasuring the response to percussion and
thermal or electrical stimulation.thermal or electrical stimulation.
• All suspected (J) are tested initially by percussionAll suspected (J) are tested initially by percussion
and their vitality tests are run with an electricand their vitality tests are run with an electric
vitalometer, ice and heat.vitalometer, ice and heat.
• Ice is the most useful single aid to locate theIce is the most useful single aid to locate the
offending (+) in early acute pulpitisoffending (+) in early acute pulpitis

• A prospective abutment that lacks the necessaryA prospective abutment that lacks the necessary
attached tissue is a very poor candidate to receiveattached tissue is a very poor candidate to receive
a crown. Any presence or absence ofa crown. Any presence or absence of
inflammation should be noted along withinflammation should be noted along with
gingival architecture and stippling. The existencegingival architecture and stippling. The existence
of pockets should be entered in record and theirof pockets should be entered in record and their
location and depth noted with periodontal probe.location and depth noted with periodontal probe.
The detection of bifurcation and trifurcationThe detection of bifurcation and trifurcation
involvement are also noted. Before making useinvolvement are also noted. Before making use
of a tooth with a furcation involvement as anof a tooth with a furcation involvement as an
abutment, Ante’s law should be applied to assessabutment, Ante’s law should be applied to assess
the remaining support of teeth.the remaining support of teeth.

• Occlusal examinationOcclusal examination::
• Finally, an evaluation should be made of theFinally, an evaluation should be made of the
occlusion. Teeth should be checked for anyocclusion. Teeth should be checked for any
wear facets, if present whether localized orwear facets, if present whether localized or
widespread. Nonworking interferences are alsowidespread. Nonworking interferences are also
looked for.looked for.
• The amount of slide between the retrudedThe amount of slide between the retruded
position and the position of maximumposition and the position of maximum
intercuspation should be noted. (Is the slide theintercuspation should be noted. (Is the slide the
straight one or does the mandible deviate to onestraight one or does the mandible deviate to one
side or the other).side or the other).

DIAGNOSIS ANDDIAGNOSIS AND
TREATMENTTREATMENT
PLANNING IN FDPPLANNING IN FDP
part 2part 2
-DR. AZEEM A. KHOJA-DR. AZEEM A. KHOJA

FULL MOUTH RADIOGRAPHS:FULL MOUTH RADIOGRAPHS:
• complete mouth radiographic series (14 pericomplete mouth radiographic series (14 peri
apical and 4 bite wing radiographs) is essential.apical and 4 bite wing radiographs) is essential.
• TMJ radiographTMJ radiograph
• Panoramic radiograph in patients with TMJPanoramic radiograph in patients with TMJ
disorders.disorders.

An Intraoral radiographic examination reveals:An Intraoral radiographic examination reveals:
• Remaining bone supportRemaining bone support
• Root number and morphologyRoot number and morphology
• root proximityroot proximity
• Quality of supporting bone, trabecular patternsQuality of supporting bone, trabecular patterns
and furcational changesand furcational changes
• Width of the periodontal ligament spaces andWidth of the periodontal ligament spaces and
evidence of trauma from occlusionevidence of trauma from occlusion
• Areas of vertical and horizontal resorptionAreas of vertical and horizontal resorption

• Axial inclination of teethAxial inclination of teeth
• Continuity and integrity of lamina duraContinuity and integrity of lamina dura
• Pulpal morphology and previous endodonticPulpal morphology and previous endodontic
treatment with or without post and cores.treatment with or without post and cores.
• Presence of apical disease, root resorption orPresence of apical disease, root resorption or
root fractures.root fractures.
• Retained root fragments, radiolucent areas,Retained root fragments, radiolucent areas,
calcifications, foreign bodies or impacted teethcalcifications, foreign bodies or impacted teeth
• Presence of carious lesions, the conditions ofPresence of carious lesions, the conditions of
existing restorations, and the proximity of cariesexisting restorations, and the proximity of caries
and restorations to the dental pulpand restorations to the dental pulp

• Calculus depositsCalculus deposits
• Oral roentgenographic manifestations ofOral roentgenographic manifestations of
systemic diseases.systemic diseases.
Radiographic modifications in case of periodontalRadiographic modifications in case of periodontal
disease- ‘Thinning’ of radiograph.disease- ‘Thinning’ of radiograph.

TREATMENT PLANNING:TREATMENT PLANNING:
• A systematic design aimed at the completeA systematic design aimed at the complete
medical or surgical care of a patient,medical or surgical care of a patient,
• the institution of measures or giving ofthe institution of measures or giving of
remedies designed to cure a disease.remedies designed to cure a disease.

• formulating a logical sequenceformulating a logical sequence
• restore the patient’s dentition to good healthrestore the patient’s dentition to good health
• optimal function and appearanceoptimal function and appearance

• appropriate planappropriate plan informs the patient about theinforms the patient about the
present conditions,present conditions,
• the extent of dental treatment proposed,the extent of dental treatment proposed,
• the time and cost of treatment andthe time and cost of treatment and
• the level of home care and professional followthe level of home care and professional follow
up needed for successup needed for success

OBJECTIVES OF TEATMENTOBJECTIVES OF TEATMENT
PLANNINGPLANNING
• Correction of existing diseaseCorrection of existing disease
• Prevention of future diseasePrevention of future disease
• Restoration of functionRestoration of function
• Improvement of appearanceImprovement of appearance

CONSIDERATIONS IN TREATMENTCONSIDERATIONS IN TREATMENT
PLANNING:PLANNING:
• PATIENTS DESIRES, EXPEPCTATIONSPATIENTS DESIRES, EXPEPCTATIONS
AND NEEDSAND NEEDS
• proper identification of the patient’s needs.proper identification of the patient’s needs.
patient’s expectations must also be realistic.patient’s expectations must also be realistic.
• Disappointment-result of poor communicationDisappointment-result of poor communication
or lack of understanding or other limitations ofor lack of understanding or other limitations of
treatment.treatment.


• AGE:AGE:
between the ages of 20 and 55 years.between the ages of 20 and 55 years.
• When partially edentulous conditions exist inWhen partially edentulous conditions exist in
patients younger or older than this, seriouspatients younger or older than this, serious
considerations should be given to some type ofconsiderations should be given to some type of
restoration other than fixed.restoration other than fixed.
• O.H. ROBERTS -based on over 1000 bridges,O.H. ROBERTS -based on over 1000 bridges,
the younger the patient at the time the bridge isthe younger the patient at the time the bridge is
cemented, the more likely it is to fail.cemented, the more likely it is to fail.

Factors affecting the success of FDP inFactors affecting the success of FDP in
relation to age:relation to age:
• Length of clinical crownLength of clinical crown
• The caries rateThe caries rate
• Periodontal conditionPeriodontal condition

Length of clinical crownLength of clinical crown::
• The younger the patient, the shorter is theThe younger the patient, the shorter is the
crown and the greater is the convergence anglecrown and the greater is the convergence angle
between the sides of the crown preparation (i.e.between the sides of the crown preparation (i.e.
the less closely the preparation can be made tothe less closely the preparation can be made to
approach the ideal of near parallel sides).approach the ideal of near parallel sides).
• An inverse relationship between retention andAn inverse relationship between retention and
convergence angle has been demonstrated byconvergence angle has been demonstrated by
Jorgensen in 1955.Jorgensen in 1955.

2)2) Caries rateCaries rate::
• The caries rate is at its highest in those patientsThe caries rate is at its highest in those patients
under 21 years of age and this factor mayunder 21 years of age and this factor may
contribute to the high failure rate in this agecontribute to the high failure rate in this age
group.group.
• After 21 years of age, the caries rate in theAfter 21 years of age, the caries rate in the
majority of patients gradually falls and is at amajority of patients gradually falls and is at a
relatively low level by the age of 35.relatively low level by the age of 35.


3)3) Periodontal conditionPeriodontal condition::
The relatively advanced periodontal diseaseThe relatively advanced periodontal disease
involving tooth mobility most common in thoseinvolving tooth mobility most common in those
patients over 45 years is probably the cause ofpatients over 45 years is probably the cause of
the increased failure rate of FDP in the older agethe increased failure rate of FDP in the older age
group.group.


Sex:Sex:
• Although the quality of esthetics is desirable oneAlthough the quality of esthetics is desirable one
in every fixed partial denture, it is more desirablein every fixed partial denture, it is more desirable
when the appliance is placed for women,when the appliance is placed for women,
particularly in the anterior part of the mouth.particularly in the anterior part of the mouth.

• Maintainance of oral hygiene:Maintainance of oral hygiene:
A removable prosthesis, since it can be cleanedA removable prosthesis, since it can be cleaned
more quickly and more readily is preferred formore quickly and more readily is preferred for
those patients who the dentist suspects won’t bethose patients who the dentist suspects won’t be
diligent and careful in maintaining oral cleanliness.diligent and careful in maintaining oral cleanliness.

• Occupation of the patientOccupation of the patient
The occupation of a patient is a factor to beThe occupation of a patient is a factor to be
considered, particularly when the prosthesis isconsidered, particularly when the prosthesis is
planned for a patient who depends largely uponplanned for a patient who depends largely upon
this personal appearance as a means of earningthis personal appearance as a means of earning
his livelihood.his livelihood.

Systemic and emotional health:Systemic and emotional health:
• Elderly or debilitated patients unable to tolerateElderly or debilitated patients unable to tolerate
the long appointments routinely required forthe long appointments routinely required for
extensive fixed partial denture may be betterextensive fixed partial denture may be better
served with more conservative care e.g.served with more conservative care e.g.
removable prosthesis.removable prosthesis.
• Patients requiring antibiotic prophylaxis shouldPatients requiring antibiotic prophylaxis should
have as much treatment performed perhave as much treatment performed per
appointment as possible to reduce the frequencyappointment as possible to reduce the frequency
of dentist induced bacteremias.of dentist induced bacteremias.

• Many medications commonly prescribed for aMany medications commonly prescribed for a
number of systemic and emotional disorders cannumber of systemic and emotional disorders can
result in significant xerostomia, which canresult in significant xerostomia, which can
unfavorably affect the outcome of treatment.unfavorably affect the outcome of treatment.
• Bruxism, common in emotionally tenseBruxism, common in emotionally tense
individuals taxes the reparative capacities ofindividuals taxes the reparative capacities of
periodontiumperiodontium

• Periodontal factorsPeriodontal factors
inflamationinflamation
furcation involvementfurcation involvement
margin placementmargin placement
biologic widthbiologic width

Inflamation:Inflamation:
• goals of periodontal therapy-goals of periodontal therapy-
- conversion of periodontal pocket depth- conversion of periodontal pocket depth
to clinically normal sulcular depthsto clinically normal sulcular depths
- establish physiologic gingival- establish physiologic gingival
architrcturearchitrcture
- provide adequate zone of attached- provide adequate zone of attached
gingivagingiva

Furcation invasions: Teeth with furcationFurcation invasions: Teeth with furcation
invasion, require ‘special considerationinvasion, require ‘special consideration’’

MARGIN PLACEMENTMARGIN PLACEMENT

Margin placement:Margin placement:
• The gingivae are healthiest when margins areThe gingivae are healthiest when margins are
placed well above (i.e. 1-2 mm) the gingival crestplaced well above (i.e. 1-2 mm) the gingival crest
intra crevicular margin placement- not theintra crevicular margin placement- not the
universal solution to dental caries.universal solution to dental caries.
• Indications for the intra crevicular gingivalIndications for the intra crevicular gingival
margin - esthetics, retention requirements,margin - esthetics, retention requirements,
location of caries or pre-existing restorations,location of caries or pre-existing restorations,
root sensitivity and areas of cervical erosion orroot sensitivity and areas of cervical erosion or
root fracture.root fracture.
At the same time, the supra gingival margins mayAt the same time, the supra gingival margins may
be more susceptible to cement dissolutionbe more susceptible to cement dissolutionwww.indiandentalacademy.com

•Biologic width:Biologic width:
A band of soft tissue attachment between the base ofA band of soft tissue attachment between the base of
the gingival sulcus and the alveolar crest that isthe gingival sulcus and the alveolar crest that is
composed of approximate 2 mm of junctionalcomposed of approximate 2 mm of junctional
epithelium (attachment epithelium) and connectiveepithelium (attachment epithelium) and connective
tissue fibers.tissue fibers.
The dento gingival attachment, referred to as theThe dento gingival attachment, referred to as the
‘biologic width’ has significant implications in‘biologic width’ has significant implications in
treatment planningtreatment planning..

• In the past, - gingival termination wasIn the past, - gingival termination was
commonly prepared as sub gingival as possible.commonly prepared as sub gingival as possible.
• The contemporary approach is to place theThe contemporary approach is to place the
margin in the gingival crevice i.e. the intramargin in the gingival crevice i.e. the intra
crevicular margin. To avoid encroaching on thecrevicular margin. To avoid encroaching on the
biologic width, the tooth preparation mustbiologic width, the tooth preparation must
terminate at least 2 mm coronal to the alveolarterminate at least 2 mm coronal to the alveolar
crest.crest.
• the presence of caries, fractured root structurethe presence of caries, fractured root structure
or previous restorations apical to the gingivalor previous restorations apical to the gingival
crest predispose to the violation of the biologiccrest predispose to the violation of the biologic
width during tooth preparation.width during tooth preparation.

• short clinical crown- may induce dentist toshort clinical crown- may induce dentist to
overextend the preparation apically in anoverextend the preparation apically in an
attempt to enhance retention.attempt to enhance retention.
• Severing the natural dento gingival attachment -Severing the natural dento gingival attachment -
chronic gingival inflammation, pocket formationchronic gingival inflammation, pocket formation
and osseous defects in the bone.and osseous defects in the bone.
• Fibrous connective tissue and epitheliumFibrous connective tissue and epithelium
remodel in an attempt to reestablish aremodel in an attempt to reestablish a
physiologic attachment.physiologic attachment.

Periodontal treatment planPeriodontal treatment plan
• Initial therapy:Initial therapy:
-control of microbial plaque-control of microbial plaque
-tooth brushing-tooth brushing
-flossing-flossing
-other aids-other aids
-scaling and polishing-scaling and polishing
-correction of defective (overhanging) restorations-correction of defective (overhanging) restorations
-root planing-root planing
-strategic tooth removal-strategic tooth removal
-stabilization of mobile teeth-stabilization of mobile teeth
-minor tooth movement-minor tooth movementwww.indiandentalacademy.com

• Evaluation of initial therapyEvaluation of initial therapy
• Surgical therapySurgical therapy
--soft tissue proceduressoft tissue procedures
gingivectomygingivectomy
open debridementopen debridement
mucosal repairmucosal repair
-hard tissue procedures-hard tissue procedures
bone inductionbone induction
osseous resectionosseous resection
-treatment of furcation involvement-treatment of furcation involvement
odontoplasty –osteoplastyodontoplasty –osteoplasty
root amputationroot amputation
hemisectionhemisection www.indiandentalacademy.com

provisionalisationprovisionalisation
restorationrestoration
• Evaluation of surgical therapyEvaluation of surgical therapy
• Guided tissue regeneration( hard and soft tissueGuided tissue regeneration( hard and soft tissue
procedures)procedures)
• MaintenanceMaintenance
• PrognosisPrognosis

Occlusion:Occlusion:
• Simultaneous equalized contacts of all teethSimultaneous equalized contacts of all teeth
(anterior and posterior) in maximum inter(anterior and posterior) in maximum inter
cuspation (centric occlusion) at a physiologiccuspation (centric occlusion) at a physiologic
vertical dimension of occlusion.vertical dimension of occlusion.
• A physiologic plane of occlusionA physiologic plane of occlusion
• A functional anterior guidance, vertical andA functional anterior guidance, vertical and
horizontal overlap of the anterior teeth that willhorizontal overlap of the anterior teeth that will
protect the posterior teeth from interceptiveprotect the posterior teeth from interceptive
occlusal contacts in eccentric portions.occlusal contacts in eccentric portions.

• A comfortable, unlocked arrangement of cusps,A comfortable, unlocked arrangement of cusps,
fossae, grooves and ridges that will not restrictfossae, grooves and ridges that will not restrict
functional jaw movements.functional jaw movements.
• Axial loading of all posterior teeth.Axial loading of all posterior teeth.
• Anatomic forms to the cusps, fossae, marginalAnatomic forms to the cusps, fossae, marginal
ridges that will minimize inter dental foodridges that will minimize inter dental food
impaction and contribute to efficientimpaction and contribute to efficient
comminution of food.comminution of food.
• Occlusal and proximal tooth contacts that willOcclusal and proximal tooth contacts that will
lend long term stability to the occlusal scheme.lend long term stability to the occlusal scheme.

• An esthetic and phonetic relationship of theAn esthetic and phonetic relationship of the
anterior teeth.anterior teeth.
• Occlusal rests fabricated of a material that wearsOcclusal rests fabricated of a material that wears
like natural enamel.like natural enamel.

• Esthetic considerations:Esthetic considerations:
An unfavorable anterior guidance or plane ofAn unfavorable anterior guidance or plane of
occlusion will not only adversely affect occlusalocclusion will not only adversely affect occlusal
function but will also produce an unnaturalfunction but will also produce an unnatural
appearance.appearance.
The long clinical crowns that commonly resultThe long clinical crowns that commonly result
from surgical periodontics are particularlyfrom surgical periodontics are particularly
troublesome to restore esthetically.troublesome to restore esthetically.

• defect in the anterior edentulous ridge--restoreddefect in the anterior edentulous ridge--restored
surgically with some form of ridge augmentationsurgically with some form of ridge augmentation
followed by a conventional FPD. Prostheticfollowed by a conventional FPD. Prosthetic
restoration may be employed using an FPD (i.e.restoration may be employed using an FPD (i.e.
with gingival porcelain) or more commonly withwith gingival porcelain) or more commonly with
a RPD.a RPD.

• ANDREWS BRIDGE SYSTEMSANDREWS BRIDGE SYSTEMS

Resin bonded bridgesResin bonded bridges

• Bonded laminate veneers can be conservativeBonded laminate veneers can be conservative
alternatives to esthetic veneer crowns.alternatives to esthetic veneer crowns.
Laminates are recommended to restore estheticsLaminates are recommended to restore esthetics
in blemished but sound anterior teeth and arein blemished but sound anterior teeth and are
particularly useful with tetracycline stained teeth.particularly useful with tetracycline stained teeth.

• ENDODONTIC CONSIDERATIONSENDODONTIC CONSIDERATIONS::
• An endodontically treated tooth is commonlyAn endodontically treated tooth is commonly
restored with conservative tooth preparation andrestored with conservative tooth preparation and
a cast restoration.a cast restoration.
insufficient remaining tooth structure to supportinsufficient remaining tooth structure to support
an extra coronal restoration- corono radicularan extra coronal restoration- corono radicular
stabilization with post and core is indicated.stabilization with post and core is indicated.
• Pulp less teeth can successfully function asPulp less teeth can successfully function as
abutments to FPD or RPD but a post and coreabutments to FPD or RPD but a post and core
is usually required for such teeth.is usually required for such teeth.

• prognosis is poor for a pulp less tooth with anprognosis is poor for a pulp less tooth with an
extremely short root or with a canal that cannotextremely short root or with a canal that cannot
be negotiated to place a post be negotiated to place a post
Elective Endodontic TherapyElective Endodontic Therapy::
• Endodontic therapy may be necessary for aEndodontic therapy may be necessary for a
supra erupted or malaligned tooth to improvesupra erupted or malaligned tooth to improve
the arch relationship while facilitating fabricationthe arch relationship while facilitating fabrication
of a cast restoration with a more favorable archof a cast restoration with a more favorable arch
position and occlusion.position and occlusion.

AbutmentAbutment
• A tooth , portion of a tooth or that of a dentalA tooth , portion of a tooth or that of a dental
implant that serves to support or retain aimplant that serves to support or retain a
prosthesis.prosthesis.

Ideal abutment:Ideal abutment:
• Ideal crown root ratioIdeal crown root ratio
• Adequate thickness of enamel and dentinAdequate thickness of enamel and dentin
• Adequate bone supportAdequate bone support
• Absence of periodontal diseaseAbsence of periodontal disease
• Proper gingival contourProper gingival contour

Abutment selectionAbutment selection
• Crown : rootCrown : root
• Root configurationRoot configuration
• Periodontal surface areaPeriodontal surface area
-Ante’s law: Ante in 1926 stated that the-Ante’s law: Ante in 1926 stated that the
abutment should have a combined pericementalabutment should have a combined pericemental
area equal to or greater than the tooth or teetharea equal to or greater than the tooth or teeth
to be replaced and this recommendation hasto be replaced and this recommendation has
been referred to as Ante’s law (term given bybeen referred to as Ante’s law (term given by
Johnston et al).Johnston et al).

• Factors modifying Ante’s law:Factors modifying Ante’s law:
Increased abutments required:Increased abutments required:
1.1. Bone loss from periodontal diseaseBone loss from periodontal disease
2.2. Mesial or distal tipping or changes in axialMesial or distal tipping or changes in axial
inclinationinclination
3.3. Migration (bodily movement) of abutment teethMigration (bodily movement) of abutment teeth
4.4. Less than favorable opposing arch relationshipsLess than favorable opposing arch relationships
5.5. Endodontically restored abutment tooth withEndodontically restored abutment tooth with
root resectionsroot resections
6.6. Arch form situation creating greater leverageArch form situation creating greater leverage
factorsfactors

7. Tooth mobility created after osseous surgery7. Tooth mobility created after osseous surgery
(Splinting procedure)(Splinting procedure)
• Root proximitiesRoot proximities
• Long axis relationshipLong axis relationship
• Arch form or arch curvatureArch form or arch curvature
• RigidityRigidity
• Margin locationMargin location
• Span lengthSpan length
• Occlusal anatomyOcclusal anatomy
• Buccolingual dimension of teethBuccolingual dimension of teeth
• Pontic - tissue contactPontic - tissue contact
• Common path of insertionCommon path of insertionwww.indiandentalacademy.com

Types of abutmentsTypes of abutments
• Pier abutmentsPier abutments
• Tilted molar abutmentsTilted molar abutments
• Canine replacement FDPCanine replacement FDP
• Cantilever FDPCantilever FDP
• Extensively damaged abutmentsExtensively damaged abutments
• Implant abutmentsImplant abutments
• Unrestored abutmentsUnrestored abutments

• Pier abutment is a lone, free standing abutmentPier abutment is a lone, free standing abutment
with edentulous spaces on both sides.with edentulous spaces on both sides.
• Physiologic tooth movement, arch position ofPhysiologic tooth movement, arch position of
the abutments and a disparity in the retentivethe abutments and a disparity in the retentive
capacity of the retainers - less than ideal plan ofcapacity of the retainers - less than ideal plan of
treatment.treatment.

• Because of the distance through whichBecause of the distance through which
movement occurs, the independent directionmovement occurs, the independent direction
and magnitude of movements of the abutmentand magnitude of movements of the abutment
teeth and the tendency of the prosthesis to flex,teeth and the tendency of the prosthesis to flex,
stress can be concentrated around the abutmentstress can be concentrated around the abutment
teeth as well as between retainers and abutmentteeth as well as between retainers and abutment
preparationspreparations

• The Pier abutment can act as a fulcrum andThe Pier abutment can act as a fulcrum and
transmits the forces on the terminal abutments,transmits the forces on the terminal abutments,
leading to the failure of the weaker retainer. Theleading to the failure of the weaker retainer. The
loosened casting will break around the marginsloosened casting will break around the margins
and caries is likely to become extensive beforeand caries is likely to become extensive before
discovery.discovery.

The non-rigid connector has been suggested as a
solution to this problem. In spite of the apparently
close fit, the movement in the non rigid connector
is enough to prevent the transfer of stress from the
segment being loaded to the rest of FPD.

Tilted molar abutmentsTilted molar abutments

• Other means to correct this problem:Other means to correct this problem:
1.1. Proximal half crownProximal half crown
2.2. Telescopic crownTelescopic crown
3.3. Non-rigid connectorNon-rigid connector

• Canine Replacement FPDCanine Replacement FPD
• FPD replacing canines can be difficult becauseFPD replacing canines can be difficult because
the canine often lies outside the inter abutmentthe canine often lies outside the inter abutment
axis. The prospective abutments are the lateralaxis. The prospective abutments are the lateral
incisor, usually the weakest tooth in the entireincisor, usually the weakest tooth in the entire
arch and the 1arch and the 1stst
premolar, the weakest posteriorpremolar, the weakest posterior
tooth.tooth.

• the forces are transmitted outward (labially) onthe forces are transmitted outward (labially) on
the maxillary arch, against the inside of the curvethe maxillary arch, against the inside of the curve
(its weakest point).(its weakest point).
• On the Mandibular canine, the forces areOn the Mandibular canine, the forces are
directed inward (lingually), against the outside ofdirected inward (lingually), against the outside of
the curve (its strongest point)the curve (its strongest point)

Cantilever Fixed Partial DenturesCantilever Fixed Partial Dentures::
• A cantilever FPD is one that has an abutment orA cantilever FPD is one that has an abutment or
abutments at one end only, with the other endabutments at one end only, with the other end
of the pontic remaining, unattached.of the pontic remaining, unattached.
• This is potentially destructive design with theThis is potentially destructive design with the
lever arm created by the pontic, and is frequentlylever arm created by the pontic, and is frequently
misused. In a cantilever design, the pontic actsmisused. In a cantilever design, the pontic acts
as a lever that tends to be depressed underas a lever that tends to be depressed under
forces with a strong occlusal vector.forces with a strong occlusal vector.

Implant abutmentsImplant abutments

• INDICATIONS ANDINDICATIONS AND
CONTRAINDICATINOS OF FDP:CONTRAINDICATINOS OF FDP:
• INDICATIONSINDICATIONS
GeneralGeneral
LocalLocal

GENERAL INDICATIONSGENERAL INDICATIONS
• PsychologicalPsychological
• Systemic diseasesSystemic diseases
• Orthodontic considerationOrthodontic consideration
• Periodontal ReasonsPeriodontal Reasons
• SpeechSpeech
• Function and StabilityFunction and Stability

LOCAL INDICATIONSLOCAL INDICATIONS
• Lack of space for suitable replacementLack of space for suitable replacement
• The morphology of the abutment teethThe morphology of the abutment teeth
• Tilted teethTilted teeth
• Teeth suitable for abutmentTeeth suitable for abutment which requirewhich require
restorationrestoration

CONTRAINDICATIONSCONTRAINDICATIONS
• Inability of patient to cooperateInability of patient to cooperate
• Age of patientAge of patient
• High caries rateHigh caries rate
• Gingival and periodontal considerationsGingival and periodontal considerations
1.1. Gingival hyperplasiaGingival hyperplasia
2.2. GingivitisGingivitis
3.3. Advanced periodontal diseaseAdvanced periodontal disease

LOCAL FACTORS CONTRAINDICATINGLOCAL FACTORS CONTRAINDICATING
A BRIDGEA BRIDGE::
• Prognosis of AbutmentPrognosis of Abutment
• Ridge form and tissue lossRidge form and tissue loss
• Unfavorable tilting or rotation of the teethUnfavorable tilting or rotation of the teeth
• Maintenance and repairMaintenance and repair
• RPD is indicatedRPD is indicated

• PROGNOSIS:PROGNOSIS:
An estimation of the likely course of the disease.An estimation of the likely course of the disease.
• can be difficult to make, but its importance tocan be difficult to make, but its importance to
patients understanding and successful treatmentpatients understanding and successful treatment
must be recognizedmust be recognized
Fixed prostheses function in a hostileFixed prostheses function in a hostile
environment, the moist oral environment isenvironment, the moist oral environment is
subject to constant changes in temperature andsubject to constant changes in temperature and
acidity and considerable load fluctuation. Aacidity and considerable load fluctuation. A
comprehensive clinical examination helpscomprehensive clinical examination helps
identify the likely prognosis. All facts andidentify the likely prognosis. All facts and
observations are first considered individuallyobservations are first considered individually
and then correlated appropriately.and then correlated appropriately.www.indiandentalacademy.com

CONCLUSIONCONCLUSION

• The history and clinical examination mustThe history and clinical examination must
provide sufficient data for the practitioner toprovide sufficient data for the practitioner to
formulate a successful treatment plan.formulate a successful treatment plan.
• If they are too hastily accomplished, details mayIf they are too hastily accomplished, details may
be missed that can cause significant problemsbe missed that can cause significant problems
during treatment, when it may be difficult orduring treatment, when it may be difficult or
impossible to make correctionsimpossible to make corrections

• Thus, to achieve predictable success in thisThus, to achieve predictable success in this
technically exacting and demanding field, theretechnically exacting and demanding field, there
must be meticulous attention to every detailmust be meticulous attention to every detail
from the initial patient interview, diagnosis,from the initial patient interview, diagnosis,
through the active treatment phases and tothrough the active treatment phases and to
planned schedule of follow up care.planned schedule of follow up care.

WELL BEGUNWELL BEGUN
isis
HALF DONEHALF DONE

BIBLIOGRAPHYBIBLIOGRAPHY
• Contemporary fixed prosthodontics- Rosensteil, Land andContemporary fixed prosthodontics- Rosensteil, Land and
Fujimoto, 4Fujimoto, 4thth
ed,ed,
• Fundamentals of fixed prosthodontics- Shillingburg, Hobo,Fundamentals of fixed prosthodontics- Shillingburg, Hobo,
Jacobi, 3Jacobi, 3rdrd
ed.ed.
• Tylman’sTheory and practice of fixed prosthodontics- Malone ,Tylman’sTheory and practice of fixed prosthodontics- Malone ,
Roth, 8Roth, 8thth
ed.ed.
• J. Prosthet Dent 1979; 42: 411 (force distribution for teeth whenJ. Prosthet Dent 1979; 42: 411 (force distribution for teeth when
loaded singly and when used as FPD abutments).loaded singly and when used as FPD abutments).
• J. Prosthet Dent 1996; 76: 424 (stress analysis of a cantileveredJ. Prosthet Dent 1996; 76: 424 (stress analysis of a cantilevered
FPD with normal and decreased bone support).FPD with normal and decreased bone support).
• limiting criteria for fixed bridge reconstruction (JPD – 1991, 65:limiting criteria for fixed bridge reconstruction (JPD – 1991, 65:
357-64).357-64).

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