basics of diagnosis and treatment planning in FPD

1. GUIDED BY:
Dr.FAYAZ PASHA
PRESENTED BY:
Dr.SOUMYADEV SATPATHY
POST GRADUATE STUDENT
DEPARTMENT OF PROSTHODONTICS,
V.S.DENTAL COLLEGE & HOSPITAL
1

2. •
•
•
•
•
•
Introduction
Definitions
Diagnostic aids
– Personal information
– Patient evaluation
– Medical history
– Past dental history
– Clinical examination
• Extra oral examination
• Intraoral examination
– Radiographic examination
Treatment plan
– Adjunctive care
• Elimination of infection
• Elimination of pathosis
Summary
Conclusion
2

3. 
Successful management of cases begin with a
thorough assessment of the patient’s physical and
psychological condition and determining a treatment
that will satisfy the realistic expectations of the
patient.
3

4. Resorption of residual alveolar ridges
 Occlusal disharmony
 Tilting of teeth
 Drifting of teeth

4

5. 
DIAGNOSIS

The determination of the nature of a disease.
(Glossary of Prosthodontic terms 8)

TREATMENT PLAN

The sequence of procedures planned for the treatment of a patient
after diagnosis.
(Glossary of Prosthodontic terms 8)
5

6.  HISTORY
 TMJ & EXTRAORAL EVALUATION
 INTRA ORAL EXAMINATION
 DIAGNOSTIC CASTS
 RADIOGRAPHIC EXAMINATION
6

7. All pertinent information concerning the reasons seeking
treatment , along with any personal information, including
relevant previous medical and dental experiences.
The chief complaint should be recorded preferably in
patient’s own words.
7

8. o
o
o
o
o
Diagnosis & treatment planning depends upon
accurate data collection & record maintenance.
Information collection --Questionnaire.
--Direct interrogation.
--Combination.
Name: Patient identification, for addressing.
Sex: Patient expectations differ with sex.
AGE: As age advances decrease in adaptability &
neuromuscular co-ordination , learning ability.
Oral & facial tissues lose elasticity &resiliency.
12/09/13
8

9. o
Address:
o
Telephone. No:
o
Family history:
o
Socio-economic status :
o
Physician tel.ph.no:
12/09/13
9

10. The accuracy and significance of the patient’s primary reason
or reasons for seeking treatment should be analyzed first
FOUR CATEGORIES




COMFORT (pain, sensitivity, swelling)
FUNCTION (Difficulty in mastication or speech)
SOCIAL (Bad taste or odor )
APPEAREANCE (Fractured or unattractive teeth or
restorations , discoloration)
10

11. Accurate and current general medical
history should include

Medication.

As well as relevant medical conditions.

If necessary the patients physician(s) can be
contacted for clarification.

Conditions affecting the treatment methods

Conditions affecting treatment plan

Systemic conditions with oral manifestations

Possible risk factors for the dental surgeon and
11

12. .
12

13. .

Information about missing teeth
and any complications that may
have occurred during tooth
removal
is
obtained.

Special evaluation data collection
procedures are necessary for
patients
who
require
prosthodontic care subsequent
to
orthognathic
surgery.

Before
any
treatment
is
undertaken, the prosthodontic
component of the proposal
treatment should be fully coordinated
with
surgical
13

14. PERIODONTAL HISTORY

The patients oral hygiene is assessed,
current plaque control measures are
discussed, as are previously received
oral hygiene instructions.

The frequency of any previous
debridments should be recorded

Dates nature of any previous
periodontal surgery should be noted.
14

15. 
Simple composites resin
or dental amalgam
fillings or may involve
crowns and extensive
fixed partial dentures.

The age of previous
existing restorations can
help the prognosis and
probable longevity of
any future fixed
prosthesis.
15

16. The findings should be reviewed periodically so that periapical health can be monitored, any recurring lesions
promptly detected.
16

17. 
Occlusal analysis should be an integral part of the
assessment of a post orthodontic dentition.

If restorative treatment needs are anticipated , they
should be undertaken by the restorative dentist.
17

18. 
The patients experiences
with removable prostheses
must be carefully evaluated.

Listening to the patients
comments about previously
unsuccessful in assessing
whether future treatment
will be more successful.
18

19. 
Previous radiographs may prove
helpful in judging the progress of
dental disease.

They should be obtained if possible,
because it is generally better to
avoid exposing the patient to
unnecessary ionizing radiation.

In most instances , however , a
current diagnostic radiographic
series is essential and should be
obtained as a part of examination.
19

20. A history of pain or clicking in
the TMJ or neuromuscular
systems, such as tenderness to
palpation, may be due to TMJ
DYSFUNCTION, which should
be normally be treated and
resolved before fixed
prosthodontic treatment begins.
20

21. An examination
consist of the
clinician’s use of sight,
touch , and hearing to
detect conditions
outside the normal
range.
21

22. 
General appearance:
Gait and weight are
assessed.

Skin color : Anemia or
jaundice.

Vital signs: Respiration,
pulse, temperature and
blood pressure are
measured and recorded.
22

23. 
FACIAL ASYMMETRY

CERVICAL LYMPHNODES

TMJ

MUSCLS OF MASTICATION
(palpated)
23

24. 
Permits a comparison between the
relative timing of left and right condylar
movements during the opening stroke.

ASYNCHRONIOUS
MOVEMENT
:Anterior disk displacement that prevents
one of the condyles from making
abnormal
translatory
movements.

Auricular palpation with light anterior
pressure
helps
identify
potential
disorders in the posterior attachment of
the disk.
24

25. 
Tenderness or pain on movement, is
noted and can be indicative of
inflammatory changes in the
retrodiscal tissues ,which are highly
vascular and innervated.

Clicking in the TMJ is often notecible
through auricular palpation but may
be difficult to detect when palpating
directly over the lateral pole of the
condylar process, because the
overlying tissue can “muffel” the
click , placement of the fingertips on
the mandible will help to identify
even a minimal click.
25

26. Mouth opening

Average opening >50mm

Restricted opening<35mm
(intracapsular changes in the
joints)

Midline deviation :normal is
12mm
26

27. 
MASSETER ,TEMPORAL
MUSCLES and other POSTURAL
MUSCLES are palpated for signs of
tenderness.

Bilaterally and simultaneously.

light pressure.

Classify the discomfort as MILD,
MODERATE or SEVERE.

In TMJ dysfunction , a systematic
sequence of muscle palpation
should be followed.
27

28. 28

29. 29

30. The sites should be numbered
and
graded
discomfort
neuromuscular
for
so
pain
and
that,
If
or
TMJ
treatment is initiated , the
examiner can then re palpate
the same sites periodically to
asses the response to treatment
.
30

31. 
Visibility during normal and
exaggerated smiling.

This can be critical during FIXED
PROSTHODONTIC TREATMENT
PLANNING

“NEGATIVE SPACE”:- The space
between maxillary and mandibular
anteriors during normal smile.

Missing teeth, diastemas and fractured
or poorly restored teeth affect negative
space and require correction.
31

32. 
Condition of the soft
tissues , teeth and
supporting structures.

This information can be
properly evaluated during
treatment planning only if
objective indices, rather
than vague assessments,
are used.
32

33. 
Status of bacterial
accumulation

The response of the host
tissues and the degree of
irreversible damage.

Long term periodontal health
is essential to successful fixed
prosthodontic treatment.

Existing periodontal disease
must be corrected.
33

34. An accurate charting of the
state of the dentition will
reveal important information
about the condition of the
teeth
and
will
facilitate
treatment planning.
34

35. 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 is given to
Initial tooth contact, Tooth
alignment, and
Eccentric contacts and jaw
maneurability,
35

36. 
RADIOGRAPHS

VITALITY TEST

DIAGNOSTIC CASTS

PERIODONTAL PROBE.
36

37. Provides supplement information to clinical information
 Extent of bone support
 Root morphology
 Peri apical pathology
37

38. Presence or absence of
teeth
Assessing third molars
impactions,
Evaluating the bone
before implant placement.
Screening edentulous
arches for buried root tips.
38

39. For assessement of TMJ disorders, More
information can be obtained from
Tomography
Arthrography
C T scanning
Magnetic resonance
imaging
39

40. Pulpal health must be
measured before restorative
treatment to

PERCUSSION and

THERMAL STIMULATION

TEST CAVITY-nonvitality
without L.A
40

41. VITALITY TEST asses only
afferent Nerve supply.
MISDIAGNOSIS occurs if N S
is damaged and blood supply
intact .
Careful inspection of
radiographs therefore an
essential aid in the
examination.
41

42. 
Not all the patients seeking fixed
prosthodontic treatment will
present diagnostic problems.

Nevertheless ,diagnostic errors are
possible, especially when a patient
complains if pain or symptoms of
occlusal dysfunction.

A logical and systematic approach
to diagnosis will help avoid
mistakes.
42

43. 
The prognosis is an estimation
of the likely course of a disease.

It is difficult to make , but its
importance to patient
understand successful
treatment planning must
nevertheless be recognised.

The prognosis of dental
disorders is influenced by.
43

44. 
GENERAL FACTORS (age of patient, lowered resistance of
the oral environment)

LOCAL FACTORS (Forces applied to a given tooth , access
for oral hygiene measures).
44

45. 
A life size reproduction of the
parts of the oral cavity and or
facial structures for the purpose
of study and treatment planning.

Diagnostic casts are the integral
part of the diagnostic procedures
necessary to give the dentist as
complete a perspective as
possible of the patients dental
needs.
45

46. 46

47. 
SEMIADJUSTABLE ARTICULATOR with a FACE BOW TRANSFER.
Articulated diagnostic casts permits a detailed analysis of occlusal
plane and the occlusion for a better diagnosis and treatment plan.
 Tooth preparations can be “rehearsed “ on the casts and diagnostic
waxing procedures allow evaluation of the eventual outcome of
proposed treatment .

47

48. 
CENTRIC RELATION RECORDS
are used to replicate on the
articulator.

LATERAL OCCLUSAL
RECORDS are used to the
condylar guidance of the
articulator.

Identify the deflective contacts.

A distinction must be made
between mounting for
diagnosis and for treatment.
48

49. 
The attachment of casts to an articulator for diagnosis will
be done with the condyles in the centric relation position.

For restoration of a significant portion of the occlusion , it
may also be done with the condyles in the centric relation
position.
49

50. 
Mouth preparation refers to
the dental procedure that need
to be accomplished before
fixed prosthodontics can be
properly undertaken.

As a general plan , the
following sequence of
treatment procedures in
advance of fixed prosthodontic
should be adhered to;
50

51. 
Relief of symptoms (chief complaint)

Removal of etiological factors (eg; excavation of caries
removal of deposits)

Repair of damage .

Maintainance of dental health.
51

52. 
The following list describes the sequence in the treatment
of a patient with extensive dental disease including
missing teeth , retained roots , caries
and defective
restorations.
52

53. 
Preliminary assessment

Emergency treatment of presenting symptoms

Oral surgery

caries control and replacement of existing
restorations

Definitive periodontal treatment
53

54. 
Orthodontic treatment

Definitive occlusal treatment

Fixed prosthodontics

Removable prosthodontics

Follow up care .
A logical TREATMENT SEQUENCE should be planned
before beginning any fixed prosthodontic intervention.
Such planning will normally multidisciplinary.

54

55. The selection of the material and design
of the restoration depends on several
factors:
DESTRUCTION OF THE
TOOTH STRUCTURE

ESTHETICS

PLAQUE CONTROL

FINANCIAL
CONSIDERATIONS

RETENTION
55

56. The destruction previously suffered
by the tooth has to be restored , such
that the remaining tooth structure
must gain strength and protection
from restoration , cast metal or
ceramic is indicated over amalgam or
composite resin .
56

57. 
PARTIAL VENEER restoration can be used to restore in highly visible
area.

The use of ceramic in some can be used as FULL VENEER.
METAL CERAMIC CROWNS

Single unit anterior

Posterior crowns

Fixed partial denture
57

58. ALL CERAMIC CROWNS

commonly used on anteriors

posteriors (adequate bulk)
58

59. 
Motivated to follow a regime of
brushing,
flossing
and
dietary
regulation to control or eliminate the
disease
process
responsible
for
destruction of tooth structure.

If these measures prove to be successful
cast metal, ceramic or metal ceramic
restorations can be fabricated.
59

60. 




“SOME ONE”

Sound alternative to the preferred
treatment plan and not apply
pressure.
Government agency
A branch of military
Insurance company
Selection should not be less than
optimum just because the patient
cannot.
60

61. 
FULLVENEER CROWNS;
unquestionably most
retentive.

SINGLE TOOTH
RESTORATION: not nearly
important.

Special concern for ;

Short teeth

Removable partial denture
abutment.
61

62. 
PLASTIC and CEMENTED restoration

PLASTIC RESTORATION: Is inserted as soft or plastic
mass into the cavity preparation , where it will harden and
be retained by mechanical undercuts or adhesion.
62

63. CEMENTED RESTORATION
 Made of cast metal ,metal ceramics or ceramic material
alone is fabricated away from the operatory and is luted in
or on patients tooth at a subsequent appointment.
 One type can be better suited for a particular application
than the other or their suitabilities may overlap.
63

64. 
When sufficient coronal tooth structure exist to retain and protect a
restoration under the anticipated stresses of mastication an
intracoronal can be employed.

In this circumstance , the crown of the tooth and the restoration itself
are dependent upon the strength of remaining tooth structure to
provide structural integrity.
64

65. 





Where extensions can be kept minimal.
Preparation retention will be minimal .
Class 5 lesions
Incipient lesions
Root caries in geriatric patients.
Interim treatment restoration to assist in the
control of a mouth with rampant caries.
65

66. 
Esthetical critical areas.

Class 4 lesions .

Restoration of posterior teeth with mixed results.
66

67. 
Minor to moderate sized lesions in esthetically non critical
areas.
67

68. 
Moderate to severe lesions with amalgam
augmented by pins.

As a final restoration when a crown is
contraindicated .

Missing cusps or endodontically premolars and
molars.

Teeth that ordinarily would be restored with mesioocculsal onlays or other extracoronal restorations.
68

69. 
Minor to moderate lesions where esthetic require
low .

Etchable base metal alloys if a bonding effect is
desired.

Restoration of MOD on molars.
69

70. 
Minor to moderate sized lesion where esthetic demand is
high.

MOD ceramic inlays can be used on molars.
70

71. 
Moderately large lesions on premolars and molars with
intact facial and lingual surfaces.

It will accomodate a wide isthmus and upto one missing
cusp on molar.
71

72. 
Insufficient coronal tooth.

Deflective axial tooth structure.

Modify contours to refine occlusion or improve esthetics.
72

73. 
To restore a tooth with one or more intact axial surfaces
with half or more of the coronal tooth structure remaining.

For short span fixed partial dentures.

If tooth destruction is not extensive.
73

74. 
Restore teeth with multiple defective axial surfaces.

Restricted to situation where there are no esthetic
expectations.
74

75. 
Multiple defective axial surfaces.

Fixed partial dentures retainer where full coverage
and good cosmetic results must be obtained.
75

76. 
Full coverage and maximum esthetics.

Restricted to situation likely to produce low
moderate stress .

Usually used on incisors.
76

77. 
Intact anterior tooth that are marred by severe staining or
developmental defects restricted to facial surface of the
tooth.

Moderate incisal clipping and proximal lesions.
77

78. SELECTION OF THE TYPE OF THE
POSTHESIS

A REMOVAL PARTIAL DENTURE.

A TOOTH SUPPORTED FIXED PARTIAL DENTURE
OR

AN IMPLANT SUPPORTED FIXED PARTIAL
DENTURE.
78

79. 
BIOMECHANICAL

PERIODONTAL

ESTHETIC

FINANCIAL and

PATIENTS WISHES.
It is not uncommon to combine two types in the
same arch.
79

80. 
Edentulous spaces greater than two posterior teeth.

Anterior space greater than four lncisors.

Edentulous space with no distal abutment.

Multiple edentulous spaces.

Tipped teeth adjoining edentulous spaces and prospective abutments
with divergent alignment.
80

81. 
Periodontally weakened.

Teeth with short clinical crowns.

Insufficient number of abutments.

If there has been a severe loss of tissues in the
edentulous ridge.

Patients of advanced age who are on fixed incomes
or have systemic problems.
81

82. 
Abutment teeth are periodontally sound.

Edentulous span is short and straight.

Expected to provide a longlife of function for the patient.

No gross soft tissue defect in the edentulous ridge.

Reserved for patients who are both highly motivated and
able to afford.
82

83. 
Defect free abutments where single missing tooth.

A single molar (muscles are not well developed).

Mesial and distal abutment are present.

Moderate resorption and no gross soft tissue defects on
edentulous ridges.
83

84. 
Younger patients whose immature teeth with large pulps
are poor risks for endodontic free abutment preparation.

Tilted tooth can be accommodated only if there enough
tooth structure to allow a change in the normal alligment
of axial reduction.

Periodontal splints.
84

85. 
Insufficient number of abutments.

Partial attitude and or a combination of intra oral factors
make a removable partial denture or FPD a poor choice.

No distal abutment.

Alveolar bone with satisfactory density and thickness in a
broad, flat ridges.
85

86. 
Configuration that permit implant placement.

Single tooth where defect free adjacent teeth.

A span length of two or six teeth can be replaced by
multiple implants.

Pier in an edentulous span (three or more teeth long).
86

87. 
Long standing edentulous space into which there has been
little or no drifting or elongation of the adjacent teeth.

If the patients percieves no functional , occlusal or esthetic
impairement.
87

88. In cases where the choice between a fixed partial denture
and a removable partial denture is not clear cut, two or
more treatment options should be presented to the
patients along with their advantages and disadvantages.
88

89. The prosthodontist is the best person to evaluate the physical
and biological factors present , while the patients feelings
should carry considerable weight on matters of esthetics &
finances .
89

90. The roots and their supporting tissues should be evaluated
for three factors

Crown root ratio

Root configuration

Periodontal ligament area
90

91. 
Optimum -2:3

Minimum -1:1 (acceptable)
91

92. 
Broader LABIOLINGULLAY than MESIODISTALLY.

Multirooted posterior teeth with widely separated roots.

Conical roots can be used -for short span.

A single rooted tooth with evidence of irregular configuration
or with some curvature in the tooth that has a nearly taper.
92

93. 
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.
93

94. 
In addition to the increased load placed on the pdl by a
long span FPD.

Longer spans are less rigid.

Bending or deflection varies directly with the cube of the
length and inversely with cube of the occlusogingivally
thickness of the pontic .
94

95. 95

96. TO MINIMIZE –

Greater occlusogingival dimension

Nickel chromium

Double abutment

Multiple grooves

Arch curvature ( minimize additional retention from
opposite arch)
96

97. PIER ABUTMENTS

Non rigid connector

Restrict to short span FPD

key way -distal contours of pier a abutment

key - mesial side of the distal pontic
97

98. 
Mild encroaching- restoring and recontouring

Tilting is severe –corrective measures
98

99. 
No FPD replacing a canine should replace more than one
additional tooth.

Edentulous spaces created by the loss of canine and any
contiguous teeth is best restored with Implants.
99

100. 
Length roots with favourable configuration.

Long clinical crowns.

Good crown root ratios and healthy periodontium.

Should replace only one tooth and have atleast two
abutments.

Pontic should posses maximum occlusogingival height to
ensure a rigid prosthesis.
100

101. 101

102. The history and clinical examination must
provide sufficient data for the practioner to
formulate a successful treatment plan.
In particular it is critical to develop a through
understanding of special patient concerns
relating to previous care and expectations about
future treatment.
A diagnosis is a summation of the observed
problems and their underlying etiologies.
The overall prognosis is influenced by general and
local factors
102

103. 
Tylmans theory and practice of fixed prosthodontic
–eigth edition

Contemporary fixed prosthodontic; Stephen.F.
Rosenstiel –third edition.

Fundamentals of fixed prosthodontic; Herbert.T.
Shillingburg –third edition
103

104. 104