This gives an overview on the diagnostic and treatment planning procedures required in fixed partial dentures and also about the biomechanics involved in the selection of an appropriate fixed prosthesis. The presentation can be available upon request. Mail me at apurvathampi@gmail.com

1. Diagnosis and treatment
planning in FPD
Apurva Thampi

2. Contents
• Introduction
• Terminologies
• Diagnosis and diagnostic aids
• Intra oral examination
• Radiographic examination
• Vitality testing
• Interocclusal records
• Treatment planning
• For single tooth restoration
• Replacing multiple missing teeth
• Conclusion
• References

3. Introduction

4. Sequalae of tooth loss
Aesthetics Speech
Drifting and
tilting
Supra-
erupted teeth
Overloading
of remaining
teeth
Loss of
masticatory
efficiency
Loss of
vertical
dimension
Mandibular
deviation
Loss of
alveolar bone
Combination
syndrome

5. Conventional restorative treatment plan
Loss of alveolar bone
Edentulousness (lost occlusion)
Major changes (impaired occlusion)
Minor changes(intact occlusion)
Healthy dentition Neglect
Restorative care
Prosthodontic
intervention

6. What are the options available??
RPD RFP FPD Implants

7. Unhealthy
unattractive
dentition with
poor function
Predictable success
Comfortable
healthy
occlusion
Meticulous attention to
every detail

8. Terminologies

9. Fixed prosthodontics
The branch of prosthodontics concerned
with the replacement and/or restoration of
teeth by artificial substitutes that cannot be
removed from the mouth by the patient
7/15/2017The Glossary of Prosthodontic terms - 9 (April 2017) 9

10. Fixed partial denture
Any dental prosthesis that is luted, screwed, or
mechanically attached or otherwise securely retained to
natural teeth, tooth roots, and/or dental
implants/abutments that furnish the primary support for
the dental prosthesis and restoring teeth in a partially
edentulous arch; it cannot be removed by the patient
The Glossary of Prosthodontic terms - 9 (April 2017)

11. Parts of a fixed partial denture
Abutment Retainer
Pontic Connector

12. Diagnosis

13. Intraoral examination
Tongue
Floor of the mouth
Vestibule
Cheeks
Hard and soft palates
Objective indices
rather than vague
assessments to be used

14. Classification of ridge defects
Class I
• Buccolingual
loss of tissue
with normal
ridge height in
the apico-
coronal direction
Class II
• Apico-coronal
loss of tissue
with normal
ridge width in
bucco-lingual
direction
Class III
• Combination of
buccolingual and
apico-coronal
loss of tissue
resulting in loss
of normal
height and width
Kazor CE, Al-Shammari K, Sarment DP, Misch CE, Wang HL. Implant plastic surgery: a review and rationale. Journal
of Oral Implantology. 2004 Aug;30(4):240-54.
Seibert in 1983

15. Classification of ridge defects

16. Periodontal examination
Gingiva
Periodontium
Clinical
attachment
level
All existing
periodontal
conditions to be
corrected before
definitive
prosthodontic
treatment

17. Periodontal examination – Gingiva
Normal
• Pink, stippled
• firmly bound to the
underlying connective
tissue.
• Free gingival margin,
sharply pointed gingiva
How to examine?
• Lightly dried
• Colour, texture, size
contour, consistency,
position
• Palpate – exudate

18. Periodontal examination – Gingiva
Width of band of
attached gingiva
Measure band of
keratinized tissue in
A-C direction –
subtract sulcus depth
Depress marginal
gingiva with side of
periodontal probe
Inject anesthetic
solution into non
keratinized mucosa

19. Periodontal examination - Periodontium
One of the most reliable
and useful diagnostic tools
Probe is inserted parallel to tooth
and “walked” circumferentially
through the sulcus – firm but gentle
steps
Others:
• Tooth mobility
• Open contact areas
• Inconsistent marginal ridge heights
• Missing or impacted teeth
• Inadequate attached gingiva
• Recession
• Furcation involvements

20. Periodontal examination –
Clinical attachment level
Attachment level Inference
At the CEJ – Free Gingival Margin on the clinical
crown
No loss of attachment
On the root structure – Free Ginigival Margin at
the CEJ
Attachment loss=probing depth ; recession is 0
Severe recession Attachment loss = probing depth + recession
Determines the amount of periodontal destruction  periodontitis
(diagnostic gold standard)

21. Dental charting

22. Occlusal examination
Initial tooth
contact
General
alignment
Lateral and
protrusive
contacts
Jaw
maneuverability

23. Occlusal examination –
Initial tooth contacts
Checked in both centric relation and maximum intercuspation
If all teeth come in contact together at the end of terminal hinge
closure – CR=MI
If any teeth come in contact first – feather-light – direction of
movement observed upon closure  slide from CR to MI

24. Occlusal examination –
General alignment
• Crowding, rotations, eruptions, spacing, malocclusion, vertical and horizontal
overlap

25. Occlusal examination –
Lateral and Protrusive contacts
Unguided
protrusive
movement
amount of
posterior
disocclusion
Guided in to
lateral excursive
movements
Presence or
absence of
contacts noted
“Fremitus test”
For teeth
subjected to
excessive loading

26. Radiographic examination
Degree of bone loss
impacted teeth,
residual roots
Root
morphology, crown-
root ratio
Presence of apical
disease
Caries
Calculus
pulp chambers &
canals
Periodontal ligament
and surrounding
bone
existing restorations
(marginal fit,
contour)

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

28. Special radiographs for TML disorders
• Transcranial exposure-reveal the lateral third of the mandibular condyle
and can be used to detect structural and positional changes
52
Tomography
CT scanning
Arthrotomography
MRI

29. Vitality testing
PERCUSSION
THERMAL
STIMULATION
TEST CAVITY

30. Vitality testing
Assess only afferent Nerve supply
Misdiagnosis may occur
Careful inspection of radiographs is also required
as an adjunt

31. Diagnostic casts
Articulated diagnostic casts
are essential
Accurate reproductions of
the maxillary and
mandibular arches made
from distortion free
alginate impressions.

32. Diagnostic casts - Advantages
an unobstructed view of the edentulous spaces
Length of the abutment teeth
The true inclination of the abutment teeth
Mesio-distal drifting
Teeth – size and location
Diagnostic situations where pontic designs need to decided

33. Differential diagnosis
Consist of the most
likely causes of the
observed condition
Definitive diagnosis is
made only after all
the evidence is
gathered

34. Prognosis
• Important for patient management and satisfaction
• Influenced by general and local factors
A forecast as to the probable
result of a disease or a course
of therapy – GPT 9
General factors
• Age and overall health
• Occlusal forces
• Understanding and
comprehension
• History and success or previous
dental treatment
Local factors
• Malocclusions
• Crowding of teeth
• Tooth mobility
• Root angulation
• Crown root ratios

35. Prosthodontic diagnostic index (PDI)
Location
and extent
of
edentulous
area
Condition
of
abutment
teeth
Occlusal
scheme
Residual
ridge
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

36. PDI –
Location and extent of edentulous areas
Minimally compromised
• Antr missing span not
exceeding 2 missing teeth
• Antr mandibular span not
exceeding 4 missing teeth
• Postr maxillary or
mandibular not exceeding
2 PM or 1 PM and 1 M
Moderately compromised
• Antr maxillary not
exceeding 2 missing
incisiors
• Antr mandibular not
missing more than 4
• Postr maxillary or
mandibular not exceeding
2 PM or 1 PM and 1 M
• Missing canine
Substantially compromised
• Postr > 3 missing teeeht
or 2 molars
• Antr or postr more than 3
missing
• Treatment requires high
level of compliance
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

37. PDI –
Condition of abutment teeth
Minimally
compromised
• No preprosthetic
therapy required
Moderately
compromised
• Insufficient tooth
structure in one or 2
sextants
• Abutments require
localized adjunctive
therapy
Substantially
compromised
• Insufficient tooth
structure
• Abutments require
extensive adjunctive
therapy
• Abutments have
guarded prognosis
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

38. PDI –
Occlusal scheme
Minimally
compromised
• No
preprosthetic
therapy
required
• Class 1 Molar
realtion
Moderately
compromised
• Requires
localized
adjunctive
therapy
• Class 1 molar
and jaw
realtionships
Substantially
compromised
• Entire occlusal
scheme
requires
management
• Class II moalr
and jaw
relations
Severely
compromised
• Decreased
vertical
dimension
• Class II div 2
or class molar
and jaw
relations
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

39. PDI – Class I
Ideal location and extent of edentulous space
• Confined to a single arch
• Does not compromise the support offered by abutments
Ideal abutment condition
Ideal occlusion
Residual ridge morphology of completely edentulism
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

40. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

41. PDI – Class II
Location and extent moderately compromised
• Edentulous areas on one or both arches
Abutments are moderately compromised
• 1 or 2 sextants have sufficient tooth structure
• Require localized adjuctive therapy
Occlusion is moderately compromised
Residual ridge - class II
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

42. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

43. PDI – Class III
Location and extent of edentulous area is substantially compromised
Condition of abutments is moderately compromised
Occlusion is substantially compromised
Residual ridge – class III
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

44. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

45. PDI – Class IV
Location and extent of edentulous area is severely compromised
Abutments are severely compromised
Occlusion is severely compromised
Residual ridge – class IV
McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

46. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system for the
completely dentate patient. Journal of Prosthodontics. 2004 Jun 1;13(2):73-82.

47. Treatment plan

48. Treatment
Planning
Single-Tooth
Restorations
The selection
of the material
The selection
design of the
restoration
Replacement
of Missing
Teeth
Removable
Partial Denture
Implant-
Supported
Fixed Partial
Denture
Conventional
Tooth-
Supported
Fixed Partial
Denture
Resin-Bonded
Tooth-
Supported

49. Identification of patient needs
Correction of
existing
disease
Prevention of
future disease
Restoration
of function
Improvement
in appearance

50. Available materials and techniques
Materials
• Plastic materials
• Cast metal
• Metal ceramic
• Resin-veneered
• Fibre-reinforced
• All ceramic
Techniques
• Fixed dental prosthesis
• Implant supported prosthesis
• Partial removable dental prosthesis
• Complete dentures
Contemporary fixed prosthodontics Rosenstiel 4th Ed

51. 12 restoration types
Intracoronal
• Glass ionomer
• Composite resin
• Simple amalgam
• Complex amalgam
• Metal inlay
• Ceramic inlay
• MOD onlay
Extracoronal
• Partial vneer crown
• Full metal crown
• Metal ceramic crown
• All ceramic crown
• Ceramic veneer
fundamenals of fixed prosthodontics Shillingberg

52. Factors for decision making
Destruction
of tooth
structure
Esthetics Plaque control
Financial
considerations
Retention

53. For single tooth restorations

54. Restoration longevity
Cast restorations survive longer in
the mouth than amalgam which in
turn will last longer than composite
restorations
Bentley C, Drake CW. Longevity of restorations in a dental school clinic. Journal of Dental Education. 1986 Oct
1;50(10):594-600.

55. For replacement of multiple missing teeth

57. Abutment evaluation
• Ideally vital tooth
• Radiographically sound RC treated tooth can also be used
• Should not be mobile
• Teeth in which pulp capping has been done should not be done

58. Abutment evaluation
Crown root ratio
Root configuration
Periodontal
ligament area

59. Abutment evaluation – Crown root ratio
• Measure of the length of tooth occlusal to the alveolar crest of bone
compared with the length of root embedded in the bone

60. Abutment evaluation – Root configuration
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

61. Abutment evaluation –
Periodontal ligament area
• 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.

62. Biomechanical considerations
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

63. Biomechanical considerations
How to
minimize
these
forces?
Greater occlusogingival dimension
Nickel chromium
Double abutment
Multiple grooves
Arch curvature ( minimize additional retention from opposite arch)

64. Special considerations
Pier
abutments
Third molar
abutments
Canine
replacement
Cantilever
fixed partial
denture

65. Special consideration – 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

66. Special consideration –
Third molar abutment
• Mild encroaching- restoring and recontouring
• Tilting is severe –corrective measures

67. Special considerations – Canine replacement
• No FPD replacing a canine should replace more than one additional tooth.
• Best restored with Implants

68. Special considerations –
Cantilever fixed partial denture
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

69. Special considerations –
Cantilever fixed partial denture

70. Conclusion
It is critical to develop a through understanding of special patient concerns
relating to previous care and expectations about future treatment.

71. Bibliogrphy
• Contemporary fixed prosthodontic; Stephen.F. Rosenstiel –4th edition.
• Fundamentals of fixed prosthodontic; Herbert.T. Shillingburg –3rd edition
• The Glossary of Prosthodontic terms - 9 (April 2017)
• McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH,
Arbree NS. Classification system for partial edentulism. Journal of
Prosthodontics. 2002 Sep 1;11(3):181-93.
• Bentley C, Drake CW. Longevity of restorations in a dental school clinic.
Journal of Dental Education. 1986 Oct 1;50(10):594-600.

72. Thank you
and
have a pleasant day
ahead!!