Diagnosis related to fixed prosthesis

Diagnosis → It is the procedure of collecting data & information

through different channels → to obtain proper line of treatment.
The diagnosis procedure should:
i)Identify the Challenges
ii)Determine their cause
iii)Give us an idea about how to overcome these challenges to achieve
success

Elements of proper diagnosis:

• History →Medical.
→Dental.
• T.M.J & occlusal evaluation.
• Clinical examination.→ general examination
→ extra- oral examination
→intra-oral examination
• Diagnostic cast analysis.
• Full mouth radiographic evaluation.
• Photography and videos.

I] History:
It is accomplished through:
i) The use of questionnaire form
ii) Patient conversation
iii) Combination

A) Personal history:
1- Name : to develop a good relation with the patient

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 2- Age: ideal patient for constructing a fixed prosthesis
between 20-50 years…………………why???
Below 20 years → large pulp horns → more prone for pulp
exposure during preparation
+ passive eruption of the gingiva will affect the esthetic of
the fixed restoration as the cervical margin will be shown.

After 50 years → Most of the teeth is periodontally affected +

insufficient physical fitness + presence of systemic diseases
3- Sex :
- Male → concerning more for function
- Female → concerning more for esthetic
4- Occupation: some jobs may be accompanied with bad
habits….
5- Address: indicate the social level of the patient
6- Telephone number: for proper communication with the
patient.

(B) Medical History:

• It is accomplished through the use of a comprehensive health
questionnaire form.
• Importance of medical history:
→To determine any special precaution to be taken before the start of
treatment.
→To determine any necessary pre-medication.
→To determine whether the treatment is postponed or eliminated because
of the patient's psychological or physical health.

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e.g:
i) Allergic reaction to → drugs e,g penicillin.
→ local anesthetics → anaphylactic shocks
→ Ni allergy ( metal dermatitis).
→ polyether impression material allergy
→ Acrylic resin allergy
ii) Hypertension & coronary heart diseases.
→ Blood pressure should be controlled first.
→ No epinephrine should be used.

iii) Rheumatic fever pre-medicated with

History of bacterial endocarditis. Amoxicillin. OR
Valvular dysfunction. Erythromycin. OR
Congenital heart inflammation. Clindamycin.

iv) Patient receiving anti-coagulants → physicians consultants.

v) Diabetic patient → periodontal breakdown or abscess formation.

Therefore well-controlled diabetic patient may receive routine dental
treatment.

vi) Epileptic patients → anxiety should be avoided.

→ no long fatiguing appointments.
→ sedative administration.

vii) Infectious diseases should be known for protective measures

e.g → HIV
→ Hepatitis.

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viii) Patient receiving radiation therapy on head and neck → dry mouth
(xerostomia) → ⇑ recurrent caries.
Moreover, dry mouth can occur due to→ Drugs taken for treatment of
hypertension and auto-immune disease.

ix)Patients with cardiac pacemakers.

i) Any electric pulp tester or root canal apex locator should be
avoided.
ii) In cases of gingivectomy or crown lengthening, electrosurgery
should be avoided.
x)Systemic disease with oral manifestation……….. ( pregnancy tumor/
gingival enlargement from Dilantin therapy/ gastro-esophageal reflex ⇒⇑
acidity ⇒ enamel erosion)

(B) Dental History:

i) Patients chief complaint:
• The patient should express in his own words the exact nature of the
complaint.
(1)Discomfort → Pain / Sensitivity / Swelling.

• For pain, the following should be noted; its location, character,

severity and frequency. Also, is it the first time to occur? What
factors precipitating it (ex. Hot, cold or sweets). Is it localized or
diffuse?

(2)Function → difficulty in speech.

→ difficulty in mastication.

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 (3)Social → bad odour.
→ bade taste.
(4)Esthetics → fractured teeth.
→ Discoloration.

ii) Previous treatment & patient attitude:

Which gives idea about → patient's level of dental awareness.
→ expected patient's cooperation.
→ Patient personality

iii) Patient's expectation from treatment:

Special attention should be given to the esthetic effect anticipated by the
patient.
e.g if patient need perfect esthetics→ therefore no metal display should
occur. i.e use all ceramic restoration instead of metal ceramic restoration
especially in females.

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►Dental charting
§ It is important for every patient as it reveals important information
about the condition of the teeth and facilitates treatment planning
§ e.g pocket depth/ caries index/ extracted tooth.
§ Clinic Software:
§ It facilitate patients appointments.
§ It keeps records of digital Images Before-During-And After dental
Treatment.
§ It also has programs that allow Patient Education.
§ Adjust the financial issues/salaries/total income/profits.
§ Laboratory stuffs

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II] T.M.J & occlusal evaluation:
(a)T.M.J →No clicking.
→No crepitation.
→No limiting of movement (average opening >50mm)
Limitation of mouth opening may cause some difficulties in
many dental procedures.
procedures
→The maximum mandibular lateral movement of about
12 mm is considered normal.
→ Deviation during closure may be due to
i) TMJ pathology
ii) Presence of premature contacts

(b) Muscle of mastication:

• Muscle pain is usually associated with para-functional jaw activity
related to stress or faulty occlusion.
• Evidence of pain in trigger zone should be evaluated before
starting treatment ⇒ it indicate muscle fatigue due to continuous
contraction ⇒ denoting decrease blood flow ( anoxia).

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 Masseter muscle Temporalis muscle
►EMG (Electromyography)
It is a device specifically designed to accurately measure the rest and
function performance of the muscles.

(c) Occlusal evaluation

- The patient’s occlusion must be evaluated to determine if it is healthy
enough to allow the fabrication of such restoration.
- Prosthodontic restoration should be designed to maintain this normal
occlusal relationship.
- If the occlusion is dysfunctional, decision will be made either to correct
the occlusion before restoration placement, or placing the restoration to
correct the occlusion.

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Computerized occlusal analysis device:
n It is a powerful diagnostic tool which is an easy and more
accurate in occlusal analysis.
n It consists of: an ultra-thin, reusable sensor which shaped to fit
the dental arch. This sensor is inserted into the sensor handle,
which connects into the USB port of computer.

When the patient bite down on the sensor, occlusal forces and occlusal
timing (from first contact to last) can be monitored on the computer
screen.

Advantage :
- Improve diagnoses and decrease treatment time
-It can views, on screen, a patient sliding from CR position into a lateral
excursion.
- It locates occlusal interferences and determines the relative force on
each interference.

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- It helps to find the most traumatic occlusion which is important
implantation in order to reduce the risk of implant failure
n Computerized occlusal analysis device together with the
electromyography evaluate the continuous relationship
between occlusion and muscle function.

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III] Clinical examination:
a- General examination:
- It includes the patient’s general appearance, skin color and vital signs
(temperature – blood pressure).

b- Extra-oral examination:
- Midline position and facial asymmetry
- Cervical lymph nodes
♦ Examination of lips:
- The patient is observed for teeth visibility during normal and
exaggerated smiling. Smile analysis is important when anterior fixed
dental prosthesis is considered.
- Some individuals show only their maxillary teeth with a considerable
gingival tissue during an exaggerated smile. Others may not show the
gingival third of upper central incisors. (High /low lip line)
- The extend of smile depends on the length and mobility of the upper lip
and the length of the alveolar process.

● Negative space: It is a dark space between upper and lower teeth which
appears during laughing. The harmony of this negative space is disrupted
in cases of; missing teeth, diastemas and fractured or poorly restored
teeth, which should be corrected.

-Buccal corridor…………………….

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Digital Intra-oral Camera
The intra-oral camera is a tiny video camera the size
of a pen designed to capture images within the mouth
and display them on a nearby computer monitor.

§ Reasons to Use an Intraoral Camera

-Increased level of diagnosis due to magnification .
- Increased communication level between dentist and patient .
- Increased treatment plan case acceptance .

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c) Intra oral examination:
Should include → Oral hygiene.
→ Soft tissue examination.
→ Abnormal habits
→ Prospective abutments.
→ Edentulous ridge.

(1) Oral hygiene:

• Indicated from the DMF index.
• The 1st thing which is observed intra-orally is the patients oral
hygiene whether → good
→ moderate
→ poor.
• If→ good oral hygiene → conservative treatment modalities can
be done e.g partial coverage restoration or laminate veneers.
→ moderate oral hygiene → full coverage restoration will
provide relatively better prognosis.
• In case of poor oral hygiene → we should perform scaling and
root curettage + proper oral hygiene measures → to modify the
oral hygiene condition to ensure long term success of the fixed
restoration.

(2) Occlusion and para-functional habits:

• Examination of any abnormal habits should be identified.
• e.g → pipe smokers → monolithic restoration should be used.
→ Bruxism → monolithic restoration should be used.

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 → Nail biting / pencil biting → monolithic restoration should be
used.
• Occlusal evaluation should be carried out for:
Wear facet (localized / or generalized)
→ Presence of any premature contact.
→ Existence & amount of anterior guidance.
→ Pattern of occlusion →canine guidance.
→ group function.
Unilateral balanced occlusion ( group function): 20-25%
●This type of occlusion is seen when all the facial ridges of the teeth on
the working side contact their opposing , while those on the non
working side do not
●i.e on the working side ⇒ canine and post canine teeth are in
contact with their opposing.
while on the non working side ⇒ no contact exist between teeth.

Mutually protected occlusion ( canine guided ): 70-75%

●This type of occlusion occurs when the posterior teeth protect the
anterior teeth in centric position
●The anterior teeth protect the canine and the posterior teeth during
the protrusive movement.
●While the canine protect the incisors and posterior teeth during lateral
movements.
Limitations for canine guidance
1) Root canal treated canine ⇒ possibility of crown root
fracture

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 2) Post-crowned canine ⇒ possibility of longitudinal root
fracture
3) Canine as bridge pontic ⇒ cement failure on the
retainers

• Type of bite:
i) Deep bite
ii)Open bite ( which may need orthodontic treatment)
iii) Cross bite

(3) Edentulous area:

• Should include → Form.
→ Texture of mucosa.
→ Color of mucosa.
→ Dimension.
→ Space problems anteriorly due to presence of diastema
→ Amount of bone loss ( vertical and/or horizontal)

(4) Prospective abutment:

• Should include:
i) Carious lesion:
- All carious lesions are detected ⇒ After excavation of the carious
lesion the amount of remaining tooth structure is evaluated.

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- Relationship between intra-coronal restoration and extra-coronal
restoration should be evaluated …….discuss.

- The old filling in the prospective abutment should be removed to detect

any recurrent caries.

-Pulp capped teeth should not be used as an abutment for F.P.D ⇒

therefore R.C.T should be done.

-Teeth that have been received repeated previous restorations may have
compromised pulpal health .

- Carious lesions can be early detected by caries detection dyes, fiberoptic

trans-illumination or laser fluorescence.

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ii) Pulp vitality. :
iii) Pulp vitality. → by electric or thermal pulp testing.
-The tested tooth should be clean /dry /and isolated
-Cold test: either ice in carpool (ice stick)/ or ethyl chloride spray
-Hot test : hot burnisher / or hot gutta percha cones
-The vitality test should be carried in the middle/cervical part of the
tooth i.e away from gingiva to avoid false sensation from the
soft tissue and away from the incisal surface to avoid false sensation
from partially vital pulp horn.

iv) Mobility:
- Tooth mobility is examined by applying force bucco-lingually
between two dental instrument handles (never by hands).
- Miller’s classification for tooth mobility:
◦ Grade 1= first distinguishable sign of movement greater than
normal.
◦ Grade 2= total movement of 1mm ⇒ can be used for F.P.D
depending on the case …..HOW???
i) If short span and the mobility is initially caused by
defective occlusal contacts ⇒ then may be used with an
added abutment.
ii) If long span ⇒ can not be used
◦ Grade 3= total movement > 1mm in any direction and /or is
depressible ⇒ extraction.

v) Periodontal condition
● Pocket depth. ( measured by periodontal probe)
●Gingival recession.

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 ●Furcation involvement.
●Epithelial attachment level

●Biological width⇒ it is the distance between the base of the

gingival sulcus and the alveolar bone crest ( 2mm)
The integrity of the biological width should not be violated by:
by the patient ⇒ by performing proper oral hygiene
by the clinician ⇒ by avoid excessive placement of finish line
Subgingivally
by the ceramist ⇒by constructing precise restoration.

●Gingiva biotype ⇒ Thick fibrotic gingival

⇒ Thin fragile gingival ⇒ which is more prone
For recession therefore sub-gingival finish line is
not indicated

vi) Coronal defects :

● Discoloration:
Intrinsic Discoloration:
Causes;
- Pulp death.
- Improper root canal treatment.
- Dental flourosis.
- Amalgam tattooing.
- Internal resorption ( pink tooth).
- Tetracycline stain.

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Treatment: bleaching, porcelain laminates or full coverage restoration.
N.B: the success of bleaching depend on:
i) Severity of discoloration
ii) Duration of discoloration
iii) Deepness of discoloration

Extrinsic discoloration:
Causes:
Smoking / coffee / tea / calculus.
Treatment: scaling / polishing / micro-abrasion / macro-abrasion.

●Fracture:
The extent of tooth fracture determines the type of restoration.

●Areas of attrition / abrasion / erosion.

- Attrition: It is a physiologic process that occurs with age due to tooth
contact during normal function.
- Abrasion: It is a mechanical loss of tooth structure usually due to
incorrect tooth brushing.
- Erosion: It is a chemico- mechanical loss of tooth structure due to;
Exposure to chemicals as lemon and alcohol.
Gastric vomiting .

● Crown morphology long / short / malformed:

Hutchinson teeth / peg shaped lateral ⇒ usually require full coverage
● Rotation .
●Drifting
●Axial inclination.

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IV] Diagnostic cast analysis:
•Criteria of good diagnostic cast:
→ Accurate.
→ No bubbles or nodules.
→ Mounted in centric occlusion on a semi-adjustable articulator.
• Importance of diagnostic cast reveal:

(1) Distribution & dimension of edentulous span:

Mesio-destal length → to assess liability to flexability.

Occluso-gingival dimension → for pontic design.
Arch curvature → to assess whether the pontics will act as lever arm on
abutments.
Distribution & extent → to assess whether R.P.D or F.P.D will be .
Constructed.

(2) Type of bite & occlusal pre-maturities:

•Type of bite → anterior or posterior cross bite should
→ deep over bite. be properly
→ over-jet assessed

•Occlusal prematurities as well as wear facets should be evaluated.

N.B one of the main advantages of diagnostic cast is to determine the
type of bite from lingual side

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 (3) Occlusal discrepancies & the need to establish a new
occlusal plane:
• With the aid of x-ray → over-erupted teeth could be easily evaluated
→ & amount of reduction needed could be determined.

(4) Change in teeth axial inclination for a common path of

insertion:
•Problems to attain a common path of insertion could be evaluated with
the aid of dental surveyor & x-ray → to determine the amount of
reduction needed without endangering the pulp.

(5) Abutment form / size / & mal-position:

•To evaluate the necessary retentive means → select the proper type of
retainer.

(5) Planning the suitable bridge design.

(6) Trial tooth preparation & waxing up prior treatment:
i.e Diagnostic wax-up to enable the patient to see the problems
encountered in the clinical treatment. (Blue print)
It facilitate treatment planning through:
i) It provide the ability to change the contour/alignment
ii)Widen or narrowing the pontic occlusal table
iii)Add or remove teeth
iv)Increase or decrease the mesio-distal dimension of certain abutment
teeth
N.B: also composite mock up can be fabricated on the diagnostic cast.

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 (7) Fabrication of vacuum formed Template to fabricate provisional
(8) Fabrication of special tray ( custom tray)

Digital pantography:
- It is a fully functional 3-dimensional computerized
pantographic registration system.
- It is used to capture both, static and dynamic occlusal
records for articulator programming and diagnostic set-ups.

Advantages:
§ Full mouth Reconstruction (Cosmetic and Implant).
§ Diagnostic Wax-ups.
§ Articulator programming for TMJ derangements and
functional disorders
§ Accurate and all records can be kept permanently.

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V] Radiographic examination:

Intra-oral films. Extra-oral films

Panoramic films.

Periapical Bite-wing Occlusal

●Digital radiography systems

-Rely on an electronic detection of an x-ray-generated image that is then
electronically processed to produce an image on a computer screen.
- Advantages of digital radiography
i)Reduced radiation of the patient.
ii) Speed of obtaining the image
iii)Enhancement of the image
iv)Computer storage
v)Does not require chemical processing.

●Cone beam technology……………………………………..

●Radiographic examination for → abutment teeth.

→ edentulous area.
→ remote area.

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[A] Abutment teeth:
(1) Coronal portion:
[Together with clinical examination]
i) Carious lesion.
ii) Local deformative defects.
e.g amelogenesis imperfecta.

(2) Pulp portion:

[Together with clinical examination]
i) Size of pulp chamber → necessary in case of over-eruption &
mesial tilting.
ii) In non-vital teeth whether endodontically treated or not.

To evaluate the perfection of endo-treated teeth.

Size / direction / number of root canals to determine its

suitability for endodontic treatment.

(3)Root portion:
X-ray is necessary to evaluate:
a) Crown / Root: → Discussed later.
b) Root configuration → Discussed later.
c) Periodontal surface area →Discussed later.

(4)Periapical area:
Checked for → any periapical prosthesis.
→ continuing of lamina dura.

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(5)Thickness of periodontal membrane:
Normal thickness → 0.18-0.27mm
→ normal functioning teeth.

Narrow thickness → functionless teeth.

Therefore if construction of F.P.D → severe pain.

Therefore P.d is 1st constructed to bring this side to .

function & normal p.m thickness.

Then fixed P.D should be constructed.

Wide thickness → indicate diseased periodontium & tooth mobility.

[B] Edentulous area:

x-ray to detect → remaining roots.
→ residual infection.
→ any lesion.
[C] Remote area:
To detect → slow growing infection (cyst) which may affect the final
prognosis of bridge.

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VI) dental photography and videos:
By using special DSLR cameras ,Macro-lens, and proper flashes
Advantages:
- Cases documentation
- Comparing before and after progress
- Useful for lab communication
- Useful for patient motivation in aesthetic cases

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● Treatment planning for replacement of missing teeth:
• Replacement of missed teeth may be done by one of the following:

R.P.D Tooth supported implant supported

Fixed partial denture fixed partial denture.

Conventional Resin-bonded
F.P.D F.P.D
• Factors affecting selection of prosthesis type:
1. Bio-mechanical consideration.
2. The prospective abutment.
3. Esthetic requirement.
4. Patient's desire.
5. Financial factors.
6. Clinician's skill.
7. Laboratory support.
8. Patient's motivation & expected cooperation.

Successful treatment planning is based on proper

identification of the patient needs. If an attempt is
made to have the patient conform to the ideal
treatment plan rather than having the treatment
plan conform to the patient needs, therefore
success is unlikely.
Treatment simplification is an essential requirement
without compromising the prognosis.
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 [1] Bio-mechanical consideration:

(1)A decision to remove a tooth:

•Questionable tooth of poor prognosis should be carefully assessed.
•advantages & disadvantages of retaining such tooth should be
properly diagnosed because sometimes extraction might be the best
choice.

(2)The edentulous span:

(a) Distribution:
● Edentulous space with no distal abutment will require R.P.D.
Other alternatives are implant supported F.P.D which
depend on → bone density
→ ridge
→ age.

Cantilever F.P.D
With extreme caution.
● Multiple edentulous spaces → R.P.D
● Bilateral edentulous spaces with more than 2 missing teeth on one
side→ R.P.D

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 (b) Length:
•↑length of the edentulous span →↑↑flexing. (Bending)
Bending length³
Bending 1
thickness³ (occluso-gingival pontic thickness)
i.e if single tooth pontic span deflected a certain amount → 2 teeth pontic
span will bend 8 times.
→ & 3 teeth pontic span will bend 27 times.

While:
If a pontic with a given occluso-gingival dimension bend a certain
amount → if its thickness ↓ by ½ → it will bend 8 times.
● Clinical sequelae of bridge bending:
i) Fracture of porcelain veneer. Failure
ii) Connector breakage. of the long
iii) Retainer loosening. span fixed
iv) Unfavorable soft tissue response P.D

●HOW TO DECREASE BENDING????????????

1-Use alloy with high yield strength e.g base metal alloys.
2-Increases occluso-gingival dimension of pontics and connectors
without affecting the gingival health(modified ridge lap)
3-Use an added abutment
4-↑ the resistance against bending forces by utilizing grooves.
5- Use of full coverage retainer
6- Sub-gingival finish lines.
7- Use metallic pontics/ or veneered pontics i.e no porcelain on the
occlusal surface.
8- Avoid over convergence/ avoid over occlusal reduction.

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● Clinical implication of bridge flexing in treatment plane:
i) Avoid replacing 3 missing post teeth with a F.P.D especially in
mandibular arch.
ii) Avoid constructing a F.P.D on short mandibular teeth.
Therefore the other alternative treatment for long edentulous span are:
Implant supported F.P.D
Which depend on → bone density
→ broad ridge.
→ favourable occlusion.
R.P.D

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( c) Arch form:
•Arch form affect the amount of stresses occurring on F.P.D ……. How?
In case of pointed arch anteriorly → pontics which lie outside the
interabutment axis line will act as lever arm → torquing movement on
the supporting abutment.

Therefore to overcome this problem→ the resistance arm ( i.e in the

opposite side of the inter-abutment axis) should be at least equal to lever
arm.
i.e added abutment is mandatory.
e.g in case of missing 2 1 1 2 → the 2 premolars on either side 4 4

are added to the 2 canines as added abutments.

d) Pier abutment:

●Problems occur:
i) Pier abutment will act as a fulcrum, therefore the transmitted forces
will cause failure between the pier tooth & its respective retainer.
ii) Looseness of the retainer.
iii) Marginal leakage → caries.
►Solution:
a)The use of non-rigid connector
i.e → precision attachment on the distal aspect of the
→ occlusal rest pier abutment…..WHY???

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Because when posterior tooth is subjected to occlusal forces → it tends to
tilt mesially , therefore this mesial movement seat the key into the key-
way.
b)Cantilever the first premolar pontic if periodontal support is adequate.
c) Implant for 4,6 can be used. (ideal treatment option)

[2] The prospective abutment:

(a) Pulpal condition:
i) Vital sound tooth → is an ideal abutment.

ii) Carious tooth caries should be removed.

If pulp involvement occur → endo. ttt

Doubtful pulpal condition → endo. ttt

The remaining sound tooth structure should be evaluated as it affect

→ possible mean of retention.
→ selection of type & material of restoration.

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iii)Endodontically treated abutment → if perfect i.e asymptomatic / good
seal & complete obturation therefore can be used as an abutment.
(b) Over-erupted teeth:
The over-erupted teeth should be adjusted to the normal occlusal plane.
→ If amount of over-eruption is within enamel → selective reshaping
(enameloplasty) followed by fluoride application.
→ If amount of over-eruption is within enamel+ dentin →crown
Construction/ or onlay.
→ If amount of over-eruption is within enamel+ dentin+ pulp → endo ttt
+ crown.
⇒ Orthodontic intrusion ( may accompanied with loss of vitality/or root
resorption)
⇒If severe over-eruption ⇒ extraction

(2) Short crown:

• Abutments with short clinical crowns → problems during construction
of F.P.D.
Therefore
(a) Consideration taken in bridge design:
i) Fixed –fixed bridge is the most indicated type.
ii) Full coverage retainers with added means of retention are to
be used.
iii) Pontic & connectors should be with considerable occluso-
gingival height →to ↑resistance to bending.

(b) Consideration taken in tooth preparation:

i) Establishing slight convergency → to ↑ retention.
ii) Extend F.L subgingivally → to ↑ occluso-gingival height.
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 iii)Avoid over occlusal reduction.
iv)Use added means of retention.

(3)Mesially tilted crown:

● Problems occur → difficult to obtain a common path of insertion.
Therefore the line of ttt depend on:
i) The degree of tilting (25°)
ii) If the 3rd molar is present or not

Therefore different treatment modalities clould be done:

i) Orthodontic uprighting of the tilted abutment.

ii)If the 3rd molar is present & slightly tilted with the 2nd molar→ slight
reduction on its mesial side (on enamel) + fluoride application →
construction of fixed bridge.

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iii) If heavy contact exist between 2nd & 3rd molar →1/2 crown is
indicated but distal surface should be intact and caries free.

iv)Non-rigid connector on the distal aspect of the premolar retainer.

v)Telescoping crown & coping can be constructed as a retainer on

the distal tilted abutment.

(C) Root portion & periodontal condition:

(1) Crown / root ratio:

•Definition: It is the ratio between the linear length of that part of
tooth above level of alveolar crest of bone to that part of root
embedded in bone.
•Optimum C/R → 2/3

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 ●Significance of C/R:
i) The root portion (resistance arm) should be greater than
crown portion (force arm) → to resist leverage action of
occlusal forces.
ii) Minimum C/R → 1/1...
But under the following condition:
Favorable opposing occlusion (i.e artificial prosthesis)
Normal occlusion pattern.
Abutment teeth are periodontally healthy.
Highly motivated patient.
Favorable root configuration i.e with divergent, broad
labio- lingually.

N.B: C/R changes throughout life → by apical movement of the

alveolar bone level e.g by aging / periodontal disease.

(2) Root shape & angulation:

→Broad roots bucco-lingually, withstand applied load than narrow ones.
→Multi-rooted posterior teeth with divergent roots withstand applied
load better than converging one.
→Single rooted tooth with elliptic cross section withstand applied load
better than those of circular ones.

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(3) Periodontal ligament surface area:
●Ante's law. (1926):
The sum of periodontal area of abutment teeth should be equal to or
greater than that of the tooth / teeth to be replaced.
Therefore according to Ante's law:
i) missing 6 → 3 units bridge 5 x 7 is safe.
A1 + A3 ≥ A2

ii) missing 5 & 6 → 4 units bridge 4 x x 7 can be acceptable as far

as no bone loss & periodontal membrane surface area of 4 & 7
are equal to those of 5 & 6.
A1 + A4 ≥ A2 + A3

iii) missing 4,5,& 6→ 5 units bridge 3 x x x 7 is risky.

♥ In 1982 → Nyman & Erricsson reported that Ante's law should be

considered as a " clinical guide line " in bridge design.
Because there are many factors which modify ante's law:
a) Well motivated patients with proper plaque control.
b) Favorable opposing occlusion (i.e artificial prosthesis.)
c) ↓ in mesio-distal length of edentulous span due to bodily
movement of teeth.

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III) Esthetic requirement:
1) The lip line:
• It may be:
a) Normal lip line
b) Low lip line
c) High lip line
• The high lip line is consider an esthetic risk factor → as during
smiling the cervical area and a large part of the gingiva is seen.
• Therefore how the position of the lip line affect our treatment
plan????
It can affect the treatment plan in 2 main aspects:
a) Position of finish line:
• In case of high lip line → the finish line should be place
subgingivally in case of porcelain fused to metal restoration
• But take care the finish line should not be placed so deep
gingivally → otherwise tearing of the epithelial attachment
→ violating the biological width.
• The biological width is the space between alveolar bone crest
and the epithelial attachment → it is 2.04 mm in length .
• Many researches point out that subgingival finish line is
accompanied by gingival recession especially with thin
gingival biotype.
• So whenever possible the finish line should be placed supra-
gingivally unless there is cervical caries/ or short teeth

b) Type of restoration:
• In case of porcelain fused to metal restoration → the
finish line could be placed supragingivally to avoid the

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 possibility of gingiva recession but with the use of
shoulder porcelain ( butt joint margin).
• The other alternative is the use of all-ceramic restoration.

2) Space problems:
• In case of wide space exist for missing upper central due to
presence of diastema → the following treatment options
are available:
a) Constructing fixed-fixed bridge with palatal loop
connector to preserve the central diastema.
b) implant placement and preserve the diastema
c) in case of patient demand to close the diastema →
orthodontic treatment / optic illusion / or selective
preparation of the abutment and distribute the space
discrepancy on the retainers and the pontic
N.B:Take care the most acceptable line of treatment
should be done after diagnostic wax up.

• In case of vertical bone resorption:

Placing the pontic in the available space will result in a
longer tooth appearance → therefore the following treatment
option should be considered:
a) Bone graft
b) Optic illusion.
By recontouring of the cervical part of the pontic more
lingually → creating more shorter tooth appearance

N.B:
• Other treatment options:
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 i)Pink porcelain to simulate gingival tissue is not
recommended for hygienic purpose
ii)The pontic is shaped to simulate normal crown and root
with emphasis on C.E.J ⇒ the root can be stained to
simulate exposed dentin ( esthetically not accepted)

● Developing the treatment plan:

1) Special points of diagnosis.
2) Sequencing of mouth preparation.
Evaluation of oral hygiene & occlusal analysis.
Oral surgery.
Periodontal treatment
Orthodontic ttt.
Endodontic ttt.
Operative ttt.
Fixed & removable prosthesis.
3) Rationale for proposed ttt plane.
4) Prognosis & its justification.

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