Fixed Prosthodontics Design

by
Dr. Mennatallah Mohie
• The need to replace missing teeth is obvious to the patient when the
edentulous space is in the anterior segment of the mouth, but it is equally
important in the posterior region.
• Dental arch is in a state of dynamic equilibrium, with the teeth supporting
each other. When a tooth is lost, the structural integrity of the dental arch
is disrupted, and there is a subsequent realignment of teeth as a new state
of equilibrium is achieved. Teeth adjacent to or opposing the edentulous
space frequently move into it . Adjacent teeth, especially those distal to the
space, may drift bodily, although a tilting movement is a far more common
occurrence.
• If an opposing tooth intrudes severely into the edentulous space, it is not
enough just to replace the missing tooth. To restore the mouth to complete
function, free of interferences, it is often necessary to restore the tooth
opposing the edentulous space. In severe cases, this may necessitate the
devitalization of the super-erupted opposing tooth to permit enough
shortening to correct the plane of occlusion; in extreme cases, extraction
of the opposing tooth may be required.
Selection of Prosthesis Type
• Implant supported fixed partial denture.

• Tooth-supported Fixed partial denture.

• Removable partial denture.

• When choosing the type of prosthesis to be used in any given situation,
biomechanical, periodontal, esthetic, and financial factors, as well as the
patient’s wishes have to be considered.
• Could combine two types in the same arch, such as a removable partial
denture and a tooth-supported fixed partial denture.
• Combining teeth and implants in the support of the same fixed partial
denture is not recommended.
• In treatment planning, there is one principle that should be kept in mind:
treatment simplification. There are many times when certain treatments
are technically possible but too complex.
• It is important to narrow the possibilities and present a recommendation
that will serve the patient’s needs and still be reasonable to accomplish. At
such times, the restorative dentist, or prosthodontist, is the one who
should manage the sequencing and referral to other specialists.
I. Removable Partial Denture
• A removable partial denture is generally indicated for long edentulous
spaces (greater than two posterior teeth, anterior spaces greater than four
incisors, or spaces that include a canine and two other contiguous teeth ie,
central incisor, lateral incisor, and canine; lateral incisor, canine, and first
premolar; or the canine and both premolars).
• An edentulous space with no distal abutment will usually require a
removable partial denture.
• Multiple edentulous spaces, each of which may be restorable with a fixed
partial denture, nonetheless may call for the use of a removable partial
denture because of the expense and technical complexity.
• Bilateral edentulous spaces with more than two teeth missing on one side
also may call for the use of a removable prosthesis instead of two fixed
prostheses.
II. Conventional Tooth-Supported
Fixed Partial Denture
• The usual configuration for a fixed partial denture uses an abutment
tooth on each end of the edentulous space to support the prosthesis.

• If the abutment teeth are periodontally sound, the edentulous span is

short and straight, and the retainers are well designed and executed,
the fixed partial denture can be expected to provide a long life of
function for the patient.
III. Resin-Bonded Tooth-Supported
Fixed Partial Denture
• The resin-bonded fixed partial denture is a conservative restoration that is
reserved for use on defect-free abutments in situations where there is a single
missing tooth, usually an incisor or premolar.
• Because it requires a shallow preparation that is restricted to enamel, the resin-
bonded fixed partial denture is especially useful in younger patients whose
immature teeth with large pulps are poor candidates for endodontic free
abutment preparations.
• Tilted abutments can be accommodated only if there is enough tooth structure to
allow a change in the normal alignment of axial reduction. This is limited by the
need to restrict most of the reduction to enamel.
• The resin-bonded prosthesis cannot be used for replacing missing anterior teeth
where there is a deep vertical overlap. Reduction deep into the underlying dentin
of the abutment teeth will be required in this situation, so a conventional fixed
partial denture should be employed.
Indications:
1-Replacement of missing anterior teeth in children and adolescents.

2-Short edentulous span. (One or two anterior teeth with mesial and distal
abutments can generally be replaced with a resin-bonded FDP.)

3-Unrestored abutments. (For bonding to anterior teeth, large multiple

restorations or a restoration involving the incisal edge would limit the resulting
bond and the abutment’s mechanical integrity.)

4-Single posterior tooth replacement.

5-Significant clinical crown length. (Retention is dependent on an adequate
surface area of enamel and clinically sufficient crown length)

6-Excellent moisture control

Contraindications:
1-Parafunctional habits.

2-Long edentulous span. (Long edentulous spans should be avoided because they
place excessive force on the metal retention mechanism.)

3-Restored or damaged abutments.

4-Compromised enamel. (Retention is dependent on an adequate surface area of

enamel therefore sound enamel is crucial for good bonding and success.
Compromised enamel on abutment teeth as a result of hypoplasias,
demineralizations, or congenital problems e.g., amelogenesis imperfecta or
dentinogenesis imperfecta adversely affects resin bond strength)

6-Deep vertical overlap. (The presence of a deep vertical overlap prevents adequate
enamel reduction and can place excessive forces on resin-bonded FDPs)
• A cantilever pontic design for resin-bonded FDPs is recommended. This has been
successful in the anterior region and is particularly useful for replacement of lateral
incisors, for which cantilevers from either the central incisor or canine are possible.
The choice is based on providing the best retention and the best esthetics.
• The most effective way to replace a missing mandibular incisor with a resin-bonded
FDP is an FDP cantilevered from the adjacent tooth.
• Advantages:
• The preparation is simplified.
• The problems associated with the occlusion and differing mobilities of abutment
teeth, which tend to place excessive stresses on the cement and retentive features,
are avoided. Cantilevered resin-bonded FDPs work well on mobile teeth.
• If a cantilevered resin-bonded FDP with a single abutment becomes loose, it falls out
of the mouth.
• Risk of caries under loose retainer is eliminated because a cantilevered bridge is
either bonded or falls out.
 IV.Implant-Supported Fixed
Partial Denture
• Fixed partial dentures supported by implants are ideally suited for use
where there are insufficient numbers of abutment teeth.
• Implant-supported fixed partial dentures can be employed in the
replacement of teeth when there is no distal abutment.
• A single tooth can be replaced by a single implant, saving defect-free
adjacent teeth from the destructive effects of retainer crown preparations.
• Entire arch can be replaced by an implant-supported complete prosthesis.
• Implants may be a better choice for fixed partial denture abutments if
prospective tooth abutments would require endodontic therapy with or
without dowel cores, periodontal surgery, and possibly root resections to
support a long-span, complex, and expensive prosthesis.
V. No Prosthetic Treatment
• If a patient presents with a long-standing edentulous space into which
there has been little or no drifting or elongation of the adjacent or
opposing teeth, the question of replacement should be left to the
patient’s wishes.
• If the patient perceives no functional, occlusal, or esthetic
impairment, it would be a dubious service to place a prosthesis.
• This in no way contradicts the recommendation that a missing tooth
routinely should be replaced. The teeth adjoining an edentulous
space usually move, but they do not always move.
• Factors affecting design of FPD:
1. Abutments Evaluation.
2. Retainers selection dictated by tooth form, position, oral hygiene
and caries.
3. Pontic choice controlled by pontic space, hygiene and esthetics.
4. Type of opposing occlusion.
5. Esthetic considerations.
6. General health condition of the patient.
Abutment Evaluation:
• When designing and fabricating a fixed partial denture, the forces that
would normally be absorbed by the missing tooth are transmitted, through
the pontic, connectors, and retainers, to the abutment teeth.
• If a tooth adjacent to an edentulous space needs a crown because of
damage to the tooth, the restoration usually can double as a fixed partial
denture retainer.
• Whenever possible, an abutment should be a vital tooth. However, a tooth
that has been endodontically treated and is asymptomatic, with
radiographic evidence of a good seal and complete obturation of the canal,
can be used as an abutment. However, the tooth must have some sound,
surviving coronal tooth structure to ensure longevity.
• Teeth that have been pulp capped in the process of preparation should not
be used as fixed partial denture abutments unless they are endodontically
treated.
1-Crown/root ratio:

• The optimum crown-root ratio for a tooth to be used as a fixed partial

denture abutment is 2:3; a ratio of 1:1 is the maximum ratio that is
acceptable for a prospective abutment under normal circumstances.

• The crown-root ratio alone is not an adequate criterion for evaluating

a prospective abutment tooth.
2- Root configuration

• Roots that are broader labiolingually than they are mesiodistally are
preferable to roots that are round in cross section.
• Multirooted posterior teeth with widely separated roots will offer
better periodontal support than roots that converge, fuse, or
generally present a conical configuration.
• The tooth with conical roots can be used as an abutment for a short-
span fixed partial denture if all other factors are optimal.
• A single-rooted tooth with evidence of irregular configuration or with
some curvature in the apical third of the root is preferable to the
tooth that has a nearly perfect taper.
3-Periodontal Ligament Area

• Ante’s Law by Johnston et al “The root surface area of the abutment

teeth had to be equal to or surpass that of the teeth being replaced
with pontics.”
• It is possible for fixed partial dentures to replace more than two
teeth, the most common example being anterior fixed partial
dentures replacing the four incisors.
• Any fixed prosthesis replacing more than two teeth should be
considered a high risk.
Biomechanical Considerations
• In addition to the increased load placed on the periodontal ligament
by a long-span fixed partial denture, longer spans are less rigid.
Bending or deflection varies directly with the cube of the length and
inversely with the cube of the occlusogingival thickness of the pontic.

• Longer pontic spans also have the potential for producing more
torquing forces on the fixed partial denture, especially on the weaker
abutment.
Added Abutments:
• A secondary abutment could sometimes be used to overcome the
problems created by unfavourable crown/root ratio or long spans.
They must have certain criteria inorder to strengthen the FDP.
1. Must have at least as much root surface area and as favorable a
crown/root ratio as the primary (adjacent to the edentulous space)
abutment it is intended to bolster. As an example, a canine can be
used as a secondary abutment to a first premolar primary
abutment, but it would be unwise to use a lateral incisor as a
secondary abutment to a canine primary abutment.
2. The retainers on secondary abutments must be at least as retentive
as the retainers on the primary abutments.
Arch curvature
• When pontics lie outside the inter-abutment axis line, the pontics act
as a lever arm, which can produce a torqueing movement.
• Eg.replacing all four maxillary incisors with a fixed partial denture, and
it is most pronounced in the arch that is pointed in the anterior. This
can best be accomplished by gaining additional retention in the
opposite direction from the lever arm and at a distance from the
intera-butment axis equal to the length of the lever arm.
• The first premolars sometimes are used as secondary abutments for a
maxillary four-pontic canine-to-canine fixed partial denture.
Examples of suitable potential designs for
some hypothetical cases
• F-F bridge on 1 and 2
• Fixed-supported on 2 and 1(inlay retained
on 2 and full coverage in 1)
• Cantilever bridge on 2and 3
• Spring cantilever on 4 and 5
• Cantilever bridge on 3
• Fixed-supported on 3 and 1 using inlay
retainer on 1
• F-F on 3 and 1
• Spring cantilever on 4 and 5
• F-F on 1,2 and 4
• F-F on 3 and 5
• Cantilever bridge on5 and 6 if they
are already restored (use canine
guided occlusion to prevent
excessive forces on pontic)
• F-F bridge on 4 and 6
• F-F on 5 and 7
• F-F on 1 and 2
• F-F on 1 and 3 or 1, 1 and 3 if
central incisor has bone recession
• F-F on 2 and 4
• If 2 is week, remove it and use 1, 1 and 4
• If canine space is very narrow, cantilever
bridge can be used on 4 and 5
• F-F on 3 and 5
• If 5 and 6 are restored , can make
cantilever bridge on 5 and 6
• F-F on 4 and 6
• Fixed supported using 4 for support
• F-F on 5 and 7
• As lower 6
• F-F on 1 and 3
• F-F on 2,3 and 2,3
• F-F on 3 and 6
• F-F on 4 and 7
• F-F on 1 and 4
• F-F on 1,2 and 5
• F-F on 2,1 and 3
• F-F on 2 and 2
• F-F on 3 and 6
• F-F on 4 and 7
• F-F on 3 and 3
• Or on 3,4 and 3,4 depending on
arch curvature
• F-F on 3 and 3