Prosthodontics oCharacterization is very  Continuity and integrity of the

 Head and Neck Examination important lamina dura

 Oral Examination Mounted Diagnostic Cast  Pulpal morphology
 General Oral Assessment 1. Original state of the patient  Previous endodontic treatment with
 Examination of the Teeth 2. Treatment plan for the patient or without post and core
 Occlusal Examination  Presence of apical disease, root
 Periodontal Examination  Essential in the analysis of patient’s reorption, or root fractures
Head and Neck Examination pre-treatment occlusal relationship  Retain root fragment, radioluscent
 Size  Presenting final treatment plan to the areas, calcifications, foreign
 Shape patient bodies, or impacted teeth
 Symmetry  Diagnostic wax up can be done on a  Presence of carious lesions and
Check for facial profile: duplicate cast to give a preview of the proximity of restorations to the
 Normal anticipated occlusal scheme and dental pulp
esthetic form  Proximity of carious lesion and
 Prognothic o As esthetic as possible
 Retrognathic restoration to the alveolar crest
o If esthetics is not improved, do not do
o In Filipinos, we have a condition FPD, but ortho treatment instead.  Calcular deposit
called Bimaxillary Protrusion.  Check for intermaxillary distance  Oral radiographic manifestations of
Check for abnormalities  Re-contouring on enamel only systemic disease
 Skin and Hair Occlusal Examination Bone Area Index
 Lymph Node Enlargement  Classification of Malocclusion  Teeth that are subjected to greater
o SCM – sternocleidomastoid than normal stress and can provide
 Vertical overlap of anterior teeth
 Cutaneous Ulceration and Scars good information on how bone
 Plane of occlusion
 Pigmentations tissue reacts to additional load
 Vertical dimension of occlusion
 Muscles of Mastication o By the use of Willis Method
o Abutment teeth of a fixed or a
 TMJ Function removable partial denture
o Supraerupted teeth, rotated teeth,
 Envelop of Motion and malignant teeth are cases that o Teeth involved in occlusal
need wax up interference
 Opening of the Mouth
o Crepitus – crackling sound  Evidence of Bruxism  Supraerupted teeth
o Natural teeth will wear off o Teeth receiving greater occlusal
Screening of Malignancy stress because of adjacent teeth
 In Prosthodontics, use two Periodontal Examination
 Gingiva should be coral pink Two Reactions of Bone
mouth mirrors to:  Deposition (+) – no trabeculation;
o Check for any discoloration  Periodontal Pockets – 1-3 mm
 Furcation involvement bone is denser
 Leukoplakia – white  Resorption (-) – has large
o Bone has undergone bone resorption
color trabeculation
 Mucogingival Defects
 Eryhtroplakia – red o Exposure of root surface Impacted tooth
color Radiographic Enterpretation  SOP prior to FPD
o Refer to oral
pathologist for  14 periapical radiograph and 4 Root fragments
biopsy bitewing radiograph  needs to be removed
General Oral Assessment  TMJ radiograph is indicated for  from extraction that was a long
 Oral Hygiene patient dysfunction time ago
 Overall caries activities  Pancreatic radiograph is indicated  how would you know if it is
o Females are more prone to caries for patients with asymmetrical or embedded in the bone or not? –
due to menstruation doubtful lesion palpate the area; if the patient
 Periodontal status Panoramic Radiograph reacts to such pressure applied,
 Quality and quantity of saliva  Excellent in determining pathologic the root fragment is not embedded
Gingival hypertrophy due to Dilantin Sodium in the bone, therefore it should be
 Will undergo gingivectomy prior to fixed
conditions but not adequate for
partial denture definitive examination. removed.
Intraoral Radiograph Condition of Existing Restorations
Examination of the Teeth  Remaining bone support  We need to redo or replace the
 Individual teeth  Root number and morphology restoration with a new one, or
o Carries and recurrent caries  Root proximity better, suggest another type of
o Condition of existing  Quality of supporting bone (bone restoration.
restorations index area)  Amalgams are more superior than
o Decalcifications  Width of the periodontal ligament composite because it lasts longer
o Fractures spaces Quality of Bone
o Erosion, abrasion, or attrition  Area of vertical and horizontal  Bone Index Area can be used as a
o Mobility of remaining natural osseous resorption and furcation parameter to determine the
invasion reaction of the bone to additional
teeth
 Axial inclination of the teeth pressure or load.
 Missing Teeth
(degree of non-parallelism)

Level of Alveolar Bone
 Important in determining how much
of the root is embedded on the
bone
 Answers the question “can it
withstand additional load?”
Root Configuration
 Condition of the root
 Vitality of the tooth
Treatment Planning in FPD
Aims:
 Restoration masticatory function
 Restoration of normal condition in
compliance with esthetic
requirement
 Restoration of ideal phonetics
 Restoration of patient’s comfort
 Restoration of the general health of
the patient
Requirements of an Ideal Artificial Crown
 It should:
o Provide adequate occlusal
contact
o Provide proper proximal
contact
o Satisfy esthetics
o Protect the teeth against
further injury
o Not cause gingival irritation
o Be retentive
o Be properly cemented
o Have correct fit
o Not be over or underextended
Considerations in Treatment Planning
 Patient’s desires, expectations,
and needs
 Systemic and emotional health
 Periodontal factors
 Occlusion
 Esthetics
 Endodontic consideration
 Abutment selection
 Available tooth structure and crown
morphology
 FPD/ RPD
 TMJ and Muscles of Mastication
A. Patient’s Opinion
 Know the patient’s needs,
insights, concerns, and
expectations regarding
treatment outcome
 The desire of the patient should
take priority; yet the dentist
should not deliver substandard
care, claiming “the patient
wanted it”
 Patient’s expectations should
be realistic
 Disappointment with the
outcome of prosthodontics care
are usually a result of poor
communication and lack of
understanding of the limitation
of treatment
Systemic and Emotional Health
 Elderly and debilitated patient
 might not be able to tolerate
the long appointment
routinely required for
extensive fixed
prosthodontics, may be
better served with
 Patients undergoing antibiotic
therapy
 Maximize treatment
performed per appointment
to minimize dentist-induced
bacteremia
 Patients under medications
 Can result to xerostomia and
will unfavorably affect the
outcome of the
 Patients with Bruxism
 May taxes the reparative
capability of the
periodontium and the
serviceability of the
restoration
 Patient with infectious disease
 May require special
precaution in the dental
operatory and laboratory to
prevent cross-contamination
Periodontal Factors
 Inflammation
 Furcation invasions
 Margin placement
 Biological Width
A. Inflammation
 Periodontal disease is common
to patients which exhibit multiple
missing teeth
 Our goal:
 To resolve the inflammation
 To convert periodontal
pocket depths to clinically
normal sulcular depths
 Establish physiologic
gingival architecture
 Provide adequate zone of
attached gingiva
 Adequate oral hygiene
B. Furcation Invasions
 Tooth with furcation involvement
may require special
consideration
 Tooth with furcation involvement
is not likely a good candidate for
abutment
C. Margin Placement
 G.V. Black’s Extension for
Precaution
 Placement of margin in a
“caries immune” areas is
not universally advocated
 All gingival finish lines be
developed are placed
above the gingival crest
for a healthier gingiva
Intraclavicular Margin Placement
 This is not a universal solution to
dental caries
 Indications:
 Esthetics
 Retention requirements
 Location of caries or
preexisting restoration
 Root sensitivity
 Presence of cervical erosions
 Root fracture
Level of Placement of Gingiva
a. Supragingiva
b. Equigingiva
c. Subgingiva
Supragingival Margin
 More susceptible to cement
dissolution
 Shouldn’t be used to patients
with poor oral hygiene
D. Biological Width
 A band of soft tissues
attachment between the base
of the gingival sulcus and the
alveolar crest
 Composition:
 1mm of junctional
epithelium (attachment
epithelium)
 1mm of connective tissue
fibers
Subgingival Preparation
 Prevention of caries formation
 Maximize retention
 Hide unesthetic margins
Contemporary Margin Placement
 Placement of margins to the
gingival crevice to avoid
encroaching on the biological width
 Tooth preparation must terminate
at least 2mm coronal to the
alveolar crest
Conditions that predisposes violation of
the Biological Width:
 Presence of Caries
 Fractured root surface
 Previous restoration place apical to
the gingival crest
  Short clinical crown for added
retention
Dentogingival Attachment
 Damaging will result to:
o Chronic gingival
inflammation
o Pocket formation
o Osseous defect formation as
the bone, fibrous connective
tissues, and epithelium
remodels in an attempt to
reestablish physiologic
attachment
 Alternative Procedures
o Elective crown lengthening
with controlled osteotomy
and apically positioned flaps
o Elective extraction or root
resection or hemisection
Occlusion
 FPD affects occlusion. Do no harm
when restoring occlusal surfaces of
the teeth.
 Occlusal equilibration should be
done to restore the plane of
occlusion
 Rule of BULL (spot grinding):
Buccal Upper
Lingual Lower
Esthetics
 FPD cases should be restored
aesthetically, if in doubt of its
aesthetic potential wax up of case,
should be done prior to preparation
of case
Endodontic Consideration
 Endodontically treated tooth:
o Can be used as FPD and
RPD abutment provided all
remaining tooth structures
can be consolidated and
protected using crown
restoration
o Extremely short root which
cannot be negotiated to
place a post as an abutment
to FPD or RPD is suited for
overdenture
o Pulpless tooth is
contraindicated as abutment
to a cantilever FPD
Elective Endodontic Therapy
 Usually done on supraerupted or
malaligned tooth to improve arch
relationship with post and core to
improve such position and
occlusion
 Tooth that has lost most of the
coronal tooth structure is often
treated endodontically to permit
placement of a post and core for Tooth with conical roots can be
retaining a complete veneer crown used as an abutment for a
short span bridge if all other
 Sagittal Osteotomy – surgical factors are optimal
procedure where ibabalik mo place  Single rooted teeth with
ng occlusion and make putol the evidence of irregular
ridge and ngipin configuration or with some
curvature in the apical third of
Abutment Selection the root are preferable to a
 Vital tooth – endodontically treated tooth with a nearly perfect
tooth can serve well as abutments taper.
provided there is a good seal and  Labiolingually conical root
complete obliteration of the canal (more stable compared to
 Supporting tissues surrounding the circular)
abutment must be reacting and  Apically divergent (apical)
free from inflammation Bone Support
 Should not exhibit mobility since  Ante’s Law
they will be carrying extra load  “The abutment teeth should
(weight of retainer or crown and have a combined
varying degrees of masticatory pericemental area equal to
force) or greater in pericemental
 The root and their supporting are than the tooth or teeth to
tissues should be evaluated for the be replaced.”
following: C. Root Surface Area
a) Crown-root ratio  Measurement of periodontal
b) Root configuration ligament attachment of the root
c) Periodontal surface area to the alveolar bone
A. Crown-root Ratio  Larger teeth with a greater
 Measurement of the length of surface are will be better
the clinical crown to the equipped to handle additional
alveolar crest of the bone stress
compared with the length of the Max
Average
Mandi
Average
root embedded in the bone Area Area
Central Central
 As the level of the alveolar Incisor
204
Incisor
154
bone moves apically, the lever Lateral Lateral
179 168
arm of the portion of the bone Incisor Incisor
increases, and the chances for Canine 273 Canine 268
harmful lateral forces is 1st 1st
234 180
Premolar Premolar
increased
2nd
220
2nd
207
 Acceptable crown-root ratio: Premolar Premolar
1:1 1st Molar 433 1st Molar 431
2nd Molar 431 2nd Molar 426
 Ideal crown-root ratio: 1:2
 Realistic optimum crown-root  For maxillary teeth:
1. 1st Molar
ratio: 2:3
B. Root Configuration 2. 2nd Molar
3. Canine
 An important aspect in the
assessment of abutment 4. 1st Premolar
5. 2nd Premolar
suitability from a periodontal
standpoint 6. Central Incisor
7. Lateral Incisor
 Roots that are broader
labiolingually than they are  For mandibular teeth:
1. 1st Molar
mesiolingually are preferable to
roots which are round in cross- 2. 2nd Molar
3. Canine
section
 Multi-rooted teeth like the 4. 2nd Premolar
5. 1st Premolar
posterior teeth with widely
separated roots will offer better 6. Lateral Incisor
7. Central Incisor
periodontal support than roots
with convergent, fuse, or Periodontal Ligament Area
 Nyman and Ericsson doubted on
conical configuration
the validity of this law
  Clinically lower surface area of
abutment teeth has been equally
supportive provided a good
periodontal health has been
maintained.
Span Length
 Relative deflection
 Directly proportional (span
legth)3
 Inversely proportional
(occlusogingival thickness)3
Direction of Forces
 The dislodging forces on a FPD
retainer tend to act in a mesiodistal
direction, as opposed to the more
common faciolingual direction of
forces on a single restoration
 Preparation should be modified
accordingly to produce greater
resistance and structural durability
Secondary Abutment
 Overcomes several problems
 Unfavorable crown-root ratio
 Long spans
 Secondary abutment should be
comparable to primary in terms of:
a. Root surface area
b. Favorable crown-root ratio
c. Retainers
Arch Curvature
 When pontics lie outside the
interabutment axis line – act as a
lever arm, which can produce a
torqueing movement
 Mainly of pointed in the anterior
 Secondary retention (K) must
extend a distance from the
primary interabutment axis equal
to the distance that the pontic
lever arm (P) extends in the
opposite direction
Health of Periodontium
 Healthy periodontal tissues are a
prerequisite for all fixed
restoration
 Adequate crown to bone ratio –
inadequate periodontal health
turns prognosis to poor in long
run where it turns to be worst in
case inadequate crown to bone
ratio
 Fixed prosthesis has been
successful even in the presence
of inadequate crown to root ratio
after periodontal tissues have
been returned to excellent health
and long-term maintenance has
been ensured
Endodontic Consideration
 Teeth in which pulpal health is
slightly doubtful also should be
endodontically treated before the
irritation of fixed prosthesis
 If unhealthy pulp tissues to be
deleterious it will jeopardize the
prognosis of the given fixed
prosthesis
 Endodontically treated teeth are
more favorable for giving a fixed
prosthesis
Pier Abutments
 An edentulous space can occur
on both sides of a tooth, creating
a tone, freestanding pier
abutment
 There is different faciolingual
and intrusive force on different
teeth in different arch
 You need to put a stressbreaker
 It has potential to produce
unfavorable leverage and an
unseating effect on the terminal
retainers, this may cause
fracture on the cement seal and
cement washout in a distinct
possibility
 If a long span fixed prosthesis is
given on this create huge stress
on the terminal abutment and
pier abutment, will act as a
fulcrum and failure of prosthesis
 Different veins regarding:
 Rocking of retainer
 Bending of retainer
 Tension between
abutment and retainer
 Intrusion of retainer on
abutment
 Two alternatives are there to
minimize the stress, i.e.
a. Non-rigid connector
 Broken stress
mechanical union of
retainer (dovetail
keyway) and pontics
(T-shaped key)
b. Cantilever (first premolar
pontic)
 Adequate
periodontal support
Third Molar Abutments
 Early loss of a mandibular first
molar with mesial tilting and
drifting of the second and third
molars
 Impossible to achieve common
path of insertion
 In an attempt to do excessive
preparation has to be done or
mesially tilted third molar will not
allow seating of prosthesis
Treatment Modality
 Extract the third molar and
upright the tilted second molar
orthodontically
 Fixed appliance
 Premolars and the
canine are barded and
lied to a passive
stabilizing wire
 A helical uprighting
spring inserted into a
tube on the banded
molar
 Activated by hooking it
over the wire on the
anterior segment
If orthodontic correction is impossible:
 Modified preparation design
 Proximal half crown: ½
crown
 Non-rigid connector on
distal aspect of the
premolar retainer
compensates for the
inclination of the tilted
molar
Telescopic Crown
 Used as a retainer on the distal
abutment
 A full crown preparation with
heavy reduction is made to
follow the long axis of the tilted
molar
 Caner coping is made to fit the
tooth preparation
 The proximal half crown that will
serve as the retainer for the fixed
partial denture is fitted over the
coping
Canine Replacement – Fixed Partial
Denture
 Difficult – it often lies outside the
interabutment axis
 Maxillary more difficult than
mandible due to labially and
lingually acting force respectively
 No fixed partial denture
replacing a canine should
replace more then one additional
tooth
Cantilever – Fixed Partial Denture
 FPDs in which only one side of
the pontic is attached to a
retainer
 Long-term prognosis of the
single abutment cantilever is
poor
 Vertical – tipping
  Horizontal forces – rotation of
abutment teeth
 3 unit FPD, resist forces much
better since the teeth have to be
moved bodily rather than merely
rotated or tipped
 Essential requirement for
abutment teeth:
a. Lengthy roots with a
favorable configuration
b. Long clinical crowns
c. Good crown-root ratio
d. Healthy periodontium
Maxillary Lateral Incisor – Cantilever Fixed
Partial Dentures
 No occlusal contact on the
pontic in either centric or lateral
excursions
 Canine must be used as an
abutment – root configuration of
a central incisor makes it an
undesirable cantilever abutment
 Solo abutment – only if it has
long root and good bone support
 Metallic rest on the distal of the
central incisor to prevent rotation
of the pontic
First Premolar – Cantilever Fixed Partial
Dentures
 Best if occlusal contact is limited
to the distal fossa
 Full veneer retainers are
required on both the second
premolar and first molar
 Excellent bone support
Molars
 When there is no distal abutment
present
 Pontics prerequisite
 Possess maximum
occlusogingival height to
ensure a rigid prosthesis
 Light occlusal contact with
absolutely no contact in
any excursion
 When the pontics loaded
occlusally, the adjacent
abutment tends to act as a
frenulum, with a lifting tendency
on the farthest retainer
 Minimize the leverage effect,
 The pontic should be kept
as small as possible
 More nearly representing
a premolar than a molar
Root Proximities
 Adequate clearance must be
present between the roots of the
proposed abutments to permit
the development of physiologic
embrasures
 If undesirable root proximity is  Phase 4
present, then it is not a good  Construction of FPD
candidate for abutment  Reinforcement of
Common Path of Insertion education and motivation
 Abutment teeth must be of patient
prepared with common path of  Phase 5
insertion for all retainers when a  Post insertion care
rigid design is employed  Periodic recall (annual)
 If the long axis of the tooth is  Reinforcement of
converge or diverge from education and motivation
parallelism by more than 25 of patient
degrees, tooth preparation
becomes more difficult
 A non-rigid connector has been
suggested as a solution
 The female component of the
non-rigid connector is commonly
placed within the confines of the
normal tooth contours on the
distal surface of the intermediate
abutment
Treatment Planning
 Phase 1
 Collection and evaluation
of the diagnostic data,
including a diagnostic
mounting and the analysis
and design of the
diagnostic cast
 Immediate treatment to
control pain and infection
 Biopsy or referral of
patient
 Development of education
and motivation of patient
 Phase 2
 Removal of deep caries
and placement of
temporary restoration
 Periodontal treatment
 Extirpation of inflamed or
necrotic pulp tissues
(endodontic treatment)
 Construction of interim
prosthesis for function or
esthetics
 Occlusal equilibrium
 Reinforcement of
education and motivation
of patient
 Phase 3
 Preprosthetic surgical
procedure
 Definitive endodontic
procedure
 Definitive restoration of
teeth
 FPD
 Reinforcement of
education and motivation
of patient