History taking and clinical examination

 Fixed prosthodontic treatment involves the replacement and

restoration of teeth by artificial substitutes.

 It is focus to restore function, esthetic, and comfort.

 Making the correct diagnosis is prerequisite to formulating an

appropriate treatment plan.

 Diagnosis is simply defined as the procedure of collecting data

and information through different channels as that a proper line of
treatment could be proposed.

Element of proper diagnosis:

There are five elements to a good diagnostic workup in preparation for
fixed prosthodontic treatment:

1. History (dental and medical).

2. TMJ/occlusal evaluation

3. Intra oral examination.

4. Diagnostic cast analysis.

5. Full mouth radiographic evaluation.

1. History:

i. Personal details:

The patient’s name, address, phone number, sex, occupation,

work schedule, and marital and financial status are noted.

[1]
 ii. Dental history:

This should be focused on:

 Patient’s chief complaint.

 Previous treatments and patient’s attitude.

 Patient’s expectation’s from treatment.

Chief complaint:

Should be recorded, preferably in the patient’s own words.

A screening questionnaire is useful for history taking.

Chief complaints usually fall into one of the following four

categories:

 Comfort (pain, sensitivity, swelling)

 Function (difficulty in mastication or speech)
 Social (bad taste or order)
 Appearance (fractured or unattractive teeth or restorations,
discoloration).
Previous treatments and patient’s attitude

This gives an insight into the patient’s level of dental awareness and
the expected patient’s cooperation.

Patient’s expectations from treatment.

iii. Medical history:

An accurate and current general medical history should include

any medication the patient is taking. As well as all relevant medical
conditions.

If necessary, the patient’s physician can be contacted for

clarification.

Good medical history is important as:

 To determine any special precautions to be taken before the

initiation of treatment.
 Some elective treatment might be eliminated or postponed
because of the patient’s physical or emotional health.
[2]
  Any necessary premedication.

The following classification may be helpful:

1. Conditions affecting the treatment methods

(e.g., any disorders that necessitate the use of antibiotic

premedication, any use of steroids or anticoagulants, and any
previous allergic responses to medication or dental materials).

2. Conditions affecting the treatment plan.

(e.g., previous radiation therapy, hemorrhagic disorders, extremes

of age and terminal illness).these can be expected to modify the
patient’s response to dental treatment and may affect the
prognosis

3. Systemic conditions with oral manifestations.

For example, periodontitis may be modified by diabetes,

menopause, pregnancy, or the use of anticonvulsant drugs, in
cases of gastroesophageal reflux disease, bulimia, or anorexia
nervosa, teeth may be eroded by regurgitated stomach acid.

4. Possible risk factors to the dentist and auxiliary personnel.

e.g, (pts who are suspected or confirmed carriers of hepatitis B,

AIDS, or syphilis).

Dental offices should practice ‘’universal precautions’’ to ensure

appropriate infection control.

[3]
2. Examination:
 An examination consists of the clinician’s use of sight, touch
and hearing to detect conditions outside the normal range.
 It is critical to record what is actually observed rather than
making diagnostic comments about the condition. E.g ,swelling,
redness, and bleeding on probing of gingival tissue should be
recorded, rather than gingival inflammation (which implies a
diagnosis).

General examination:
 The patient general appearance, gait and weight are assessed.
 Skin color is noted for signs of anemia or jaundice, vital signs such
as respiration, pulse, temperature, and blood pressure are
measured and recorded.

Extra oral examination:

 Facial asymmetry small deviations from normal may hint at serious

underlying conditions.

 Cervical lymph nodes are palpated.

 TMJs and muscles of mastication.

Temporomandibular joints:

 TMJ should be healthy with no evidence of clicking, crepitation or

limitation of movement on opening, closing or lateral shifting.

 A maximum mandibular opening resulting in less than 35mm of

interincisal movement is considered to be restricted (average
opening is greater than 50 mm).

 The maximum lateral movements of the pateint can be measured

(normal is about 12 mm).

 Midline deviation on opening and/or closing is recorded.

[4]
 Muscles of mastication:

 Muscle pain is usually associated with parafunctional jaw activity

related to stress or faulty occlusion.

 Evidence of pain in either muscles or TMJ should be properly

evaluated before starting treatment.

Lips:

 Tooth visibility during normal and exaggerated smile can be critical

in fixed prosthodontic treatment planning, especially for margin
placement of certain metal -ceramic crown

 More than 25% do not show the gingival third of the maxillary
central incisors during an exaggerated smile.

 The negative space (dark space) between the maxillary and the
mandibular teeth is assessed during the examination.

 Missing teeth, diastemas, and fractured or poorly restored teeth

disrupt the harmony of the negative space and often require
correction.

Intra oral examinations:

 It can reveal considerable information concerning the condition of

the soft tissues, teeth and supporting structures.The tongue, floor
of the mouth, vestibule cheeks, and hard and soft palates are
examined, and any abnormalities are noted.

 This should be carried in a systematic manner to include the

following:

 Oral hygiene and caries index.

 Abnormal habits.

 Edentulous ridge.

 Occlusion.

 Prospective abutment.

[5]
1. Oral hygiene and caries index:

The first thing to be observed intraorally is the:

• Patient’s oral hygiene.

• Amount and areas of plaque and calculus.

• General periodontal condition.

Any existing periodontal disease must be treated before any

definitive prosthodontic treatment is undertaken.

2. Abnormal habits

Examination for any abnormal oral habits should be identified (e.g.,

Pipe smokers, pencil biting, and bruxism).this would affect the

prosthesis type, retainer and bridge design.

3. Edentulous ridge

 No. and dimensions of edentulous spans should be recorded.

 Examine form, texture, and color of ridge mucosa.
 Dimensions of edentulous span are a critical deciding factor in
the treatment planning.
4. Occlusion:

Occlusal evaluation should be carried out for:

 Type of occlusion (canine protected or group function).

 Wear facets (localized or widespread).
 Presence of any premature contacts.
 Lateral and protrusive contacts (Cuspal interferences in
eccentric movements).
 The degree of vertical and horizontal overlap of the teeth is
noted.
 On protrusive movement any contact on posterior teeth is
noted.
 When the patient is guided into lateral excursive movement,
the presence or absence of contacts on the nonworking and
working sides is noted.
 Teeth that are subjected to excessive loading may develop
varying degrees of mobility.

[6]
  Initial tooth contact.
The relationship of teeth in both centric relation and the maximum
intercuspation should be assessed. If all teeth come together
simultaneously at the end of terminal hinge closure, the centric
relation (CR) position is said to coincide with the maximum
intercuspation (MI).

If initial contact occurs between two posterior teeth, the

subsequent movement from the initial contact to the MI position is
referred to as a slide from CR to MI

 General alignment.
The teeth are evaluated for crowding, rotation, supraeruption,
spacing, malocclusion, and vertical and horizontal overlap. Teeth
adjacent to edentulous spaces often have shifted position slightly.
Small amounts of tooth movement can significantly affect fixed
prosthodontic t treatment (tipped teeth and supraerupted teeth)

 Jaw maneuverability
The ease with which the patient moves the jaw and the way it can
be guide through hinge closure and excursive movements should
be assessed, because these factors are a good guide to
neuromuscular and masticatory function.

5. Prospective abutments

The clinical evaluation of the propose abutments should be

performed in a systemic manner for the following:

 Carious lesion (localized or widespread).

 Condition of the pulp (vital or non-vital).

 Mobility

 Periodontal condition (gingival condition, pocket depth, gingival

recession, furcation involvement should be recorded).

 Coronal defects: examined for

 Color variation (extrinsic or intrinsic)

[7]
  Tooth surface loss (attrition,erosion,abrasion).
 Crown morphology (long,short,malformed).
 Rotation and overlapping.
 Supra and infraeruptions.
 Axial inclination.

3. Diagnostic cast analysis:

Accurate diagnostic casts transferred to a semi adjustable

articulator are essential in planning fixed prosthodontic treatment.

Criteria of good diagnostic casts:

1. Accurate reproduction of both arches.

2. No bubble or nodules on occlusal surfaces.

3. Mounted in CR on a semiadustable articulator by means of a face-

bow and occlusal wax records.

Purposes:
1. Reveal aspects of the occlusion not always easily detectable
intraorally. (The relationship of the lingual cusps in the occluded

2. Distribution and dimensions of edentulous span:

 Mesio-distal length (to assess liability to flexing).

 Occluso-gingival dimension (for pontic design).

 Arch curvature (to assess whether the pontics will act as a

lever arm on the abutments).

3. Type of bite and occlusal prematurities.

The type of bite whether being anterior or posterior, cross bite,

deep overbite or over jet could be properly assessed. Occlusal
prematurities as well as wear facets, their number, size and
location could be properly evaluated.

[8]
 4. Occlusal discrepancies.

Over erupted teeth can be easily spotted and evaluated and the
amount of reduction needed could be determined

5. Changes in teeth axial inclination for a common path of insertion

Together with radiographic evaluation the amount of reduction

needed without endangering the pulp could be properly guaged

6. Abutment teeth form, size and malposition considering the

necessary retentive means.

7. Diagnostic waxing procedures allow evaluation of the eventual

outcome of proposed treatment.

8. Trial tooth preparation prior to initiating the treatment.

9. Construction of Provisional restorations

4. Radiographic examination:

Radiographs provide essential information to supplement the clinical

examination. Detailed knowledge of the extent of bone support and
the root structure of standing tooth is essential for establishing a
comprehensive fixed prosthodontic treatment plan.

Intra-oral films:

 Periapicals
 Bitewings
Extra-oral films:

 Panoramic

Panoramic films provide useful information about:

 The presence or absence of teeth.

 In assessing third molars and impactions.
 Evaluating the bone before implant placement.
 Screening edentulous arches for buried root tips.
 Providing an overview of the calcified structures and sinuses.

[9]
 Intra oral radiographs are utilized to evaluate:

a. Teeth and investing structures.

b. Edentulous area.
c. Remote area.

a. Radiographic examination of the Teeth and investing structures:

1) Coronal portion.

Any carious lesions both on the unrstored proximal surfaces and

recurring around previous restorations are noted.
Any local formative defects (hypo plastic pits, amelogenesis
imperfect)

2) Pulp portion:

 vital teeth(size of pulp chamber)

 Non vital teeth (whether endodontically treated or not).

3) Root portion:

Radiographic evaluation of the root and supporting tissues for:

a. Crown-root ratio.
b. Root configuration.
c. Periodontal surface area.

Crown/root C/R ratio:

 It is a ratio between the length of tooth occlusal to the alveolar

crest of bone compared with the length of root embedded in the
bone.
 The optimum crown-root ratio for a tooth to be utilized as a fixed
partial denture abutment is 2:3.
 A ratio of 1:1 is the minimum ratio that is acceptable for
prospective abutment.

[10]
 Root configuration.

• Broader roots labiolingual are preferable than those rounded cross

section.

• Multirooted widely separated roots provide better support than

converging, fusing roots.

Periodontal surface area:

 It has been stated that ‘’ the sum of the periodontal membrane

surface area of abutment teeth should be equal or larger than the
tooth/teeth to be replaced. ‘’

 This statement was referred as ‘’Ante’s Law’’

 Ante’s Law should be considered as A clinical guideline in bridge

design.

4) Peri apical area:

 Continuity of the lamina Dura.

 Any Periapicals pathosis.

5) Thickness of periodontal membrane:

 Widening of periodontal membrane should be correlated with

occlusal prematurities or occlusal trauma.

 Continuity of lamina dura and it’s uniformity in width.

[11]
b. Edentulous area:

The following are to be detected radiographically:

 Remaining roots.
 Residual infections.
 Any lesion.
It is important to be detected since cemented bridge might interfere
with surgical interference with necessity of bridge removal.

c. Remote area:

It is necessary to consider examination of remote areas in order to

detect any existing slow growing infection which might affect the final
prognosis.

[12]
 Treatment planning
 Treatment planning consists of formulating a logical sequence of
treatment designed to restore the patient’s dentition to good
health, with optimal function and appearance.

 It should be presented in written form and should be discussed in

detail with the patient.

I. Identification of patient needs:

 Successful treatment planning is based on proper identification of
the patient’s needs.

 Treatment is necessary to accomplish one or more of the following

objectives:

1. Correction of existing disease.

2. Prevention of future disease

3. Restoration of function.

4. Improvement of appearance.

II. Treatment planning for single tooth restoration:

Intracoronal restorations:

When sufficient coronal tooth structure exists to retain and protect

a restoration under the force of mastication, an intracoronal
restoration can be employed.

i. Glass ionomer.

ii. Composite resin.

iii. Amalgam.

iv. Metal inlay.

[13]
 v. Ceramic inlay

vi. MOD Onlay.

Extra-coronal restorations:

If insufficient coronal tooth structure exists to retain the restoration,

an extra-coronal restoration, or crown, is needed. It may also be
used to correct the occlusion or improve esthetics.

 Partial veneer crown.

 Full metal crown.

 Metal ceramic crown.

 All ceramic crown.

 Resin veneer.

 Ceramic veneer.

 Fiber-Reinforced Resin.

III. Treatment of tooth loss:

Decision to remove a tooth.

The decision to remove a tooth is part of the treatment planning

process and is made after assessing the advantages and
disadvantages associated with retention of the tooth.
A decision about replacing a missing tooth is best made at the time its
removal is recommended, rather than months or years after the fact.

Consequences of removal without replacement:

a. Supraclusion of the opposing tooth or teeth.

b. Tilting of the adjacent teeth.
c. Loss of proximal contact.

[14]
 d. Disturbances in the health of the supporting structures and the
occlusion.

IV. Treatment planning for the replacement of missing

teeth:

Selection of the prosthesis type:

Replacement of missed teeth may be accomplished by one of three

prosthesis types:

1. Removable partial denture.

2. Tooth-supported fixed partial denture.
 Conventional fixed prosthesis.
 Resin-bonded fixed prosthesis.
3. Implant supported fixed prosthesis.
4. No prosthetic treatment.

Removable partial denture:

Indications:

1) Edentulous spaces greater than two posterior teeth,anterior

spaces greater than four incisors.
2) Spaces that include a canine and two other contiguous teeth.
3) An edentulous space with no distal abutment.
4) Multiple edentulous spaces.
5) Bilateral edentulous spaces with more than two teeth missing on
one side.

[15]
 6) Periodontally weakened primary abutments.
7) An insufficient number of abutments for FPD.
8) Severe loss of tissue in the edentulous ridge to restore the space
both functionally and esthetically.

Conventional tooth-supported fixed partial denture:

 When a missing tooth is to be replaced, a FPD is preferred by

the majority of patients.
 If the abutment teeth are periodontally sound, the edentulous
space is short and straight, and the retainers are well designed
the FPD can be expected to provide a long life of function.
 There should be no gross soft tissue defect in the edentulous
ridge.

Resin-bonded tooth –supported fixed partial denture:

Indications:

1) Caries-free abutment teeth.

2) Mandibular incisors replacements.
3) Maxillary incisors replacements.
4) Single posterior tooth replacements.
5) Young patients with favourable occlusion.

Implant-supported fixed partial denture:

Indications:

1. Insufficient numbers of abutment teeth.

2. Inadequate strength in the abutments to support a
conventional FPD.
3. Patients unable to wear RPDs.
4. When there is no distal abutment
5. Availability of alveolar bone (quality and quantity).
6. In single tooth replacement with sound adjacent teeth.
7. Long span edentulous area.

[16]
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 and there is no functional occlusal and esthetic
impairment.

Factors affecting the selection of prosthesis type:

1) The biomechanical considerations.

2) The prospective abutment.
3) Esthetic requirements.
4) Patient’s desires.
5) Financial factors.
6) Clinician’s skills.
7) Laboratory support.
8) Patient’s motivation and expected cooperation.

The Biomechanical Considerations:

The edentulous span:
 Distribution.
 Length
 Arch form.

i. Distribution :

 An edentulous space with no distal abutment.

 Multiple edentulous spaces.
 Bilateral edentulous spaces with more than two missing teeth
on one side.
All these situations require a removable partial denture or
implant restoration.

ii. length:

› In addition to the increased load placed on the periodontal

ligament by a long-span fixed partial denture, longer spans are
less rigid.
› All fixed partial dentures, long or short, flex to some extent
when subjected to load. The longer the span the greater the
flexing.

[17]
› Bending or deflection varies directly with the cube of the length
and inversely with the cube of the occlusogingival thickness of
the pontic.
› Compared with a FPD having a single tooth pontic span, a two-
tooth pontic span will bend 8 times as much. A three-tooth
pontic will bend 27 times as much as a single pontic.
› A pontic with a given occlusogingival dimension will bend eight
times as much if the pontic thickness is halved.

[18]
[19]
Clinical sequalea of bridge flexing:

 Excessive flexing under occlusal load may cause failure of a long-

span FPD.
 It can lead to:

1. Fracture of porcelain veneer.

2. Connector breakage
3. Retainer loosening.
4. UN favourable soft tissue response.

Clinical implication of bridge flexing:

 Replacing three posterior teeth with a fixed partial denture usually

exhibits unfavourable prognosis especially in the mandibular arch.
 Constructing a long span fixed partial denture on short mandibular
teeth is expected to have a very disappointing prognosis.

Alternative treatment modalities:

 An implant supported fixed partial denture.

 Removable partial denture.
 To minimize bending produced due to long and/or thin edentulous
span, it is advisable to:
I. Increase the occlusogingival length of the pontics and
connectors.
II. Use an alloy of higher yield strength, such as nickel-
chromium
III. Double abutments are sometimes used as a mean of
overcoming problem created by long span. A secondary
abutment must have at least as much root surface area
and as favourable a crown-root ratio as the primary
abutment.

[20]
 III. Arch form (curvature):

 Arch curvature has its effect on the stresses occurring in a FPD

constructed in the anterior segment, especially in the upper
anterior region.
 When pontics lie outside the interabutment axis line, the pontics
act as a lever arm, which can produce a torquing movement on the
supporting abutment.
 This is a common problem in replacing all four maxillary incisors
with a FPD, and is it is most pronounced in the arch that is pointed
in the anterior.
 Some measure must be taken to offset the torque. This can best
be accomplished by gaining additional retention in the opposite
direction from the lever arm and at a distance from the
tnterabutment axis equal to the length of the lever arm
 It was suggested to involve the two 1st premolars together with the
canines in the replacement of missing four maxillary incisors to
gain excellent retention.

The Prospective Abutment:

Informations concerning the proposed abutments obtained through a

comprehensive examination are utilized to assess and evaluate its
suitability in treatment planning.

A. The pulpal condition:

[21]
 After the pulpal health has been assessed by evaluating its
response to thermal and electric testing, the tooth condition might
be as follows:

I. Vital sound (unrstored) abutment tooth:

An unrstored, caries-free tooth is an ideal abutment. It can be

prepared conservatively for a strong retentive restoration with
optimum esthetics.
In an adult patient, an unrstored tooth can be safely prepared
without jeopardizing the pulp as long as the design and technique
of tooth preparation are wisely chosen.

II. Carious abutment tooth:

After caries removal as well as all the undermined weak enamel,

assessment of the remaining sound tooth structure and the pulpal
condition should be performed.
The existing situation would influence the line of treatment in the
following aspects:
 Selecting the most suitable type of restorative material
and the necessary retentive means needed.

 Doubtful pulpal condition or those teeth that have been

pulp capped should not be used as FPD abutments
unless being endodontically treated. There is too great
risk that these abutments might need later on an
endodontic treatment which would jeopardize the
overall success of treatment.

III. Endodontic treated abutment teeth.

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 successfully as an abutment.

Clinical consideration in treatment planning:

 Before deciding an endodontic treatment, proper assessment

should be done to evaluate whether the tooth is restorable or not.

[22]
 Tooth position whether strategic or not (distal abutment).

 Post and cores are usually constructed to compensate for the lost
coronal tooth structure (retention problems).
 Failures do occur on teeth with short roots or little remaining
sound coronal tooth structure.

B. Coronal variations and tooth alignment:

i. Over-erupted teeth:

The diagnostic cast is a valuable adjunct in the precise

gauging of the amount of tooth over eruption.
 To restore the dentition to complete function, free of
interferences, over erupted teeth should be adjusted to
the normal occlusal plane.
 In severely super erupted opposing teeth, Intentional
endodontic therapy might be necessary to permit
enough shortening to correct the occlusal plane.

ii. Short crowns:

Careful selection of the bridge design, with the most suitable

retentive retainers and types of pontics should be highly
stressed on in case of using abutments with short clinical
crowns.

Considerations taken in bridge design and clinical procedures:

a. FFB is the most indicated type.

b. Full coverage retainers with additional retentive means
(groves, boxes) are to be used.
c. Establishing relative slight convergence.
d. Extend the finish line more cervically.
e. Occlusal reduction of posterior teeth should be
prepared to receive retainer with occlusal metal
coverage.

[23]
 f. Pontics and connectors should be of considerable
occluso-.gingival. Dimension to enhance resistance to
bending.
g. Crown lengthening procedure (if it is indicated)

iii. Mesially tilted second molar:

Early loss of 1st mandibular molar would create a problem if the

space is ignored, the second molar may tilt Mesially. It then
becomes difficult or impossible to make a satisfactory FPD,
because the positional relationship no longer allows for parallel
paths of insertion without interference from the adjacent teeth.

Different treatment modalities:

1) If the tilting is slight, the problem can be remedied by restoring or

recontouring the mesial surface of the third molar, the over tapered
second molar preparation should include additional retentive
means as facial and lingual grooves.

2) If the tilting is severe, the up righting the tilted abutment

orthodontically is considered the treatment of choice.
.
3) A proximal (mesial) ½ crown can be used as a retainer on the
distal abutment.

Conditions favouring the construction of the mesial half crown:

a. Intact (untouched) sound distal surface of the 2nd

molar.
b. Patient is highly motivated to clean his teeth.
c. No marked discrepancy between the marginal ridges of
the 2nd and 3rd molars.

4) A non rigid connector on the distal aspect of the premolar retainer

to compensate for the inclination of the tilted molar

This is performed by constructing a full crown preparation on

the molar with its path of insertion with the long axis of the

[24]
 tilted molar, and a full coverage crown on the premolar with
its distal surface accommodates a keyway for the nonrigid
connector.

5) A telescope crown and coping can be constructed 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. An inner coping is made to fit the tooth
preparation, and the proximal half crown that will serve as the
retainer for the FPD is fitted over the coping. this restoration allows
for total coverage of the clinical crown while compensating for the
discrepancy between the paths of insertion of the abutments.

C. Root portion and periodontal condition:

 The supporting tissues surrounding the abutment teeth should be

healthy and free from any inflammation before any fixed partial
denture to be constructed.
 The following aspects should be evaluated:
1. Crown-root ratio.
2. Root shape and angulations.
3. Periodontal ligament surface area.
[25]
1. Crown –root ratio

Definition: It is a ratio between the lengths of tooth occlusal to

the alveolar crest of bone compared with the length of root
embedded in the bone.
The optimum crown-root ratio for a tooth to be utilized as a fixed
partial denture abutment is 2:3.

Significance of the C/R:

 The root portion (embedded in the alveolar bone) is considered

the supporting tooth part resisting the leverage action of the
occlusal forces.
 The root portion (resistance arm) should be greater than the
crown portion (force arm).

 The C/R is liable to changes throughout life (aging or periodontal

disease).
 A C/R of 1:1 is the minimum acceptable ratio to be used but under
the following conditions:

a. Favourable opposing occlusion(artificial prosthesis or mobile

Periodontally involved teeth).
b. Normal occlusal pattern.
c. Abutment teeth with good periodontal condition.
d. Highly motivated patient.

[26]
 e. Favourable root configration.

2. Root shape and angulations:

The root shape and its angulations should be highly considered.

 Broader roots labiolingualy than they are mesiodistally are

preferable to root that are round in cross section.
 Multirooted posterior teeth with widely separated roots offers better
periodontal support than the converging or fusing ones.
 A single-rooted tooth with evidence of irregular configuration is
preferable to the tooth that has a nearly perfect taper.

3. Periodontal ligament surface area:

In 1926 (Ante) suggested that the periodontal ligament surface

area of the abutment teeth should be equal to/or larger than that of
the tooth or teeth to be replaced.
Thus based on this concept, missing one tooth would be safely
restored with three Units Bridge if all other conditions are
favourable. On the other hand, restoring two missed teeth with four
units bridge is considered as an acceptable approach as far as no
periodontal disease, and the abutment teeth have root surface
areas approximately equal to those of missing teeth.

[27]
 However, according to Ant’s law, missed three posterior teeth are
considered a high risk to be replaced using only two abutments
(against ant’s law)

Factors modifying Ant’s law:

1. Well motivated patients and highly proficient in plaque control.

2. Opposing occlusion (sound natural dentition or artificial removable
prosthesis.
3. Decrease in mesiodistal length of edentulous span due to bodily
movement of teeth.

Special problems:

1. Pier abutments

Edentulous spaces can occur on both sides of a tooth, creating a

lone, freestanding pier abutment.
Physiologic tooth movement,arch position of the abutments, and
the retentive capacity of the retainers can make a rigid five-unit

[28]
 FPD a less than ideal plan of treatmen.because of these
movements can creat stresses on the abutment teeth as well as
between the retainers and abutment preparations.forcs are
transmitted to the terminal retainers as a result of the middle
abutment acting as a fu
lcrum,causing failure of the weaker retainer.the loosened retainer
will leak around the margin, and the caries is likelly to become
extensive before discovery.
The use of nonrigid connector (a broken stress mechanical union
of retainer and pontic) has been recommended to reduce this
hazard.
The location of the stress-breaking device is important it is usually
placd on the distal side of the middle abutment.
Implant restoration shold be considered as alternative treatment
option. Compound bridge (F.F.B. + cantilever bridge) should be
considered as well.

2. Tilted molar abutments

As discussed before

3. Canine –replacement fixed partial denture:

FPDs replacing canines can be difficult because the canine often

lies outside the interabutment axis.
The prospective abutments are the lateral incisor and the first
premolar (the weakest teeth).
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 A FPD replacing a maxillary canine is subjected to more stresses
than that replacing a mandibular canine, since forces are
transmitted outward (labially) on the maxillary arch, against the
inside of the curve (its weakest point). On the mandibular canine
the forces are directed inward (lingually), against the outside of the
curve (its strongest point).
Any FPD replacing a canine should be considered a complex FPD.
Implant restoration replacing the canine should be considered.

4. Cantilever fixed partial dentures

FPDs in which only one side of the pontic is attached to a retainer

are referred to as cantilevered. An example would be a lateral
incisor pontic attached only to a metal ceramic retainer on a
canine.
The long-term prognosis of the single abutment cantilever is poor.
A cantilever induces lateral forces on the supporting tissues, which
may be harmful and lead to tipping, rotation, or drifting of the
abutment. These harmful forces are resisted by

 Multiple abutment teeth.

 There should be no occlusal contact on the pontic in either
centric or lateral excursions.
 There should be a rest on the mesial of the pontic against a
rest preparation on the distal of the central incisor to prevent
rotation of pontic and abutment.
 The mesial aspect of the pontic can be slightly wrapped
around.
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  Implant restoration and RPD should be considered.

5. Replacing multiple anterior teeth

Special considerations in this situation include problems with

appearance and the need to resist laterally directed tipping forces.
The four mandibular incisors can usually be replaced by a simple
FPD with retainer on each canine. If a lone incisor remains, it
should be removed because its retention can jeopardize the long
term result. Mandibular incisors because of their small size
generally are poor abutment teeth.
The loss of several maxillary incisors presents a much greater
problem in term of restoring appearance and providing support
because of the curvature of the arch(discussed before).
Tipping forces must be resister by means of two abutment teeth at
each end of a long span anterior FPD.
If anterior bone loss has been severe, there may be a ridge defect.
In these patients, a partial RPD should be considered to restore
the missing teeth as well as the supporting tissues especially when
the person has a high smile line.
Generally speaking implant restorations should be considered as
an alternative treatment option when it is indicated.

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Treatment sequence
1. Treatment of symptoms

 Discomfort.
 Pain.
 Swelling.
 Sensitivity.

2. Stabilization of deteriorating conditions.

Dental caries.
Periodontal disease.

3. Definitive therapy.

Oral surgery.
Periodontics
Endodontics.
Orthodontics
Prosthodontics.

 Occlusal adjustment.
 Anterior restorations.
 Posterior restorations.
 Complex prosthodontics.

4. Follow up and maintenance.

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