DIAGNOSIS IN

FIXED PARTIAL DENTURE

 CONTENTS

 Introduction
 Terminology
 Parts of a fixed partial denture
 Diagnostic aids
 Chief complaint
 Medical and past dental history
 Extra oral examination
 Intra oral examination
 Radiographic examination
 Diagnostic casts
 Prognosis
 Mouth preparation
 INTRODUCTION

 The objective of any rehabilitative procedure is to increase masticatory efficiency, retain

the remaining teeth and preserve their supportive tissues and to achieve the best possible
aesthetic result
 To achieve these objectives, a treatment plan must be derived from a thorough and
accurate diagnosis
 An evaluation is made from data obtained from the history, examination, mounted
diagnostic casts and evaluation of abutment teeth
 TERMINOLOGY (GPT-9)

 FIXED PARTIAL DENTURE: Any dental prosthesis that is luted, screwed, or

mechanically attached or otherwise securely retained to natural teeth, tooth roots, and/or
dental implants/abutments that furnish the primary support for the dental prosthesis and
restoring teeth in a partially edentulous arch; it cannot be removed by the patient.
 DIAGNOSIS: The determination of the nature of a disease.
 PROGNOSIS: A forecast as to the probable result of a disease or a course of therapy
PARTS OF A FIXED PARTIAL DENTURE

Abutment Retainer

Pontic Connector
DIAGNOSTIC AIDS

 Personal information
 Vitality test
 Radiographs
 Diagnostic casts
 Photographs
Personal information

Name

Age

Gender

Address
Past medical and dental
history
Family history
AGE

 The changes that occur in the oral cavity concomitant with age need to be understood in
order to treat the condition successfully

OLDER PATIENTS
• Systemic diseases and
medications – more
YOUNGER PATIENTS
relevant
• Show better healing ability
• As age progress, there will
be lot of changes in oral
cavity
CHIEF COMPLAINT

COMFORT FUNCTION SOCIAL APPEARANCE

• Pain • Difficulty in • Bad odour & • Compromised
• Sensitivity mastication and Taste aesthetics in terms
• swelling speech of Fractured teeth,
restorations,
discolorations
MEDICAL HISTORY

 An accurate and current general medical history should include any medication the patient is taking
as well as all relevant medical conditions.
 Any disorders that necessitate the use of antibiotic premedication, any use of steroids or
anticoagulants and any previous allergic responses to medical or dental materials should be
recorded.
 Any condition affecting the treatment plan. Example: Various radiation therapy, haemorrhagic
disorders should be recorded.
 Possible risk factors to the dentist and auxiliary personnel. Example: Carriers of Hepatitis B, AIDS
or Syphilis are recorded so that adequate measures can be followed when treating known carriers.
 A history of allergies, adverse drug reactions, hypertension, diabetes mellitus, cardiac disease,
emotional disorders, seizures, oral trauma, prosthetic joint replacements, head and neck
malignancies, and other medical conditions influence dental treatment.
 PAST DENTAL HISTORY

Detect the general

attitude of the patient Periodontal history
as concern dentistry
Endodontic history
Detect patient
awareness about oral Restorative history
health
Orthodontic history
Signifying the Removable prosthodontic
patient’s previous history
treatment procedures
Oral surgical history
and their attitude
towards present TMJ dysfunction history
situation
PERIODONTAL HISTORY

 Oral hygiene is assessed

 Frequency of any previous debridement should be recorded
 Nature of any previous periodontal surgery should be noted
RESTORATIVE & ENDODONTIC
HISTORY

 Single composites resin or dental amalgam fillings or may involve crowns and extensive
FPD
 Age of previous existing restorations can help in prognosis and probable longevity of any
future fixed prosthesis
 Endodontically, the findings should be reviewed periodically so that peri apical health can
be monitored, any recurring lesions promptly detected
ORTHODONTIC HISTORY

 Apical root resorption subsequent to orthodontic treatment

 As the crown and root ratio is affected, future prosthodontic treatment and its prognosis
may be affected
REMOVABLE PROSTHODONTIC
HISTORY

 Patients experience with RPD must be carefully evaluated

 Listening to patients comments about previously unsuccessful in assessing whether future
treatment will be more successful
ORAL SURGERY HISTORY

 Missing teeth and any complications that may have occurred during tooth removal is
obtained
EXTRAORAL EXAMINATION

 Facial Asymmetry
 Cervical Lymph nodes
 TMJ
 Muscles of mastication
 Mouth opening
 Lips
Facial asymmetry

 Special attention is given to facial asymmetry because small deviations from normal may
hint at serious underlying conditions
 Bell’s palsy, condylar hypoplasia & hyperplasia, hemifacial microsomia, fracture of
condyle etc.
Cervical lymphnodes

 Palpate the lymphnodes for any abnormalities

TMJ

 Palpated bilaterally just anterior to the auricular tragi while the patient opens and closes
the mouth
 Tenderness, clicking or pain on movement is noted and can be indicative of inflammatory
changes in the retrodiscal tissues, which are highly vascular and innervated
Muscles of mastication

 MASSETER : Palpate extra-orally by placing the fingers over the lateral surfaces of the
rami of the mandible
 TEMPORALIS : Fingers are placed over the patients temples to feel the temporalis
muscle
 MEDIAL PTERYGOID : Index finger is used to touch the medial pterygoid muscle on
the inner surface of the ramus
 LATERAL PTERYGOID : Palpated by place the finger on the lateral aspect of the
pharyngeal wall of the throat
 This palpation is difficult and sometimes uncomfortable for the patient
Mouth opening

 Average mouth opening > 50 mm

 Restricted mouth opening < 35 mm
 Any deviation from midline is also recorded
 Maximum lateral movement can be measured (Normal 12 mm)
Lips

 Patient is observed for tooth exposure during normal and exaggerated smiling
 Critical in planning of fixed prosthodontic treatment especially when need to fabricate
crowns or fixed dental prosthesis is anticipated in the esthetic zone
 When the patient laughs, the jaws open slightly and a dark space is often visible between
the maxillary and mandibular teeth
 Missing teeth, Diastemas, Fractured or poorly restored teeth affect negative space and
require correction
INTRA ORAL EXAMINATION

Tongue

Floor of the mouth

Vestibule

Cheeks

Hard and soft palate

 CLASSIFICATION OF RIDGE DEFECTS
(Seibert in 1983)
Class I - Buccolingual loss of tissue with normal ridge height in apico-coronal direction

Class II - Apico-coronal loss of tissue with normal ridge width in bucco-lingual direction

Class III - Combination of bucco-lingual and apico-coronal loss of tissue resulting in loss of normal height and width
RIDGE AUGMENTATION PROCEDURES

 Ridge preservation
 Bone regeneration in fresh extraction sockets
 Horizontal bone augmentation
 Ridge splitting/expansion
 Vertical ridge augmentation
Bone grafts- Autograft, Allograft, Xenograft, Alloplast
PERIODONTAL EXAMINATION

 Gingiva
 Periodontium
 Clinical attachment loss
 PERIODONTAL EXAMINATION - Gingiva

Examination
Normal
• Lightly dried
• Coral pink with stippling
• Colour, Texture, Size,
• Firmly bound to the
Conture, Consistency,
underlying connective
Position
tissue
• Palpation - Exudate
PERIODONTAL EXAMINATION - Periodontium

• Tooth mobility
• Open contact areas
• Inconsistent marginal ridge height
• Recession
• Furcation involvement
• Inadequate attached gingiva
• Missing or impacted teeth
 PERIODONTAL EXAMINATION –
Clinical attachment level

Attachment Level Inference

At the CEJ- Free gingival margin on the No loss of attachment
clinical crown
On the root structure- Free gingival margin at Attachment loss = probing depth
the CEJ
Severe recession Attachment loss= probing depth + recession
 OCCLUSAL EXAMINATION

 Initial tooth contact

 General alignment – crowding, rotation, spacing, malocclusion
 Lateral and protrusive contacts – Fremitus test
 OCCLUSIONS IN FPD

Bilaterally balanced Mutually protected

occlusion Group function occlusion
VITALITY TESTING

 Percussion
 Thermal Stimulation
 Test Cavity
HEAT TEST
COLD TEST
RADIOGRAPHIC EXAMINATION

 Degree of bone loss

 Impacted teeth, residual roots
 Root morphology, crown-root ratio
 Presence of apical disease
 Dental caries
 Pulp chambers and canals
 PDL and surrounding bone
 Existing restorations(marginal fit, contour)
PANOROMIC RADIOGRAPHS

 Presence or absence of teeth

 Assessing third molars impactions
 Evaluating the bone before implant placements
 Screening edentulous arches for buried root tips
SPECIAL RADIOGRAPHS FOR TMJ DISORDERS

 Transcranial exposure – reveal the lateral third of the mandibular condyle and can be used
to detect structural a d positional changes
 More information can be obtained from
• Tomography
• Arthrography
• C T scanning
• Magnetic resonance imaging
DIAGNOSTIC CASTS

 A life size reproduction of the parts of the oral cavity and or facial structures for the
purpose of study and treatment planning
 Articulated diagnostic casts are essential in planning fixed prosthodontic treatment
 To accomplish their intended goal, they must be accurate reproductions of the maxillary
and mandibular arches made from distortion free alginate impressions
 The diagnostic casts should be mounted on a semi-adjustable articulator with a face bow
ADVANTAGES

 For diagnosing problems and arriving at a treatment plan

 Allow an unobstructed view of the edentulous spaces and an accurate assessment of the span length, as
well as occlusogingival dimension
 Length of the abutment teeth
 The true inclination of the abutment teeth
 Curvature of the arch in the edentulous region can be determined so that it will be possible to predict
whether the pontics will act as a lever arm on the abutment teeth
 Mesio-distal drifting, rotation, faciolingual displacement of prospective abutment teeth
 Occlusal discrepancies can be evaluated and the presence of centric prematurities or excursive interfences
can be determined
 Diagnostic wax-up can be carried out
PROGNOSIS

 Important for patient management and satisfaction

 Influenced by general and local factors

General factors Local factors

• Age and overall health • Malocclusions
• Occlusal forces • Crowding of teeth
• Understanding and comprehension • Tooth mobility
• History and previous dental • Root angulations
treatment • Crown root ratios
PROSTHODONTIC DIAGNOSTIC INDEX
(PDI)

 Location and extent of edentulous area

 Condition of abutment teeth
 Occlusal scheme
 Residual ridge
LOCATION AND EXTENT OF
EDENTULOUS AREAS
 MINIMALLY COMPROMISED:
• Anterior missing span not exceeding 2 missing teeth
• Anterior mandibular span not exceeding 4 missing teeth
• Posterior maxillary or mandibular not exceeding 2 premolar or 1 premolar and 1 molar
 MODERATE COMPROMISED:
• Anterior maxillary not exceeding 2 missing incisors
• Anterior mandibular not missing more than 4
• Missing canine
• Posterior maxillary or mandibular not exceeding 2 premolar or 1 premolar and 1 molar
 SUBSTANTIALLY COMPROMISED:
• Posterior > 3 missing teeth or 2 molars
• Anterior or posterior more than 3 missing
• Treatment requires high level of compliance
PDI- Condition of abutment teeth

Moderately Substantially
Minimally compromised
compromised compromised
• No preprosthetic • Insufficient tooth • Insufficient tooth
therapy required structure in one or 2 structure
sextants • Abutments require
• Abutments require extensive adjunctive
localized adjunctive therapy
therapy • Abutments have
guarded prognosis
PDI – Occlusal Scheme

Minimally Moderately Substantially Severely

compromised compromised compromised compromised
• No preprosthetic • Requires • Entire occlusal • Decreased
therapy required localized scheme requires vertical
• Class I molar adjunctive management dimension
relation therapy • Class II molar • Class II div 2 or
• Class I molar and jaw relations Class molar and
and jaw jaw relations
relationships
PDI – Class I

 Ideal location and extent of edentulous space

• Confined to a single arch
• Doesnot compromise the support offered by abutments
 Ideal abutment condition
 Ideal occlusion
 Residual ridge morphology of completely edentulism
PDI – Class II

 Location and extent moderately compromised

• Edentulous area on one or both arches
 Abutments ore moderate compromised
• 1 or 2 sextants have sufficient tooth structure
• Require localized adjunctive therapy
 Occlusion is moderately compromised
 Residual ridge –Class II
PDI – Class III

 Location and extent of edentulous area is substantially compromised

 Condition of abutment is moderately compromised
 Occlusion is substantially compromised
 Residual ridge – Class III
PDI – Class IV

 Location and extent of edentulous area is severely compromised

 Abutments are severely compromised
 Occlusion is severely compromised
 Residual ridge – Class IV
MOUTH PREPARATION

 Mouth preparation refers to the dental procedure that need to be accomplished before
fixed prosthodontics can be properly undertaken
 As a general plan, the following sequence of treatment procedures in advance of fixed
prosthodontic should be adhered to
• Relief of symptoms (chief complaint)
• Removal of etiological factors (Eg. Excavation of caries removal of deposits)
• Repair of damage
• Maintenance of dental health
 The following list describes the sequence in the treatment of a patient with extensive
dental disease including missing teeth, retained roots, caries and defective restorations
• Preliminary assessment
• Emergency treatment of presenting symptoms
• Oral surgery
• Caries control and replacement of existing restorations
• Definitive periodontal treatment
• Orthodontic treatment
• Definitive occlusal treatment
• Fixed prosthodontics
• Follow up
REFERENCES

 Tylman’s theory and practice of Fixed Prosthodontics – 8 th edition

 Fundamentals of fixed prosthodontics- Shillingburg- 1 st South Asia edition
 Contemporary Fixed Prosthodontics-Rosenstiel- 3 rd edition
 Glossary of Prosthodontic terms - 9