GUIDED BY:

.Dr FAYAZ PASHA

PRESENTED BY:Dr.SOUMYADEV SATPATHYPOST GRADUATE STUDENT

DEPARTMENT OF PROSTHODONTICS,V.S.DENTAL COLLEGE & HOSPITAL1

• Introduction• Definitions• Diagnostic aids

– Personal information– Patient evaluation– Medical history– Past dental history– Clinical examination

• Extra oral examination• Intraoral examination

– Radiographic examination• Treatment plan

– Adjunctive care• Elimination of infection• Elimination of pathosis

• Summary• Conclusion 2

Successful management of cases begin with a thorough assessment of the patient’s physical and psychological condition and determining a treatment that will satisfy the realistic expectations of the patient.

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Resorption of residual alveolar ridges Occlusal disharmony Tilting of teeth Drifting of teeth

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DIAGNOSIS The determination of the nature of a disease. (Glossary of Prosthodontic terms 8)(Glossary of Prosthodontic terms 8)

TREATMENT PLAN The sequence of procedures planned for the treatment

of a patient after diagnosis. (Glossary of Prosthodontic terms 8)(Glossary of Prosthodontic terms 8)

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HISTORY TMJ & EXTRAORAL EVALUATION INTRA ORAL EXAMINATION DIAGNOSTIC CASTS RADIOGRAPHIC EXAMINATION

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All pertinent information concerning the reasons seeking treatment , along with any personal information, including relevant previous medical and dental experiences.

The chief complaint should be recorded preferably in patient’s own words.

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o Diagnosis & treatment planning depends upon accurate data collection & record maintenance.

o Information collection --Questionnaire. --Direct interrogation. --Combination.

o Name: Patient identification, for addressing.o Sex: Patient expectations differ with sex.o AGE: As age advances decrease in

adaptability & neuromuscular co-ordination , learning ability.

Oral & facial tissues lose elasticity &resiliency.

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o Address:o Telephone. No:o Family history:o Socio-economic status :o Physician tel.ph.no:

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FOUR CATEGORIES

COMFORT (pain, sensitivity, swelling) FUNCTION (Difficulty in mastication or

speech) SOCIAL (Bad taste or odor ) APPEAREANCE (Fractured or

unattractive teeth or restorations , discoloration)

The accuracy and significance of the patient’s primary reason or reasons for seeking treatment should be

analyzed first

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Medication. As well as relevant medical conditions. If necessary the patients physician(s) can

be contacted for clarification. Conditions affecting the treatment methods Conditions affecting treatment plan Systemic conditions with oral

manifestations Possible risk factors for the dental surgeon

and patient

Accurate and current general medical history should include

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.

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. Information about missing teeth

and any complications that may have occurred during tooth removal is obtained.

Special evaluation data collection procedures are necessary for patients who require prosthodontic care subsequent to orthognathic surgery.

Before any treatment is undertaken, the prosthodontic component of the proposal treatment should be fully co-ordinated with surgical component.

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The patients oral hygiene is assessed, current plaque control measures are discussed, as are previously received oral hygiene instructions.

The frequency of any previous debridments should be recorded

Dates nature of any previous periodontal surgery should be noted.

PERIODONTAL HISTORY

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Simple composites resin or dental amalgam fillings or may involve crowns and extensive fixed partial dentures.

The age of previous existing restorations can help the prognosis and probable longevity of any future fixed prosthesis.

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The findings should be reviewed periodically so that peri-apical health can be monitored, any recurring lesions promptly detected.

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Occlusal analysis should be an integral part of the assessment of a post orthodontic dentition.

If restorative treatment needs are anticipated , they should be undertaken by the restorative dentist.

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The patients experiences with removable prostheses must be carefully evaluated.

Listening to the patients comments about previously unsuccessful in assessing whether future treatment will be more successful.

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Previous radiographs may prove helpful in judging the progress of dental disease.

They should be obtained if possible, because it is generally better to avoid exposing the patient to unnecessary ionizing radiation.

In most instances , however , a current diagnostic radiographic series is essential and should be obtained as a part of examination.

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A history of pain or clicking in the TMJ or neuromuscular systems, such as tenderness to palpation, may be due to TMJ DYSFUNCTION, which should be normally be treated and resolved before fixed prosthodontic treatment begins.

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An examination consist of the clinician’s use of sight, touch , and hearing to detect conditions outside the normal range.

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General appearance: Gait and weight are assessed.

Skin color : Anemia or jaundice.

Vital signs: Respiration, pulse, temperature and blood pressure are measured and recorded.

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FACIAL ASYMMETRY CERVICAL LYMPHNODES TMJ MUSCLS OF MASTICATION

(palpated)

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Permits a comparison between the relative timing of left and right condylar movements during the opening stroke.

ASYNCHRONIOUS MOVEMENT :Anterior disk displacement that prevents one of the condyles from making abnormal translatory movements.

Auricular palpation with light anterior pressure helps identify potential disorders in the posterior attachment of the disk.

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Tenderness or pain on movement, is noted and can be indicative of inflammatory changes in the retrodiscal tissues ,which are highly vascular and innervated.

Clicking in the TMJ is often notecible through auricular palpation but may be difficult to detect when palpating directly over the lateral pole of the condylar process, because the overlying tissue can “muffel” the click , placement of the fingertips on the mandible will help to identify even a minimal click.

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Average opening

>50mm

Restricted opening<35mm (intracapsular changes in the joints)

Midline deviation :normal is 12mm

Mouth opening

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MASSETER ,TEMPORAL MUSCLES and other POSTURAL MUSCLES are palpated for signs of tenderness. Bilaterally and simultaneously. light pressure. Classify the discomfort as MILD, MODERATE or SEVERE. In TMJ dysfunction , a systematic sequence of muscle palpation should be followed.

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The sites should be numbered and graded for pain and discomfort so that, If neuromuscular or TMJ treatment is initiated , the examiner can then re palpate the same sites periodically to asses the response to treatment .

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Visibility during normal and exaggerated smiling.

This can be critical during FIXED PROSTHODONTIC TREATMENT PLANNING

“NEGATIVE SPACE”:- The space between maxillary and mandibular anteriors during normal smile.

Missing teeth, diastemas and fractured or poorly restored teeth affect negative space and require correction.

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Condition of the soft tissues , teeth and supporting structures.

This information can be properly evaluated during treatment planning only if objective indices, rather than vague assessments, are used.

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Status of bacterial accumulation

The response of the host tissues and the degree of irreversible damage.

Long term periodontal health is essential to successful fixed prosthodontic treatment.

Existing periodontal disease must be corrected.

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An accurate charting of

the state of the dentition

will reveal important

information about the

condition of the teeth and

will facilitate treatment

planning. 34

The initial clinical examination starts with the clinician asking the patient to make a few simple opening and closing movements while carefully observing the opening and closing strokes.

Special attention is given to Initial tooth contact, Tooth

alignment, andEccentric contacts and jaw maneurability,

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RADIOGRAPHS

VITALITY TEST

DIAGNOSTIC CASTS

PERIODONTAL PROBE.

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Provides supplement information to clinical information

Extent of bone support Root morphology Peri apical pathology

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Presence or absence of teeth

Assessing third molars impactions,Evaluating the bone before implant placement.Screening edentulous arches for buried root tips.

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For assessement of TMJ disorders, More information can be obtained from Tomography

Arthrography

C T scanning

Magnetic resonance imaging

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Pulpal health must be measured before restorative treatment to

PERCUSSION and

THERMAL STIMULATION

TEST CAVITY-nonvitality without L.A

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VITALITY TEST asses only afferent Nerve supply.

MISDIAGNOSIS occurs if N S is damaged and blood supply intact .

Careful inspection of radiographs therefore an essential aid in the examination.

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Not all the patients seeking fixed prosthodontic treatment will present diagnostic problems.

Nevertheless ,diagnostic errors are possible, especially when a patient complains if pain or symptoms of occlusal dysfunction.

A logical and systematic approach to diagnosis will help avoid mistakes.

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The prognosis is an estimation of the likely course of a disease.

It is difficult to make , but its importance to patient understand successful treatment planning must nevertheless be recognised.

The prognosis of dental disorders is influenced by.

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GENERAL FACTORS (age of patient, lowered resistance of the oral environment)

LOCAL FACTORS (Forces applied to a given tooth , access for oral hygiene measures).

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A life size reproduction of the parts of the oral cavity and or facial structures for the purpose of study and treatment planning.

Diagnostic casts are the integral part of the diagnostic procedures necessary to give the dentist as complete a perspective as possible of the patients dental needs.

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SEMIADJUSTABLE ARTICULATOR with a FACE BOW TRANSFER.

Articulated diagnostic casts permits a detailed analysis of occlusal plane and the occlusion for a better diagnosis and treatment plan.

Tooth preparations can be “rehearsed “ on the casts and diagnostic waxing procedures allow evaluation of the eventual outcome of proposed treatment .

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CENTRIC RELATION RECORDS are used to replicate on the articulator.

LATERAL OCCLUSAL RECORDS are used to the condylar guidance of the articulator.

Identify the deflective contacts.

A distinction must be made between mounting for diagnosis and for treatment.

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The attachment of casts to an articulator for diagnosis will be done with the condyles in the centric relation position.

For restoration of a significant portion of the occlusion , it may also be done with the condyles in the centric relation position.

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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;

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Relief of symptoms (chief complaint)

Removal of etiological factors (eg; excavation of caries removal of deposits)

Repair of damage .

Maintainance of dental health.

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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.

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Preliminary assessment

Emergency treatment of presenting symptoms

Oral surgery

caries control and replacement of existing restorations

Definitive periodontal treatment

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Orthodontic treatment

Definitive occlusal treatment

Fixed prosthodontics

Removable prosthodontics Follow up care .

A logical TREATMENT SEQUENCE should be planned

before beginning any fixed prosthodontic intervention. Such planning will normally multidisciplinary.

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DESTRUCTION OF THE

TOOTH STRUCTURE ESTHETICS PLAQUE CONTROL FINANCIAL

CONSIDERATIONS RETENTION

The selection of the material and design of the restoration depends on several factors:-

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The destruction previously suffered by the tooth has to be restored , such that the remaining tooth structure must gain strength and protection from restoration , cast metal or ceramic is indicated over amalgam or composite resin .

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PARTIAL VENEER restoration can be used to restore in highly visible area.

The use of ceramic in some can be used as FULL VENEER.

METAL CERAMIC CROWNS Single unit anterior Posterior crowns Fixed partial denture

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commonly used on anteriors

posteriors (adequate bulk)

ALL CERAMIC CROWNS

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Motivated to follow a regime of brushing, flossing and dietary regulation to control or eliminate the disease process responsible for destruction of tooth structure.

If these measures prove to be successfulcast metal, ceramic or metal ceramic restorations can be fabricated.

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“SOME ONE” Government agency A branch of military Insurance company Selection should not be less

than optimum just because the patient cannot.

Sound alternative to the preferred treatment plan and not apply pressure.

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FULLVENEER CROWNS; unquestionably most retentive.

SINGLE TOOTH RESTORATION: not nearly important.

Special concern for ; Short teeth Removable partial

denture abutment. 61

PLASTIC and CEMENTED restoration

PLASTIC RESTORATION: Is inserted as soft or plastic mass into the cavity preparation , where it will harden and be retained by mechanical undercuts or adhesion.

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CEMENTED RESTORATION Made of cast metal ,metal ceramics or ceramic

material alone is fabricated away from the operatory and is luted in or on patients tooth at a subsequent appointment.

One type can be better suited for a particular application than the other or their suitabilities may overlap.

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When sufficient coronal tooth structure exist to retain and protect a restoration under the anticipated stresses of mastication an intracoronal can be employed.

In this circumstance , the crown of the tooth and the restoration itself are dependent upon the strength of remaining tooth structure to provide structural integrity.

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Where extensions can be kept minimal. Preparation retention will be minimal . Class 5 lesions Incipient lesions Root caries in geriatric patients. Interim treatment restoration to assist in

the control of a mouth with rampant caries.

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Esthetical critical areas.

Class 4 lesions .

Restoration of posterior teeth with mixed results.

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Minor to moderate sized lesions in esthetically non critical areas.

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Moderate to severe lesions with amalgam augmented by pins.

As a final restoration when a crown is contraindicated .

Missing cusps or endodontically premolars and molars.

Teeth that ordinarily would be restored with mesio-occulsal onlays or other extracoronal restorations.

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Minor to moderate lesions where esthetic require low .

Etchable base metal alloys if a bonding effect is desired.

Restoration of MOD on molars.

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Minor to moderate sized lesion where esthetic demand is high.

MOD ceramic inlays can be used on molars.

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Moderately large lesions on premolars and molars with intact facial and lingual surfaces.

It will accomodate a wide isthmus and upto one missing cusp on molar.

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Insufficient coronal tooth.

Deflective axial tooth structure.

Modify contours to refine occlusion or improve

esthetics.

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To restore a tooth with one or more intact axial surfaces with half or more of the coronal tooth structure remaining.

For short span fixed partial dentures.

If tooth destruction is not extensive.

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Restore teeth with multiple defective axial surfaces.

Restricted to situation where there are no esthetic expectations.

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Multiple defective axial surfaces.

Fixed partial dentures retainer where full coverage and good cosmetic results must be obtained.

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Full coverage and maximum esthetics.

Restricted to situation likely to produce low moderate stress .

Usually used on incisors.

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Intact anterior tooth that are marred by severe staining or developmental defects restricted to facial surface of the tooth.

Moderate incisal clipping and proximal lesions.

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A REMOVAL PARTIAL DENTURE. A TOOTH SUPPORTED FIXED PARTIAL

DENTURE OR AN IMPLANT SUPPORTED FIXED PARTIAL

DENTURE.

SELECTION OF THE TYPE OF THE POSTHESIS

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BIOMECHANICAL PERIODONTAL ESTHETIC FINANCIAL and PATIENTS WISHES.It is not uncommon to combine two types

in the same arch.

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Edentulous spaces greater than two posterior teeth. Anterior space greater than four lncisors. Edentulous space with no distal abutment. Multiple edentulous spaces. Tipped teeth adjoining edentulous spaces and

prospective abutments with divergent alignment.

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Periodontally weakened. Teeth with short clinical crowns. Insufficient number of abutments. If there has been a severe loss of tissues

in the edentulous ridge. Patients of advanced age who are on

fixed incomes or have systemic problems.

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Abutment teeth are periodontally sound. Edentulous span is short and straight. Expected to provide a longlife of function for the

patient. No gross soft tissue defect in the edentulous

ridge. Reserved for patients who are both highly

motivated and able to afford.

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Defect free abutments where single missing tooth.

A single molar (muscles are not well developed).

Mesial and distal abutment are present. Moderate resorption and no gross soft tissue

defects on edentulous ridges.

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Younger patients whose immature teeth with large pulps are poor risks for endodontic free abutment preparation.

Tilted tooth can be accommodated only if there enough tooth structure to allow a change in the normal alligment of axial reduction.

Periodontal splints.

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Insufficient number of abutments. Partial attitude and or a combination of intra

oral factors make a removable partial denture or FPD a poor choice.

No distal abutment. Alveolar bone with satisfactory density and

thickness in a broad, flat ridges.

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Configuration that permit implant placement. Single tooth where defect free adjacent teeth. A span length of two or six teeth can be

replaced by multiple implants. Pier in an edentulous span (three or more teeth

long).

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Long standing edentulous space into which there has been little or no drifting or elongation of the adjacent teeth.

If the patients percieves no functional , occlusal or esthetic impairement.

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In cases where the choice between a fixed partial denture and a removable partial denture is not clear cut, two or more treatment options should be presented to the patients along with their advantages and disadvantages.

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The prosthodontist is the best person to evaluate the physical and biological factors present , while the patients feelings should carry considerable weight on matters of esthetics & finances .

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The roots and their supporting tissues should be evaluated for three factors

Crown root ratio

Root configuration

Periodontal ligament area

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Optimum -2:3

Minimum -1:1 (acceptable)

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Broader LABIOLINGULLAY than MESIODISTALLY. Multirooted posterior teeth with widely separated

roots. Conical roots can be used -for short span. A single rooted tooth with evidence of irregular

configuration or with some curvature in the tooth that has a nearly taper.

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Larger teeth have a greater surface area and better able to bear added stress.

“ ANTE’S LAW” the root surface area of the abutment teeth had to equal or surpassed that of the teeth being replaced with pontics.

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In addition to the increased load placed on the pdl by a long span FPD.

Longer spans are less rigid.

Bending or deflection varies directly with the cube of the length and inversely with cube of the occlusogingivally thickness of the pontic .

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Greater occlusogingival dimension Nickel chromium Double abutment Multiple grooves Arch curvature ( minimize additional retention

from opposite arch)

TO MINIMIZE –

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Non rigid connector

Restrict to short span FPD

key way -distal contours of pier a abutment

key - mesial side of the distal pontic

PIER ABUTMENTS

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Mild encroaching- restoring and recontouring

Tilting is severe –corrective measures

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No FPD replacing a canine should replace more than one additional tooth.

Edentulous spaces created by the loss of canine and any contiguous teeth is best restored with Implants.

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Length roots with favourable configuration. Long clinical crowns. Good crown root ratios and healthy periodontium. Should replace only one tooth and have atleast

two abutments.

Pontic should posses maximum occlusogingival height to ensure a rigid prosthesis.

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The history and clinical examination must provide sufficient data for the practioner to formulate a successful treatment plan.

In particular it is critical to develop a through understanding of special patient concerns relating to previous care and expectations about future treatment.

A diagnosis is a summation of the observed problems and their underlying etiologies.

The overall prognosis is influenced by general and local factors

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Tylmans theory and practice of fixed prosthodontic –eigth edition

Contemporary fixed prosthodontic; Stephen.F. Rosenstiel –third edition.

Fundamentals of fixed prosthodontic; Herbert.T. Shillingburg –third edition

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