11.10.

2010

Diagnosis and treatment planning in fixed partial denture

Preeti Kalia 2nd Year P.G. Department of Prosthodontics AECS Maaruti Dental College

Planning is bringing the future into the present so that you can do something about it now 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. The plan should be presented in written form and discussed in detail with the patient. A good plan informs the patient about the present conditions, the extent of dental treatment proposed the time and cost of treatment and the level of home care and professional follow up needed for success. Foremost is to identify the patient's needs and their preferences which must be correlated with the range of treatments available.For long term success when a fixed partial denture is being considered the Abutment teeth must be carefully assessed. Diagnostic casts They are made from impressions of the dental arches. These casts are used to evaluate soft tissue contours, vestibular morphology and frenum attachments ,bony contours,crown length and morphology ,tooth alignment and paths of insertion ,available pontic space ,existing restorations ,esthetic factors and the occlusion.They are commonly made with irreversible hydrocolloid.The impressions are poured as soon as possible.The casts are mounted on a semi adjustable articulator with a face bow transfer .This is a fundamental record of the patient's pre-treatment occlusal relationships and aids in presenting the finalized treatment plan to the patient. Articulated diagnostic casts permit a detailed analysis of the occlusal plane and occlusion and diagnostic procedures can be performed 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 the proposed treatment. Radiographic interpretation A well defined complete mouth radiographic series - 14 periapical and 4 bite wing radiographs is essential .The radiographic interpretation is combined with all other available findings when making a definitive diagnosis and developing a treatment plan. An intraoral radiographic examination reveals1) Remaining bone support 2) Root number and morphology 3) Quality of supporting bone, trabecular patterns and reactions to functional changes 4) Width of the periodontal ligament spaces, and evidence of trauma from occlusion 5) Areas of vertical and horizontal osseous resorption and furcation invasions 6) Axial inxl ination of teeth 7) Continuity and integrity of lamina dura 8) Pulpal morphology and previous endodontic treatment with or without post and cores 9) Presence of apical disease,root resorption or root fractures 10) Retained root fragments, radiolucent areas ,calcifications,foreign bodies or impacted teeth 11) Presence of carious lesions ,the condition of existing restorations and the proximity of caries and restorations to the dental pulp 12) Proximity of carious lesions and restorations to the alveolar crest Definitive diagnosis After a careful review of all available information a definitive diagnosis is made.The dental diagnosis includes a determination of the periodontal Health,occlusal relationships , TMJ function, condition and status of remaining dentition including previous dental treatment,

dental caries, defective restoration, and pulpal disease Treatment options follow from the diagnosis. Identification of patients needs Successful treatment planning is based on proper identification of the patient s needs. If an attempt is made to have the patient to confirm to the ideal treatment plan rather than to haw the treatment plan conform to the patient's needs, success is unlikely. Treatment is required to accomplish one or more of the following objectives -Correcting an existing disease, preventing future disease, restoring function and improving appearance Correcting an existing disease Clinical examination reveals the presence of existing disease such as presence of periodontal problem or dental caries etc. The disease process can be arrested by identification and reduction of the initiating factors, identification and improvement of the resistive factors or both For example oral hygiene instructions will reduce the amount of residual plaque, an initiating factor and thus will reduce further dental

Prevention of future disease The likelihood of future disease can be predicted by evaluating the patient's disease experience and by knowing the prevalence of the disease in the general population. Treatment should be proposed if future disease seems likely in the absence of such of intervention. Restoration of function Although objective measurement may be difficult the level of function is assessed during the examination. Treatment may be proposed to correct impaired function mastication or speech Improvement of appearance Patients often seek dental treatment because they are dissatisfied with their appearance the dentist should develop expertise in this area and should be prepared to appraise the appearance of the patient's dentition and listen carefully to the patient's views. However long term dental health should not be compromised in an attempt to improve appearance.Patient should be advised as to the possible adverse consequences of treatment. Treatment of tooth loss Most teeth are lost as a result of dental caries or periodontal disease. The decision to remove a tooth is part of the treatment planning process and is made after assessing the advantages and disadvantages associated with the retention of the tooth . Sometimes it is possible to retain a tooth with an appropriately hopeless prognosis by using highly specialized and complex techniques. In other cases removing the tooth is the treatment of choice A decision about replacing a missing tooth is best made at the time its removal is recommended. Consequences of removal without replacement

The decision to replace or not replace missing teeth requires a careful analysis of the Costs and benefits of the action. The loss of posterior occlusion may lead to excessive xs on the remaining dentition with consequent damage and poor function. Adequate function is possible with reduced posterior occlusion. Deciding not to replace a tooth may lead to a situation in which the balance of the forces exerted on that tooth by the adjacent and opposing teeth and supporting tissues and by the tissues of the cheeks, lips and tongue is upset The consequences may be supraclusion of the opposing tooth or teeth .tilting of the adjacent teeth and loss of proximal contact .However the teeth adjacent to an edentulous space have not been shown to be at greater risk of damage and the rate of change of teeth adjacent to an edentulous space is usually slow. If the situation is not carefully monitored and significant movement of adjacent teeth has occurred .simple replacement of the missing teeth at this late stage may prevent further disruption although it may be insufficient to return the dentition to full health. Extended treatment plans including acemay be needed to compensate for the lack of treatment at the time of tooth removal. Selection of abutment teeth Whenever possible FPD's should be designed as simply as possible with a single well anchored retainer fixed rigidly at each end of the pontic .The use of multiple splinted abutment teeth .nonrigid connectors or intermediate abutments makes the procedure much more difficult and often the result compromises the long term prognosis. Treatment planning for single tooth restorations Intracoronal restorations When sufficient coronal tooth structure exists to retain and protect a restoration under the anticipated stresses of mastication, an intracoronal restoration can be employed. Here the restoration itself is dependent on the strength of the remaining tooth structure for structural integrity, a) Glass lonomer: 1) In small lesions where extension can be kept minimal. 2) Useful for restoring Class V lesions caused by erosion or abrasion. 3) Also employed for incipient lesions on the proximal surfaces of posterior teeth by the use of "tunnel" preparation which leaves the marginal ridge intact. 4) Very useful for the restoration of root caries in geriatric and periodontal patients. 5) Serves as an interim treatment restoration to assist in the control of a mouth with rampant caries b) Composite resin 1) In minor to moderate-lesions in esthetically critical areas. A tooth that has received a class IV resin restoration will require a crown. 2) Due to polymerization shrinkage and insufficient abrasion resistance, its use on posterior should be restricted to small occlusal and mesioocclusal restorations on first premolars. To overcome the problem of polymerization shrinkage, bench polymerized inlay which have greater hardness and a thin layer of resin used for fixing it to the tooth structure will be less susceptible to significant shrinkage at the margin than a restoration that is bulk cured in situ.

c) Simple amalgam Simple amalgam, without pins or other auxiliary retention Is widely used for onc-to-threesurface restoration of minor-to-moderate sized lesions In cui helically non-critical areas. They are best used when more than half of coronal dentin is Intact d) Complex amalgam Augmented by pins or other auxiliary means of retention, it can be used to restore teeth with moderate to severe lesions, in which less than half of the coronal dentin remains. It can be used as a final restoration when a crown is contrindicated because of limited finances. Ideally, however, a crown should be constructed over the pin retained amalgam, using It as a core or foundation restoration. e)Metal inlay Minor to moderate lesions on teeth where the esthetic requirements are low can be restored with this restoration. The preparation of the isthmus should be narrow to minimize the stress in the surrounding tooth structure.Pre-molars should have one intact marginal ridge to preserve structural integrity .Additional bulk of the tooth structure found in a molar permits the use of this type in a MOD configuration. f)MOD onlay: Can be used for restoring moderately large lesions on premolars and molars with intact facial and lingual surfaces. It can accommodate a wide Isthmus and up to one missing cusp on a molar. Cannot be used as a retainer for fixed partial denture.

g)Ceramic inlay Used in minor to moderate lesions that will permit a narrow preparation isthmus on teeth where the esthetic requirements are high. Premolars should have one intact marginal ridge, but MOD ceramic inlays can be used in molars. Extracoronal restorations If insufficient tooth structure exists to retain the restoration within the crown of the tooth, an extracoronal restoration, or crown is needed a) Resin veneer crown: These were popular before metal ceramic technique was fully developed, but problems with wear and discoloration of the polymethylmethacrylate veneer -. limited their use to long term provisional restorations. Curing resin veneer techique incorporate Bis-GMA based materials which have better physical properties than the earlier acrylic resins and the adhesive techniques to improve the bond to the supporting metal. Fibre reinforced resin: Advances in composite resin technology especially the introduction of glass and polyethylene fibers have prompted the use of indirect composite resin restorations for inlays, crowns and FPDs. Excellent marginal adaptation and esthetics result are achievable but because these are newer technologies little is known about their long term performances. b) Partial veneer crown: 1) Leave one or more axial surface unveneered

2) To restore tooth with one or more intact axial surface with half or more of the coronal tooth structure remaining 3) It will provide moderate retention and can be used as a retainer for short span fixed partial denture c) Full metal crown: 1) To restore teeth with multiple defective axial surfaces or when less than half of coronal dentin remains. 2) Provides maximum use restricted to situations, where there are no esthetic requirements. d) Metal-ceramic crown 1) Provides maximum retention. 2) Combines fiill coverage with good cosmetic result e)All-ceramic crown 1) Their use must be restricted to situations likely to produce low to moderate stress usually used for incisors and maximum esthetics is required. 2) Main drawback of this material is they are not resistant to fracture as metal ceramic crowns, require removal of large quantities of tooth structure. And difficulty in achieving an acceptable marginal fit. 1) Produces good cosmetic result on otherwise intact anterior teeth that are marred bv f)Ceramic veneer 1) Produces good cosmetic result on otherwise intact anterior teeth that are marred by severe staining or developmental defects restricted to facial surface of the tooth. 2) They are used to restore moderate incisal chipping and small proximal lesions. Treatment planning for the replacement of missing teeth : Dental arch is in a state of dynamic equilibrium with the teeth supporting each other. When a tooth is lost the structural integrity of the dental arch is disrupted and there is a subsequent realignment of teeth as a new state of equilibrium is achieved. Teeth adjacent to or opposing the edentulous spaces frequently move into it. Adjacent teeth especially those distal to the space, may drift bodily although a tilting movement is far more common occurrence. If opposing tooth intrudes severely into the edentulous space, it is just not enough to replace the missing tooth but also it is necessary to restore the tooth opposing the edentulous space for a mouth free of interferences. This may also necessitate the devitalization of supraerupted opposing tooth to permit enough shortening to correct the plane of occlusion. Selection of type of prosthesis: Missing teeth can be replaced by one of three prosthesis type: A RPD, tooth supported FPD or an implant supported FPD or no treatment, the factors that need to be considered are biomechanical, periodontal, esthetic and financial considerations. The basic principle in treatment planning is treatment simplification. At the same time the sequencing and referral to other specialties should be done. Communication and be open to suggestions is important and one should be comfortable with plannedtreatment.

especially those distal to the space, may drift bodily although a tilting movement is far more common occurrence. Removable partial denture: Indications A edentulous space greater than two posterior teeth, anterior space greater than four incisors or spaces that include a canine, lateral incisor canine and first premolar, or the canine and both premolars.An edentulous space with no distal abutment will require a removable partial denture. Bilateral edentulous space with more than two teeth missing on one side- RPD may be considered instead of FPD Tipped teeth adjoining edentulous spaces and prospective abutments with divergent alignments may lend themselves more readily to utilization as RPD rather than as FPD abutments. Because periodontal ly weakened primary abutments may serve better in retaining a well designed RPD than in bearing the load of a FPD It is also possible to design the partial denture framework so that retentive clasps will be placed on teeth other than those adjacent to the edentulous space. Teeth with short clinical crowns or teeth that are just generally short will not be good FPD abutments Insufficient number of abutments select RPD instead of FPD Severe loss of tissue in the edentulous ridge, RPD restores space better than FPD both functionally and esthetically. However for successful RPD treatment, the patient should demonstrate acceptable OH I and show signs of reliable recall programme. Contraindications: 1. Patients of advanced age who are on fixed incomes or have systemic health problems. require cut down on the amount of time required to restore the mouth or make treatment more affordable. 2. Muscular discoordination, large tongue 3. Unfavourable attitude towards RPD Conventional tooth supported FPD This is the preferred- treatment of choice by majority of the patient. Indications 1. Span length a. Posterior span: 2 or fewer b. Incisors 4 or lower 2. Span configuration: a Usually has distal abutment but can be used with short cantilever pontic 2. Abutment alignment Less than 25 inclination can be accommodated by preparation modification 4. Abutment condition: a. Good if abutments need crowns

b. Non vital teeth can be used if there is sufficient coronal tooth structure. 5. Occlusion: Favourable loading magnitude, direction, frequency and duration 6. Periodontal condition: Good alveolar bone support,crown root ratio 1:1 or better ,no mobility,favourable root morphology,provides rigid stabilization 6. Ridge form: Moderate resorption No gross soft tissue defect should be present in the edentulous ridge. If present augment the ridge with grafts to enable the construction of fixed prosthesis 7 General features Dry mouth high caries risk with FPD Muscular d iscoord ination Mandibular tori Palatal soft tissue lesions Large tongue Exaggerated gag reflex Unfavourable attitude towards RPD Patient cannot cope with aging,tooth loss Favourable opposing occlusion: removable prostheses or periodontally weakened natural dentition may permit FPD in less than optimal situations. Must be within dentists skill Resin bonded tooth supported FPD: Indications Indications 1. Span length: a- Single tooth b. Possible for 2 incisors 2. Span configuration: Abutments mesial and distal to pontic 3. Abutment alignment: Less than 15 inclination mesiodistally Should be in same faciolingual plane Preparations are not easily modified because of minimal reduction 4 Abutment condition Detect free abutments Incisor, premolar replacements 5. Occlusion: Cannot be used for incisor replacement in presence of deep vertical overlap 6. Periodontal condition No mobility Periodontal splints with auxiliary resistance in tooth preparation 7. Ridge form Moderate resorption No gross soft tissue defects

8. General features: Well suited for young patients Can be used for replacing molars if masticatory muscles are not too well developed

Implant supported fixed partial denture: 1. Indications a. Single tooth abutment 2. Span configuration: No distal abutment Pier in 3 - abutment pontic 3. Abutment alignment - Need for implant abutment requires close coordination between surgeon and restorative dentist 4. Abutment condition-Defect free abutments require no restoration 5. Occlusion: Occlusal forces must be as nearly vertical as possible to prevent unfavorable lateral loading of implants 6. Periodontal condition :Dense bone 7. Ridgeform: Broad flat ridge 8. General features: a. Able to survive in dry mouth b. May be better choice if teeth will require extensive treatment and will still be weak questionable abutments c. Unfavourable attitude towards RPD d. Must be within dentists skills No prosthetic treatment: If a patient presents with a long standing edentulous space into which there has been little or no drifting or elongation of the adjacent or opposing teeth, the question of replacement should be left to the patient's wishes, if the patient perceives no esthetic, functional occlusal impairment it would be a dubious service to. place a prosthesis. Abutment Evaluation Abutment teeth must be able to withstand the forces normally directed to the missing teeth, in addition to those usually applied to the abutments.The forces that would normally be absorbed by the missing tooth are transmitted through the pontic,connectors and retainers to the abutments. If a tooth adjacent to an edentulous space needs a crown because of damage to the tooth the restoration can double up as a retainer.Whenever possible an abutment should be a vital tooth. However, a tooth that has been endodontically treated which is asymptomatic with radiographic evidence of a good seal and complete obturation of the canal, can be used as an abutment. If the endodontically treated tooth does not have a sound tooth structure, it must treated through the use of a dowel core, or a pin-retained amalgam or composite resin core. Teeth that have been pulp capped in the process of preparing the tooth should not be used as FPD abutments unless they are endodontically treated. - The supporting tissues surrounding the abutment teeth must be healthy and free from inflammation before any prosthesis can be contemplated.

- Normally, abutment teeth should not exhibit mobility, since they will be carrying an extra load. The roots and their supporting tissues should be evaluated for 3 factors: i) Crown-root ratio. ii) Root configuration. iii) Periodontal ligament area. I) Crown root ratio

It is a measure of the length of the tooth occlusal to the alveolar crest of bone compared with the length of the root embedded in the bone. As the level of the alveolar bone moves apically, the lever arm of that portion out of bone increases and the chance for harmful lateral force is increased. The optimum crown-root-ratio for a tooth to be utilized as a fixed partial denture

1) Crown root ratio It is a measure of the length of the tooth occlusal to the alveolar crest of bone compared with the length of the root embedded in the bone. As the level of the alveolar bone moves apical l y, the lever arm of that portion out of bone increases and the chance for harmful lateral force Is increased. The optimum crown-root-ratio lor a tooth to be utilized as a fixed partial denture is 2:3 and a 1 :l ratio is the minimum acceptable under normal circumstances. However, there are situations in which a crown-root-ratio greater than 1:1 (i.e. length of crown greater than length, of the tooth) may be considered adequate if occlusion opposing a proposed fixed partial denture is comprised of artificial teeth, occlusal force will be diminished, with less stress on abutment teeth. It is seen that occlusal forces exerted against prosthetic appliances has been shown to be considerably less than that against natural teeth. RPD - 26 lb FPD - 54.4 lb Natural teeth I50 lb 2) Root configuration Roots that are broader labiolingually are preferable to roots that are round in cross section. Multirooted posterior teeth with widely separated roots will offer better periodontal support than roots that converge, fuse or generally present a conical configuration. The tooth with conical roots can be used as an abutment for a short span fixed partial denture if all other factors are optimal. A single rooted tooth with evidence of irregular configurations or with some curvature in the apical third is preferable to the tooth that has a nearly perfect taper. 3) Periodontal ligament area: - Larger teeth have greater surface area and are When suppoting bone has been lost to periodontal ligament disease the involved teeth have a lessened capacity to serve as abutment . Millimeter per millimeter , the loss ofperiodontal support from root resorption is only 1/3 to 1/2 as critical as the loss of alveolar crestal bone. Johnston et al in in their statement designated as "Ante's law" said that the root surface area of the abutment teeth had to equal or surpass that of the teeth being replaced with pontics. Fixed partial dentures with short pontic spans have a better prognosis than those with long spans. Failures with long span bridges have been attributed to leverage and torque than overload. Biomechanical factors and material failure play an important role in the failure for long span restorations.

There is evidence that teeth with poor periodontal support can serve successfully as fixed denture abutments in carefully selected cases.Teeth with severe bone loss and marked mobility can be used as fixed partial denture and splint abutments. Elimination of mobility is not the goal in such cases, but to prevent further increase in mobility of that tooth by stabilizing it. They said that this is possible in highly motivated patients who are proficient in plaque removal. Biomechanical Considerations All fixed partial dentures, long or short spanned bend and flex. Bending or deflection varies directly with the cube of the length and inversely with the cube of occlusogingi val thickness of the pontic. Compared with a fixed partial denture 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. Biomechanical Considerations Ail fixed partial dentures, long or short spanned bend and flex. Bending or deflection varies directly with the cube of the length and inversely with the cube of occlusogingival thickness of the pontic. Compared with a fixed partial denture 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 8 times if the pontic thickness is halved.Longer pontic spans have the potential for producing more torquing forces on the FPD especially on the weaker abutment. To minimize flexing caused by long/short spans, pontic designs with a greater occlusogingival dimension should be selected. The prosthesis may also be fabricated of an alloy with a higher yield strength, such as nickel- chromium. The dislodging forces of a fixed partial denture retainer tend to act in a mesiodistal direction, as opposed to the more common buccolingual direction of forces on a single restoration. Preparations should be modified accordingly to produce greater resistance and structural durability. Multiple grooves, including some on buccal and lingual surfaces are commonly employed for this purpose. Double abutments are sometimes used as a means of overcoming problems created by unfavourable crown-root ratios and long span. There are several criteria that, must be met, if a secondary abutment is to strengthen the fixed partial denture. A secondary abutment must have atleast as much root - surface area and as favourable a crown-root ratio as the primary abutment. E.g.: A canine can be used as a secondary abutment to a first premolar primary abutment, but it would be unwise to use a lateral incisor as a secondary abutment to a canine primary abutment. Arch curvature has its effects on the stresses occurring in .a fixed partial denture. When the pontics lie outside the intcrebutment axis line, the pontics act as a lever arm which can produce a torquing movement. This is a common problem in replacing all 4 maxillary incisors with a fixed partial denture. The best way to offset this torque is by gaining additional retention in the opposite direction from the lever arm. The secondary retention must be at a distance equal to the length of the lever arm from the interabutment axis. E.g.: The first pre-molars some times are used as secondary abutments for maxillary fourpontic canine-to-canine FPD.

Replacement of a single missing tooth Unless bone support has been weakened by advanced periodontal disease a single missing tooth can almost always be replaced by a three unit FPD that includes one mesial and one distal abutment tooth. An exception is when the FPD is replacing a maxillary or mandibular canine .Under these circumstances the small anterior abutment tooth needs to be splinted to the central incisor to prevent lateral drift of the FPD. A) Canine Replacement FPDs

This is a problem because often the canine lies outside the interabutment axis. The abutments are the lateral incisor, usually the weakest in the entire arch and the first premolar, the weakest posterior tooth. A FPD replacing maxillary canine is subjected to more stresses than that replacing a mandibular canine, since forces are transmitted outward on the maxillary arch. So the support from secondary abutments will have to be considered. An edentulous space created by the loss of a canine and any 2 contiguous teeth is better restored with a removable partial denture. B) Cantilever FPDs A cantilever FPD is one that has an abutment or abutments at one end only, with the other end of the pontic remaining unattached. This is a potentially destructive design with the lever arm created by the pontic.The pontic acts as a lever that tends to be depressed under forces with a strong occlusal vector. Abutment teeth for cantilever FPDs should be evaluated for lengthy roots with a favourable configuration, good crown root ratios and long clinical crowns. Generally, cantilever FPDs should replace only one tooth and have atleast 2 abutments. A cantilever can be used for replacing a maxillary lateral incisor with canine as the abutment. There should be no occlusal contact on the pontic in either centric or lateral excursions. A cantilever pontic can also be used to replace a missing 1 premolar with second premolar and 1 molar as abutment. The occlusal contact should be limited to the distal fossa on the 1 premolar pontic. Cantilever FPDs can also be used to replace molars when there is no distal abutment present. Most commonly the 1 molar is replaced with the 2 premolars as abutments. The pontic should have maximum occlusogingival height, there should be light occlusal contact On the pontic with no contact in any excursions. Buccoiingual width should be kept minimum and the pontic should resemble more of a premolar. Assessment of the abutment teeth Each tooth must be thoroughly investigated before proceeding with tooth preparation .Radiographs are made and pulpal health is assessed by evaluating the response to thermal and electrical stimulation. Existing restorations,cavity liners and residual caries are removed and careful check is made for possible pulpal exposure. Teeth in which pulpal health is doubtful should be endodontically treated before the initiation of fixed prosthesis . Conventional endodontic treatment is normally preferred for cast restorations. Endodonticaily treated abutments

A tooth treated endodonticaily can serve as an abutment with a post and core foundation for retention and strength but sometimes it is better to remove a badly damaged tooth rather than attempt endodontic treatment Unrestored abutments An unrestored caries free tooth is an ideal abutment .It can be prepared conservatively for a strong retentive restoration with optimum esthetics .The margin of the retainer can be placed without modifications to accommodate existing restoration or caries. Mesially tilted second molar A common problem that occurs is the mandibular second molar abutment that has tilted mesially into the space formerly occupied by the first molar. There is further complication if 3 molar is present. It will usually have drifted and tilted with the 2 molar. If the encroachment is slight, the problem can be remedied by restoring or rccontouring the mesial surface of the third molar with an overtapered preparation on the second molar where the retention must be bolstered by the addition of facial and lingual grooves. If the tilting is severe, other corrective measure will have to be followed. The treatment of choice is uprighting of the molar by orthodontic treatment. The third molar if present is often removed to facilitate the distal movement of the 2 molar. After removal of the appliance, the teeth are prepared and a temporary FPD is fabricated to prevent post treatment relapse.If orthodontic correction is not possible or if only partial correction is possible then the long axes of the abutments should converge by no more than 25 to 30 o. A mesially tipped molar will exhibit less stress in the alveolar bone but there will be an increase in stress along the premolar. A proximal half crown can be used as a retainer on the distal abutment. This preparation design is a 3 crown that has been rotated 90o. It can be used only if the distal surface is untouched by caries and there is low incidence of proximal caries in the mouth. A telescoping crown and coping can also be used as a retainer for the tilted molar. 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. The proximal half crown that will serve as the retainer for the FPD is fitted over the coping. A non-rigid connector is another solution to the problem. A full crown preparation is done on the tilted molar, with its path of insertion parallel with the long axis. A box form is placed on the distal surface of the premolar to accommodate a key way in the distal of the premolar crown. Span length Excessive flexing under occlusal loads may cause failure of a long span FPD. It can lead to fracture of a porcelain veneer ,breakage of a connector, loosening of a retainer or an unfavourable soft tissue response and thus render a prosthesis useless. The longer the span the greater the flexing. Replacing three posterior teeth with an FPD rarely has a favourable prognosis especially in the mandibular arch. It is better to recommend an implant supported prosthesis or a RPD. When a long span FPD is fabricated .pontics and connectors should be made as bulky as possible to ensure optimum rigidity without jeopardizing gingival health. The prostheses should be made of a material that has high strength and rigidity. Replacing multiple anterior teeth

The 4 mandibular incisors can be usually replaced by a simple FPD with retainers on each canine. It is not necessary to include the first premolars. If a lone incisor remains ,it should be removed because its retention unnecessarily complicates the design and fabrication of the FPD and can jeopardize the long term result. The loss of several maxillary incisors presents a much greater problem in terms of restoring appearance and providing support. Because of the curvature of the arch forces directed against a maxillary incisor pontic tend to tip the abutment teeth .The canines and premolars are used as abutment teeth. If anterior bone loss has been severe due to trauma or periodontal disease there may be a ridge defect In these patients an RPD should be considered. Special Problems Pier abutments: An edentulous space can occur on both sides of a tooth, creating a lone, freestanding pier abutment. Physiologic tooth movement, arch position of the abutments and a disparity in the retentive capacity of the retainers can make arigid 5-unit fixed partial denture as a less than ideal plan of treatment.Because of the distance through which movement occurs, the independent direction and magnitude of movements of the abutment teeth and the tendency of the prosthesis to flex ,stress can be concentrated around the abutment teeth as well as between retainers and abutment preparations, It has been theorized that forces are transmitted to the terminal retainers as a result of the middle abutment acting as a fulcrum, causing failure of the weaker retainer. However a photoelastic stress analysis study conducted by Standlee and Caputo in 1988 has shown that the prosthesis bends rather than rocking.Intrusion of the abutments under the loading could lead to failure between any retainer and its respective abutment. The retention on the smaller anterior tooth is usually less than that of the posterior tooth because of its smaller dimensions. The loosened casting will leak around the margin and caries is likely to become extensive before discovery. - The use of a non-rigid connector has been recommended to reduce this hazard, The movement in a non-rigid connector is enough to prevent the transfer of stresses from the segment being loaded to the rest of the FPD.The non rigid connector is a broken stress mechanical union of retainer and pontic.. The most commonly used non-rigid design is a T shaped key that is attached to the pontic and a dove tail key way placed within a retainer.The use of the nonrigid connector is restricted to a short span fixed partial denture replacing one tooth. The magnification of force created by a long span is too destructive to the abutment tooth under the soldered retainer. Prostheses with non rigid connectors should not be used if prospective abutment teeth exhibit significant mobility. There must be equal distribution of occlusal forces on all parts of the fixed partial denture. A non rigid FPD transfers shear stress to supporting bone rather than concentrating it in the connectors. It appears to minimize mesiodistal torquing of the abutments while permitting them to move independently . A rigid FPD distributes the load more evenly than a non rigid design making it preferable for teeth with decreased periodontal attachment. It is usually placed on the middle abutment since placement on either of the terminal abutments could result in the pontic acting as a lever arm. The key way of the connector should be placed within the normal distal contours of the pier abutment and the key should be placed on the mesial side of the distal pontic.The long axes of the posterior teeth usually lean slightly in a mesial direction and vertically applied occlusal forces produce further movement in this direction. If the keyway of the connector is placed on the distal side of the pier abutment mesial movement seats the key into the keyway more sol idly.Placement of the keyway on the mesial side causes the key to be unseated during its mesial movements. This could cause a pathologic mobility or failure of the retainer.

Treatment sequence of symptoms The relief of discomfort accompanying an acute condition is a priority in planning treatment. Discomfort due to a fractured tooth,acute pulpitis, acute exacerbation of chronic pulpitis ,a dental abscess ,acute pericoronitis or gingivitis should be identified and treated. Stabilization of deteriorating conditions Second phase of treatment Involves stabilizing conditions such as dental caries or periodontal disease by removing the etiological factors, increasing the patients resistance or doing both. a) Replacement of defective restorations b) Removal of carious lesions c) Recontourtng of overcontoured crowns near furcation areas d)Proper oral hygiene Instruction adequately Implemented at home 3) Definitive therapy After the stabilization phase has been completed successful elective long term treatment aimed at promoting dental health.restorlng dental health ,restoring on and Improving appearance can begin, a) Oral surgery- The treatment plan should allow time for healing and ridge remodel ling , Teeth with a hopeless prognosis, unerupted teeth and residual root and root tips should be removed early, All preprosthetic surgical procedures should be undertaken during the early phase of treatment b)Periodontics- Any surgery,pocket elimination .mucoginglval procedure,guided tissue regeneration or root resection Is performed at this time c) Endodontics- If a tooth with doubtful pulpai health is to be used as an abutment for an FPD it should be endodontically treated prophylactically. d)Orthodontics- Minor orthodontic tooth movement is a common adjunct to fixed prosthodontics. A tooth can be uprighted, rotated ,moved laterally intruded or extruded to improve its relationship before fixed prosthodontic treatment. e)Fixed prosthodontics - Occlusal adjustments- They are often necessary before the initiation of fixed prosthodontics. An accurate and well tolerated occlusal relationship may be obtainable only if a discrepancy between maximal intercuspation and centric relation is eliminated first. Any supraeruption or drifting must be corrected rather than allowed to compromise the patient's occlusal scheme. - If both anterior and posterior teeth are to be restored the anterior teeth are usually restored first because they influence the border movements of the mandible and thus the shape of the occlusal surfaces of the posterior teeth. If the posterior teeth are restored first a subsequent change in the lingual contour of the anterior teeth could require considerable adjustments of the posterior restorations. - Restoring opposing posterior segments at the same time is often advantageous. This allows the development of an efficient occlusal scheme through the application of an additive wax technique .Treatment of one side of the mouth should be completed before the other side is treated ,restoring all 4 posterior segments at the same time might lead to considerably more complications or the patient and dentist. 4) Follow up A specific program of follow up care and regular recall is an essential part of the treatment plan .The aim is to monitor dental health identify the signs of disease early and initiate prompt corrective measures as necessary .Restorations do not last forever ,are

subject to wear and may need replacement .Adequate follow up will help maintain long term health. Conclusion In preparing for battle I have always found that plans are useless, but planning is indispensable. Dwight D. Eisenhower

References 1) Malone W.F.P., Koth D.L., Cavazos E. : Tylmans theory of practice of fixed prosthodontics. 8 th edition,1977, lshiyaku publications, St.Louis,1-24 2) Rosenstiel R.F., Land M.F., Fujimoto J.: Contemporary fixed prosthodontics. 4th edition,1988, Mosby Publications, India, 42-109 3) Shillingburg H.T., Hobo S., Whisett L.D., Jacobi R., Brackett S.E. Fundamentals of fixed prosthodontics, 3 Ed., Quintessence Publication,2007,India ,73-104 4) D.J Jacobs, J.G Steele, R.W Wassell,Considerations when planning treatment, British Dental Journal 2002;192,5:257-267 5) D.J Jacobs, J.G Steele, R.W Wassell,Changing patterns and the need for quality, British Dental Journal 2002;192,3: 144-148 6) D.J Jacobs, J.G Steele, R.W Wassell,Material selection, British Dental Journal 2002;192,4: 199-211 7) Thomas J . Mc Garry ,Classification system for partial edentulism , J Prosthodont 2002; 11,3:181-193 8) FixedDTP.ppt 9) FPDintro.ppt