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Diagnosis – Treatment planning- Treatment

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 DIAGNOSIS

 The determination of the nature of a

disease.

TREATMENT PLAN

 The sequence of procedures planned for the treatment of a patient after

diagnosis.

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 Sequel of tooth loss

 Resorption of residual alveolar ridges

 Occlusal disharmony
 Tilting of teeth
 Drifting of teeth

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 FIVE ELEMENTS

 HISTORY

 EXTRAORAL EXAMINATIONS

 INTRA ORAL EXAMINATION

 DIAGNOSTIC CASTS

 RADIOGRAPHIC EXAMINATION

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 HISTORY
- 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 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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 CHIEF COMPLAINT

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)

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 MEDICAL HISTORY
Accurate and current general medical history should include ::

 Medication.

 As well as relevant medical conditions.

 If necessary the patients physician(s) can be

contacted for clarification.
 Conditions affecting treatment plan
 Systemic conditions with oral manifestations
 Possible risk factors for the dental surgeon
and patient .
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DENTAL
. HISTORY

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 ORAL SURGICAL HISTORY
 Information about missing teeth and any complications
that may have occurred during tooth removal is
obtained.

 Before any orthognathic treatment is

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

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 PERIODONTAL HISTORY

 The patients oral hygiene is

assessed, current plaque control
measures are discussed, along with
previously received oral hygiene
instructions.

 The frequency of any previous

debridments or any previous
periodontal surgery should be
recorded .

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 RESTORATIVE HISTORY

 The age and condition of previous

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

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

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 ORTHODONTIC HISTORY

 Root resorption (detected on radiographs) may be

attributable to previous orthodontic treatment and have
implications for future prosthodontic treatment

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REMOVABLE PROSTHODONTIC HISTORY

 The patients experiences with

removable prostheses must be
carefully evaluated.

 Listening to the patients

comments about previously
unsuccessful treatment will
help in assessing whether
future treatment will be more
successful.

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 RADIOGRAPHIC HISTORY

 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 some instances , however , a

current diagnostic radiographic
series is essential and should be
obtained as a part of examination.

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 EXAMINATION
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 EXAMINATION

 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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 EXTRAORAL EXAMINATION

 FACIAL ASYMMETRY

 CERVICAL LYMPH NODES

 TMJ

 MUSCLS OF MASTICATION

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 TMJ DYSFUNCTION HISTORY

- Auricular palpation with light anterior pressure helps

identify potential disorders in the posterior attachment
of the disk.

- 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 treated and resolved before fixed

prosthodontic treatment begins.

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 Mouth opening

 Average opening >50mm

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

 Midline deviation :normal is

12mm

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 MUSCLES OF MASTICATION

 Masseter ,Temporals and Pterygoids are palpated for

signs of tenderness.
 Bilaterally and simultaneously.

 Light pressure.

 Classify the discomfort as

mild, moderate or severe.

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 LIPS ::
 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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 INTRAORAL EXAMINATION
 Condition of the soft tissues ,
teeth and supporting
structures.

 This information can be

properly evaluated during
treatment planning.

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 PERIODONTAL EXAMINATION

 Long term periodontal health is

essential to successful fixed
prosthodontic treatment.

 Existing periodontal disease must be

corrected.

 Status of bacterial accumulation.

 The response of the host tissues and

the degree of irreversible damage.

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 OCCLUSAL EXAMINATION ::
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, and
Eccentric contacts and
jaw maneurability,

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 DIAGNOSTIC AIDS
 RADIOGRAPHS

 VITALITY TEST

 DIAGNOSTIC CASTS

 PERIODONTAL PROBE.

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 RADIOGRAPHIC EXAMINATION

 Extent of bone support

 Root morphology

 Peri apical pathology

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PANOROMIC RADIOGRAPHS
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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TRANSCRANIAL RADIOGRAPHS

Arthrography

C T scanning

Magnetic resonance
imaging

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VITALITY TEST :
Pulpal health must be
measured before restorative
treatment by

 PERCUSSION and

 THERMAL STIMULATION

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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.

 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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INTEROCCLUSAL RECORDS ::

 Centric relation records are used to

replicate on the articulator.

 Lateral occlusal records are used to

the condylar guidance of the
articulator.

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- Articulate with inter
occlusal record

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

 Mock tooth preparations can be done on the casts

along with diagnostic waxing procedures which will
allow evaluation of the eventual outcome of proposed
treatment .

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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

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 Relief of symptoms (chief complaint)

 Removal of etiological factors (eg; excavation of caries

removal of deposits)

 Repair of damage tissues.

 Maintenance of dental health.

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TREATMENT PLANNING

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SELECTION OF THE TYPE OF THE
POSTHESIS ::

 A REMOVAL PARTIAL DENTURE.

 A TOOTH SUPPORTED FIXED PARTIAL

DENTURE OR

 AN IMPLANT SUPPORTED FIXED PARTIAL

DENTURE.

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REMOVABLE PARTIAL DENTURE

 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 abutments.

 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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CONVENTIONAL TOOTH SUPPORTED FIXED
PARTIAL DENTURE
 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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RESIN BONDED TOOTH SUPPORTED FIXED
PARTIAL DENTURE
 Defect free abutments where single missing tooth.

 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 aligment of
axial reduction.

 Periodontal splints.

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IMPLANT SUPPORTED FIXED PARTIAL
DENTURE
 Insufficient number of abutments.

 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 missing tooth where defect free adjacent teeth.

 A span length of more than two to six teeth, which can be

replaced by multiple implants.

 Pier in an edentulous span (three or more teeth long).

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NO PROSTHETIC TREATMENT
 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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 CASE PRESENTATION ::

In cases where the choice between a fixed partial denture and

a removable partial denture is not clear, all 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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Factors effecting design of the restoration :-

 DESTRUCTION OF THE TOOTH STRUCTURE

 ESTHETICS

 PLAQUE CONTROL

 FINANCIAL CONSIDERATIONS

 RETENTION

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 DISTRUCTION OF THE TOOTH STRUCTURE ::

The distruction 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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 ESTHETICS
 PARTIAL VENEER restoration can be used to restore in highly visible
area.

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 ALL CERAMIC CROWNS ::

 commonly used on anteriors

 posteriors (adequate bulk)

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 PLAQUE CONTROL
 Motivate 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 successful

cast metal , ceramic or metal ceramic restorations can be fabricated.

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FINANCIAL CONSIDERATIONS

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 RETENTION ::

 Special concern for :-

- Short teeth

- Removable partial
denture abutment.

o full veneer crowns;

unquestionably most
retentive.

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 INTRA CORONAL RESTORATION

 When sufficient coronal tooth structure exist to retain and protect a

restoration under the anticipated stresses of mastication ,an intracoronal
can be employed.

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METAL INLAY :
 Minor to moderate lesions where esthetic
requirement is low .

 Etchable base metal alloys, if a bonding effect is

desired.

 Restoration of MOD on molars.

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 CERAMIC INLAY ::

 Minor to moderate sized lesion, where esthetic demand is

high.

 MOD ceramic inlays can be used on molars.

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MOD ONLAY
 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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EXTRA CORONAL RESTORATION

 Insufficient coronal tooth.

 Deflective axial tooth structure.

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PARTIAL VENEER CROWN
 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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CERAMIC VEENERS

 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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FULL METAL
 Restore teeth with multiple defective axial surfaces.

 Restricted to situation where there

are no esthetic expectations.

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METAL CERAMIC CROWN
 Multiple defective axial surfaces.

 Fixed partial dentures retainer where full coverage

and good cosmetic results must be obtained.

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ALL CERAMIC CROWN

 Full coverage and maximum esthetics.

 Restricted to situation likely to produce low moderate

stress .

 Usually used on incisors.

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ABUTMENT
EVALUATION

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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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 CROWN ROOT RATIO

 Optimum -2:3

 Minimum -1:1 (acceptable)

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 ROOT CONFIGURATION ::

 Broader LABIOLINGULLAY than MESIODISTALLY.

 Multirooted posterior teeth with widely separated roots.

 Conical roots can be used -for short span.

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PERIODONTAL LIGAMENT AREA ::
 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 .

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 Edentulous ridge.
 Siebert grouped ridge deformities into three
categories:

 Class 1: 32.4% of defects, Loss of faciolingual ridge

width, with normal height.

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Class 2: 2.9% of defects, Loss of ridge
height with normal width.

Class 3: 55.9% of defects. Loss of both

ridge width and height.

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Allen ridge classification

 Mild : less than 3mm

 Moderate : 3-6mm
 Severe : greater than 6mm
 BIOMECHANICAL CONSIDERATIONS

 Increased load placed on the periodontium by a long span

FPD.

 Longer spans are less rigid.

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 - 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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TO MINIMIZE –

 Greater occluso-gingival dimension

 Nickel chromium

 Double abutment

 Multiple grooves

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Special Situations

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 PIER ABUTMENTS ::

 Non rigid connector

 Restrict to short span FPD

 key way -distal contours

of pier a abutment

 key - mesial side of the distal pontic

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MOLAR ABUTMENTS ::

 Mild encroaching- restoring and recontouring

 Tilting is severe –corrective measures

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 CANINE – REPLACEMENT FIXED
PARTIAL DENTURE

 Edentulous spaces created by the loss of canine and any

contiguous teeth is best restored with Implants.

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CANTILEVER FIXED PARTIAL DENTURES ::

 Long 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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 A WORD OF CAUTION::

-The history and clinical examination must provide sufficient data for the
practitioner 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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