Diagnosis And Treatment Planning In Fixed Partial Denture
Question 1. Discuss the importance of diagnosis and treatment planning in fixed partial dentures.
Diagnosis is the examination of the physical state, evaluation of the mental or psychological makeup, and understanding the needs of each patient to ensure a predictable result.
Treatment planning means developing a course of action that encompasses the ramifications and sequelae of treatment to serve the patient’s needs.
fixed partial denture Diagnosis
Diagnosis in fixed partial denture includes:
- Chief complaints.
- History taking of the patient.
- Examination.
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- General examination
- Temporomandibular joint examination
- Extraoral examination
- Intraoral examination
- Occlusal evaluation
- Abutment tooth evaluation.
- Making of diagnostic casts.
- Full-mouth radiographs.
Fixed Partial Denture Chief complaints
Are mainly of four categories:
- Comfort (pain, sensitivity, swelling).
- Function (difficulty in mastication or speech).
- Social (bad taste or odor).
- Appearance (fractured or discolored tooth).
Comfort
fixed partial denture Pain
Location, character, severity, and frequency of the pain should be noted as well as the first time it occurred, the factors increasing pain (For example. hot or cold things), and any changes in its character.
fixed partial denture Swelling
The location, size, consistency, and color change during inflammation and the duration, and frequency of the swelling need to be noted.
fixed partial denture Function
Difficulties in chewing can be due to a fractured cusp or generalized malocclusion. Speech difficulty may be due to local causes or systemic problems.
fixed partial denture Social
A bad taste or smell may be due to poor oral hygiene or periodontal disease.
fixed partial denture Appearance
- Missing or crowded teeth
- Fractured tooth or restoration
- Malpositioned or discolored teeth
- Congenital anomalies of dentition.
fixed partial denture History
- Personal details (name, age, sex, address).
- Medical history.
- Drug history.
- Dental history.
- Periodontal history
- Restorative history
- Endodontic history
- Orthodontic history
- Removable prosthodontic history
- Oral surgical history
- Radiographic history
- TMJ dysfunction history.
fixed partial denture Medical history
- Any cardiac ailments, requiring antibiotic premedication before treatment, CNS disorders or other systemic diseases affecting treatment method. Hypertensive patients and coronary disease patients should not be given epinephrine
- Any previous radiation therapy, blood disorders, or terminal illness affecting treatment plan
- Systemic conditions with oral manifestations
- Infective diseases such as aids, hepatitis, and syphilis need to be evaluated.
fixed partial denture Drug history
Previous medication history, drug allergies, and if the patient is taking any medicines routinely should be noted.
Dental history
Periodontal history
Oral hygiene status, any previous oral hygiene prophylaxis, or any previous periodontal surgery is noted.
Restorative history
All restorations of amalgam and tooth-colored restorations along with the time of these restorations are noted.
Endodontic history
If the endodontically restored tooth is a prospective abutment tooth then a radiographic evaluation of the periapical health is noted.
Orthodontic history
If the radiographic evaluation shows root resorption, it can be due to previous orthodontic treatment. Occlusal adjustment with minor tooth movement can promote long-term positional stability of the teeth and reduce, or eliminate, parafunctional activity.
Removable prosthodontic history
Previous removable prostheses must be carefully evaluated and the duration of wear needs to be noted.
Oral surgical history
Missing teeth and periods of edentulousness should be noted.
Radiographic history
Previous radiographs and current diagnostic radiographic series aid in assessing the progress of the disease. It also aids in locating impacted teeth, root tips, cysts, and tumors.
TMJ dysfunction history
- Pain or clicking in the temporomandibular joints.
- Tenderness to palpation.
- Difficulty in opening the mouth.
- Deviation while opening.
- The above symptoms with any treatment done earlier for the dysfunction as occlusal appliances, medications, or exercises should be noted.
fixed partial denture Examination
General examination
General appearance, gait, weight skin color (anemia or jaundice). Vital signs, such as respiration, pulse, temperature, and blood pressure, are measured and recorded.
Temporomandibular joint examination
- Bilateral palpation anterior to the auricular tragi while the patient opens and closes the mouth, can locate disorder in the posterior attachment of the disk
- Tenderness clicking, or pain is noted
- A jaw opening of less than 40 mm indicates a restriction
- Deviation from the midline is also recorded
- Maximum lateral movement can then be measured (normal is about 12 mm)
- Masseter and temporal muscles are palpated for signs of tenderness and classified as mild, moderate, or severe.
Extraoral examination
Includes noting of:
- Facial asymmetry
- Cervical lymph node palpation
- TMJs and the muscles of mastication
- Lips: Smile line, negative space between the maxillary and mandibular teeth when the patient laughs, missing teeth, diastema, and fractured or poorly restored teeth are noted.
Intraoral examination
Soft tissues, teeth, and supporting structures such as the tongue, floor of the mouth, vestibule, cheeks, and hard and soft palates are examined and findings are noted.
Periodontal examination
- Oral hygiene status assessment
- Examination of gingiva, periodontium, and the response to the host tissues (BPE)
- Healthy gingiva is pink, stippled, and bound to the underlying connective tissue
- The texture, size, contour, consistency, position, and color are noted. Any exudate or pus is examined for
- The width of the keratinized attached gingiva around each tooth is assessed.
Examination of teeth
- Absence of teeth, dental caries, any restorations, wear faceting, fractures, abrasions, malformations and erosions are noted
- Pocket depths (usually six per tooth) are recorded on a periodontal chart.
Occlusal examination
- General alignment
- Lateral and protrusive contacts
- Centric relation
- Jaw maneuverability.
General alignment
The teeth can be evaluated for crowding, rotation, over-eruption, spacing, malocclusion, and vertical and horizontal overlap.
Lateral and protrusive contacts
The presence or absence of tooth contact in eccentric movements is verified with a thin Mylar strip. Tooth movement (fremitus) should be identified by palpation.
Centric relation
The relationship of teeth in both centric and intercuspal positions is assessed. If a slide from CR to IP is present, its horizontal and vertical components can be estimated and a note made of any lateral deviation.
Jaw manoeuvrability
The ability and ease with which the patient moves the jaw and the guiding movements should be assessed.
Check for habitual occlusion.
Abutment tooth evaluation
- Abutment teeth need to be strong enough to withstand the forces directed to the missing teeth in addition to those usually applied to the abutments
- Abutment teeth should not exhibit mobility
- An asymptomatic endodontically treated tooth can be considered for an abutment provided it can withstand the forces transmitted to it
- The supporting tissues surrounding the abutment teeth should be healthy and free from inflammation.
Evaluation of abutment teeth includes:
- Crown–root ratio
- Tooth configuration
- Periodontal surface area
- Vitality testing.
Crown–root ratio
An abutment teeth should have a combined pericentral area equal to or greater in peri cemental area than the tooth or teeth to be replaced (Antes law).
Tooth configuration
- Root shape: Short conical roots give less support. Divergent multiple roots give good support.
Periodontal surface area
Root surface area: Larger teeth will have greater surface area and will handle stress better.
Vitality testing
Prior to any restorative treatment, pulpal health must be assessed by measuring the response to percussion as well as thermal and electrical stimulation.
Diagnostic casts
- Articulated diagnostic casts aid in planning treatment procedures, provide information about static and dynamic relationships of the teeth, and help to view several aspects of the occlusion not detectable within the confines of the mouth.
Advantages of diagnostic cast
- Changing the arch relationship before orthognathic procedures
- Changing the tooth position prior to orthodontic procedures
- Modifying the occlusal scheme before attempting any selective occlusal adjustment
- Trial tooth preparation and waxing can be done before fixed restorative procedures
- The selection of an optimum path of withdrawal of a fixed partial denture can be assessed.
Radiographic examination
- Periapical radiographs.
- Bitewing radiographs.
- Panoramic films.
- Transcranial exposure, serial tomography, arthrography, CT scanning, or magnetic resonance imaging in case of TMJ disorders.
Periapical Radiographs Uses
- To assess the extent of bone support, the quality of supporting bone
- Detailed root morphology of each abutment tooth
- Width of periodontal ligament space
- Bone resorption (vertical, horizontal)
- Inclination of teeth
- Continuity of lamina dura
- Pulpal morphology and previous endodontic treatment
- Any periapical pathology can be evaluated
- Evaluation of crown–root ratio
- Evaluation of the shape, length, and direction of the root
- Helps in checking for the periodontal situation of the abutment tooth, as widening or thickening of lamina dura, occlusal prematurities, or trauma can cause thickening.
Bitewings Use
Evaluation of caries on proximal surfaces and secondary caries on previous restorations.
Panoramic Films Uses
- Evaluation of bone resorption, pattern of bone resorption, and quality of bone support
- To check for the presence of retained root tips, impacted tooth
- To determine the thickness of soft tissue on the ridge in an area of pontic placement
- They do not provide a detailed view for assessing bone support, root morphology, or caries.
Treatment Planning
Treatment planning helps to design and select the material of choice for a particular situation.
The design and material choice depends on:
- Amount of tooth structure present
- Esthetics
- Plaque control.
Choice of restoration
In the following situations, fixed partial dentures are contraindicated and the restoration of choice is a removable partial dentures.
- Large edentulous space
- Edentulous space with no distal abutment
- Bilaterally edentulous with no distal abutment
- Grossly tipped teeth
- Periodontally weak teeth
- Teeth with short clinical crowns
- Severe bone resorption
- Young age
- Large tongue
- Extensive caries with poor oral hygiene.
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