Fixed partial dentures
Diagnosis and treatment planning for fixed
prosthodontics
Thomas W. Brehm, D.D.S.*
1Jniuersity of Kentucky, Co&ye oj Dentdry, LPrington, Ky.
N othing is more important in the construction
adequate diagnosis and a well-devised
of fixed partial dentures than ilrl
treatment plan. Although these two subjects
are usually considered together. astute dentists must recognize their subtle differ-
mces.
Ijiagnosis is an evaluation of the condition of the patient when he presents for
treatment. Treatment planning concerns the treatment procedures by which the
dentist will restore the patient to an optimum state of dental health.
To be an accurate diagnostician, the dentist must have a thorough knolvledge of
both health and disease. He must live up to his title of doctor by treating the whole
patient. There is no place in modern dentistry for the narrow perspective of onlv
being concerned about “holes in teeth.”
COLLECTING DIAGNOSTIC DATA
Fixed prosthodontics is primarily a form of dental treatment for young a11d
middle-aged adults. Most patients seeking fixed prosthodontic care are between Ii<
and 60 years of age. All diagnostic data should be collected in a definite and s!‘s-
tematic. manner, and this information should be properly recorded.
Radiographs and photographs. A Panorex radiograph is acceptabir For initial
scanning of the oral cavity, but it is not detailed enough for final diagnosis. Ever\
prospective patient for fixed prosthodontic care should have full-mouth and bite-
wing radiographs. The radiographs will show the size, shape, and lerlgth of the
abutement tooth roots. the sir-c and position oi the pulfj chambers in these teeth.
the amount and thickness of the periodontal ligament. the amount and nature oj
the alveolar bone, and evidence of pathosis such as caries. cysts, tooth fragnrerits.
and abscesses. Full-face and profile photographs should be rnade of the patient.
Such photographs serve as excellent preoperative records.
Occlusal factors. Diagnostic casts rnounted in centric relation on the articulator-
Read before the American Academy of Crown and Bridge Prosthodontics, Chicago, 111
*4ssoclate Professor and Dlrector of Flxed Prosthodontics.
876
Fig. 1. (A) The difference between the attached and the unattached gingiva is readily dis-
tinguishable. (B) An ulcer develops when the unattached gingiva is contacted by a pontic.
are an essential requirement for diagnosis. The casts show the length of the eden-
tulous spaces, the vertical distance betvveen the dental arches, and the form, size.
and individual positions of the remaining teeth. Occlusion can also be observed on
these casts and verified in the patient’s mouth. If occlusal discrepancies exist or if
traumatic occlusion is evidenced, then equilibration should be completed before the
fixed prosthodontic treatment is started. Otherwise the fixed partial denturr will
perpetuate existing occlusal disharmonies.
The interocclusal distance is an important consideration for treatment planning,
particularly if any alteration in the vertical relation of occlusion is anticipated. This
measurement should be made during the diagnostic appointment.
Existing oral hygiene and uitality of teeth. Every thorough diagnosis should in-
cludr a check on the state of the patient’s oral hygiene. An examination with a
periodontal probe for pocket depth should be routine. All existing carious lesions
should be charted, and an effort should br madr to determine thr caries suscepti-
bility of the patient. Every aid in preventive dentistry should be used before con-
structing a fixed prosthesis. Removable partial denturrs are easier to clean, and if
the patient is lazy or indifferent with his home care. the dentist should be slow to
recommend fixed replacements.
All prospective abutment teeth should be tested for vitality, both thermally and
electrically. With satisfactory endodontic therapy, pulpless teeth can be used as
abutments for fixed partial dentures.
Condition of soft tissue and saliva. A soft-tissue examination is a necessity. The
size and position of the tongue are important in tooth alignment and phonetics. The
contour and height of the lips are critical for proper esthetics. The differentiation
between the attached and unattached gingiva of the edentulous ridge is of extreme
importance in determining placement of pontics (Fig. 1). Also, every dentist has
the continuing responsibility to search for soft-tissue tumors in the oral region.
The type and amount of saliva should be noted. Impression making is easier in
the presence of serous saliva rather than the mucin type, and generally serous saliva
is associated with a lovv caries index.
Patient history. A medical history is an essential part of any diagnosis, and the
dentist is responsible to determine the state of health of the patient. The uncon-
078 Breltm
Fig. 2. Initial re,sidual alveolar ridge resorption under an immediate temporan
parti al denture.
trolled diabetic patient, the patient \\ itll cardiovascular diwase or .I lustor!- c.i
rheumatic fever. the asthmatic, patient. xlcl the twrs0n taking arltic.o~,~~ll;rllt~~ ili
other drugs can prewnt a hi,gh risk as a dental patienr.
It is also beneficial to know the patient’s occupation. Certain occupations Gil
influenw the treatment plan. Actors are \.f’r\ conbciouz of esthetics and phonetic>.
and woodwind musicians need strength in anterior restorations to Lvithstand abra
sion from these musical instruments.
THE TREATMENT PLAN
L)f~r~elopin.g tlfe treatment plnn. Treatment planning logically follo\vs tiiagnosk::
The purpose of ;I well-drkised treatmf\nt plan is to w-establish a \i~ll-functioning
oral relationship that is mrchanically and physiologically sound and c~stheticall~
pleasing. The treatment plan should bc formulated before an) treatnwnt i\ CROUP
for. tile patient. 3‘h~l treatnlent plan may b(x changcxd or modified brc~~r~s~ oi t.ondl.
tions cliscovered during treatmwt.
‘r‘he best treatment possible will vary gwatly from patient to patient and must h(,
dr~trrrtlined individualI\-. In certain instancw. tile best treatment i\ no t~eatmerl:
at all. If the partially rrstorcd function and service. of a fixed partial denture :I!‘(
outweighed by the harm this restoration will do to ttw teeth and supporting tissue-.
then no fixed restoration should be constructed
Ideally. el’ery missing tooth should bc replaced SOOII after it has hecs11loht. 1’0 cl{,
so prevents drifting of the adjacent teeth and elongation of the opposing teeth .IIM
restores masticating efficiency esthetics, and phonetic:.
General factors in treatment plannincg fo?- fined prosthodontic-s. It is dificuit u*
be specific: in treatment planning for fixed prosthodontics. because e\-cry patient 15.
different and every treatmcxnt plan should be indi\Gdualized. However. somra ,qenw-ai-
izations can be made.
Immediatc~ fixed partial dentures shonlcl not br c,onstructed. ‘1%~ patient shotlId
wear a11 immediate temporary removable partial denture until ridge healirlg has oc’-
currc,d (Fig. 2’
Diagnosis and treatment for prosthodontics 879
Fig. 3. (A) Three anterior abutment teeth with short clinical crowns. (B) The same three
teeth immediately following gingival surgery. (C) The same three teeth four weeks after
gingival surgery.
A tooth that has been out of function for a long time does not make a good
abutment for a fixed partial denture. Its periodontal ligament is thin, and the
additional stress of supporting the prosthesis can cause periodontal breakdown.
Such a tooth should he brought into function gradually by means of a removable
restoration before using it to support a fixed partial denture.
Tipped teeth do not make good abutments for fixed partial dentures. Paral-
lelism of the preparations is difficult to obtain, and it is impossible to transfer OC-
clusal force along the long axis of such teeth. If a tooth is tilted more than 25 de-
grees, an orthodontic uprighting procedure should he considered.
A pier abutment needs a very strongly designed retainer because of the rocking
action to which it is subjected. No fixed partial denture is any stronger than its
weakest retainer.
.4 tooth with hone loss from periodontal disease is not a good fixed partial den-
ture abutment. At least half of the root should have support from alveolar bone.
If the teeth opposing the edentulous span have elongated, they should he short-
ened and recontoured to restore a harmonious plane of occlusion before constructing
a fixed partial denture.
A tooth with a short clinical crown does not make a good abutment for a
fixed partial denture. Frequently, a localized gingivectomy or an apically reposi-
tioned flap can increase the length of the clinical crown (Fig. 3 )
SELECTING A SUITABLE PROSTHESIS
Selecting tooth form and shade. The diagnostic appointment is a good time to
select the tooth form and shade. Tooth shade should complement the patient’s com-
880 &Qfi?~
Diagnosis and treatment for prosthodontics 881
6. The economic considerations: The design of retainers will be somewhat influ-
enced by the patient‘s ability to pay for the proposed treatment.
SUMMARY
Oral diagnosis and treatment planning have been individually defined and col-
lectively related. The importance of these two subjects in the construction of fixed
partial dentures has been stressed. The steps in an adequate diagnosis have been
listed, and the coordination of this information into a satisfactory treatment plan
has been demonstrated, with some generalizations made about treatment planning
for fixed partial dentures. Some factors influencing the choice between fixed and
removable partial dentures have been enumerated, and the reasons for selectin? cer-
tain designs for fixed retainers were outlined.
References
1. Ante, I. H.: The Fundamental Principles of Abutments, Mich. State Dent. Sot. Bull. 8:
14.23, 1926.
2. Tylman, S. I).. and Tylman, S. G.: Theory and Practice of Crown and Bridge Prostho-
dontics, ed. 6, St. Louis, 1970, The C. V. Mosby Company.
3. Johnston J. F., Phillips, R. W., and Dykema, R. W.: Modern Practice in Crown and
Bridge Prosthodontics, ed. 3, Philadelphia, 1971, W. B. Saunders Company.
4. Wilson, W. tI.$ and Lang, R. L.: Practical Crown and Bridge Prosthodontics, New York,
1962, McGraw-Hill Book Company, Inc.
UNIVERSITY OF KENTUCKY
COLLEGE OF DENTISTRY
LEXINGTON, Ku. 40506
