Fixed Prosthodontics Lecture Notes PDF

Fixed Prosthodontics Lecture No:3 Diagnosis and treatment plan Lecturer: Dr.Lana Bahram Khidher BDS,Ph.D in Prosthodontic  Diagnosis and treatment planning Diagnosis : It is the determination of nature of disease process Treatment plan: The sequence of procedures pl...

Fixed Prosthodontics Lecture No:3 Diagnosis and treatment plan Lecturer: Dr.Lana Bahram Khidher BDS,Ph.D in Prosthodontic  Diagnosis and treatment planning Diagnosis : It is the determination of nature of disease process Treatment plan: The sequence of procedures planned for the treatment of a patient following diagnosis. decide the prognosis of the patients Treatment: Is any measure designed to remedy a careful evaluation of all available information, a definitive diagnosis and a realistic treatment plan that offers a favorable prognosis.  There are seven elements to a good diagnostic work-up: Chief complaint Vitality testing history extra-oral examination intra-oral examination diagnostic casts radiographic evaluation 1.Chief Complaint: It should be recorded in patients own words. The accuracy and significance of patient’s primary reason /reasons should be analyzed first. This will reveal problems and conditions of which the patient is often unaware. The complaints usually belong to one of the following categories: 1. Comfort – in terms of pain, sensitivity or swelling. 2. Function – difficulty in mastication or speech. 3. Social – brought about by bad odour and taste. 4. Appearance – compromised aesthetics in terms of fractured or unattractive teeth, restorations or discolourations. 2.History: A patient’s history should include all necessary information concerning the reasons for seeking treatment along with any personal details and past medical and dental experiences that are pertinent. A screening questionnaire is useful for history taking..Medical History: An accurate and current general medical history should include any medication the patient is taking as well as all relevant medical conditions 1. Cardiovascular: It may limit treatment appointments, as these patients cannot tolerate long appointments. They may need prophylactic medications before and/or during treatment. Electrosurgical procedures are avoided in patients with pacemaker. 2. Hypertension: Adrenaline may be avoided in local anesthetic and during retraction procedures. 3. Diabetes mellitus: If uncontrolled, they are predisposed to periodontal breakdown. This affects the prognosis. Stress of dental appointment can also affect them. 4. Xerostomia: Dry mouth patients are prone to caries which can affect the restoration margins. Common causes are drugs and radiation. It affects prognosis. 5. Medications: Medications, that the patient is currently taking, are noted to obtain any history of drug allergy or adverse drug reactions. Anticoagulants may need to be discontinued if any surgical procedure is contemplated. 6. Infectious diseases: To prevent cross-contamination with dental clinical and laboratory personnel. 7. Sensitivity to dental materials: Impression materials and nickel are the most common causes. This may modify treatment plan..Dental History: Obtaining a dental history provides information about previously rendered dental treatment and highlights the following: Genetic predisposition to periodontal disease, malocclusion and facial deformities. Cause for tooth loss Complications following dental procedures. Patient attitude towards oral hygiene measures 3.Clinical examination CLINICAL EXAMINATION consist of the clinician’s use of sight, touch, and hearing to detect conditions outside the normal range. General appearance: Gait and weight are assessed. Skin color : Anemia or jaundice. Vital signs: Respiration, pulse, temperature and blood pressure are measured and recorded. EXTRAORAL EXAMINATION FACIAL ASYMMETRY CERVICAL LYMPHNODES TMJ MUSCLS OF MASTICATION (palpated) DIAGNOSTIC AIDS  RADIOGRAPHS  VITALITY TEST  DIAGNOSTIC CASTS  PERIODONTAL PROBE Pulpal health must be measured before restorative treatment to  PERCUSSION and  THERMAL STIMULATION  VITALITY TESTS Temporo-mandibular joints:  The TMJ is palpated bilaterally just anterior to the auricular tragic.  During mandibular movement clicking, crepitus or alteration of the range of joint is noted.  Maximum jaw opening less than 40mm indicates jaw restriction, because the average opening is greater than 50mm.  Any deviation from the midline is also recorded. Maximum lateral movement can be measured (normal is about 12mm). Muscles of mastication A brief palpation of masseter, temporalis, medial pterygoid, lateral pterygoid, trapezius and sternocleido mastoid muscles may reveal tenderness. The patient may demonstrate limited opening due to spasm of the masseter or temporalis muscle. Intraoral Examination: First the patient’s general oral hygiene is observed. The presence or absence of inflammation should be noted along with gingival architecture and stippling. The existence of pockets should be entered in the record and their location and depth chartered. The presence and amount of tooth mobility should be recorded with special attention paid to any relationship with occlusal prematurities and to potential abutment teeth Radiographic Evaluation: The radiograph should be examined carefully for caries , presence of P.A lesion , the quality of the previous endodontic treatment , alveolar bone level, crown-root ratio , root configuration ,direction of root, Number can be examined ,also the presence of retained root in edentulous areas should be recorded Summary of supplement information, to clinical information, provides by radiographic examination, during this diagnosis phase, are: Extent of bone support Root morphology Peri-apical pathology PANOROMIC RADIOGRAPHS Presence or absence of teeth Evaluating the bone before implant placement. Assessing third molars impactions Screening edentulous arches for buried root tips. Vitality Testing: Prior to any restorative treatment, pulpal health must be assessed, usually by measuring the response to percussion , thermal and electrical stimulation. A diagnosis of non-vitality can be confirmed by preparing a test cavity before the administration of local anesthetic. Electric pulp tester can be also helpful in the assessment of vitality the confines of the mouth. Diagnostic Casts: They should be mounted on a semi adjustable articulator Advantages: 1) Allow an un obstructed view of the edentulous space 2) Allow accurate assessment of the span length and the curvature of the ridge or arch in the edentulous region 3) The shape and length of the abutment teeth can be measured to determine which preparation design will provide adequate retention and resistance. 4) Evaluate path of insertion ( axial inclination of abutment) to determine the need for any modification. 5) No., size and location of wear can be evaluated. 6) Over erupted teeth can be easily spotted and the amount of correction needed can be determine. 7) Evaluate occlusion and Interocclusal space necessary to re-establish a proper occlusal plane. 8) Evaluate the need for any occlusal correction. 9) Used for diagnostic wax-up. 10) Construction of special try and provisional restoration. Diagnostic photographs : There is much diagnostic information to be gained by including photography to comprehensive treatment planning. It allows the practitioner to show the patient a photograph (s) concerning his complain or problem immediately , thereby helping the patient to co-diagnose, understand their needs and complications much better when they can see a picture of their own pathology work with the patient chairside while showing his problem and discus the treatment. WHAT IS AN IDEAL TREATMENT PLAN? Treatment plan that achieves the best possible long-term outcomes for the patient, while addressing all patient concerns and active problems, with the minimum necessary intervention. 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 fdp should be adhered to; 1) Relief of symptoms (chief complaint) 2) Removal of etiological factors (eg; excavation of caries ,removal of deposits) 3) Repair of damage. 4) Maintenance of dental health. 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. Preliminary assessment Emergency treatment of presenting symptoms Oral surgery Caries control and replacement of existing restorations Definitive periodontal treatment Orthodontic treatment Definitive occlusal treatment Fixed prosthodontics Removable prosthodontics Follow up care SELECTION OF THE TYPE OF THE POSTHESIS: FACTORS CONSIDERED BIOMECHANICAL PERIODONTAL ESTHETIC FINANCIAL and PATIENTS WISHES.  Selection should not be less than optimum just because the patient cannot.  Sound alternative to the preferred treatment plan and not apply pressure.  SELECTION OF THE TYPE OF THE POSTHESIS  Conventional Tooth Supported Fixed Partial Denture 1) Abutment teeth are periodontal sound. 2) Edentulous span is short and straight. 3) Expected to provide a long-life of function for the patient. 4) No gross soft tissue defect in the edentulous ridge. 5) Reserved for patients who are both highly motivated and able to afford   RESIN BONDED TOOTH SUPPORTED FIXED PARTIAL DENTURE 1) Defect free abutments where single missing tooth. 2) A single molar (muscles are not well developed). 3) Mesial and distal abutment are present. 4) Moderate resorption and no gross soft tissue defects on edentulous ridges. 5) Younger patients whose immature teeth with large pulps are poor risks for endodontic free abutment preparation. 6) Tilted tooth can be accommodated only if there enough tooth structure to allow a change in the normal alignment of axial reduction. 7) Periodontal splints   Removable partial denture abutment 1) Edentulous spaces greater than two posterior teeth. 2) Anterior space greater than four lncisors. 3) Edentulous space with no distal abutment. 4) Multiple edentulous spaces. 5) Tipped teeth adjoining edentulous spaces and prospective abutments with divergent alignment   IMPLANT SUPPORTED FIXED PARTIAL DENTURE 1) Insufficient number of abutments. 2) Partial attitude and or a combination of intra oral factors make a removable partial denture or FPD a poor choice. 3) No distal abutment. 4) Alveolar bone with satisfactory density and thickness in a broad, flat ridges. 5) Configuration that permit implant placement. 6) Single tooth where defect free adjacent teeth. 7) A span length of two or six teeth can be replaced by multiple implants. 8) Pier in an edentulous span (three or more teeth long).  It is not uncommon to combine two types in the same arch. 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 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 NO PROSTHETIC TREATMENT ????!!!!!!!!!!!!!! 1) Long standing edentulous space into which there has been little or no drifting or elongation of the adjacent teeth. 2) If the patients perceives no functional, occlusal or esthetic impairment.  Fixed Prosthodontics Lecture No:4 Clinical Consideration Before Bridge Construction Lecturer: Dr.Lana Bahram Khidher B.D.S,Ph.D in Prosthodontic A. General factors  B. Local factors Teeth 1. Evaluation of Abutment Abutment Teeth And Factors That Influence On Selection  4-Root surface area of abutment Ante’s law ‘ 'The abutment teeth should have a combined peri-cemental area equal to or greater in peri-cemental area than the tooth or teeth to be replaced