‫بسم هللا الرحمن الرحيم‬

Diagnosis
Related to Fixed Prosthodontics

By
Assoc. Prof. Lamia Dawood
 Diagnosis
 Definition:
It is the procedure of collecting data and
information through different channels so that a
proper line of treatment could be proposed.
  Diagnostic Elements
I. History.
II. Clinical Examination.
III. Diagnostic Cast Analysis.
IV. Full Mouth Radiographs.
 History
Should include all pertinent information
concerning the reasons for seeking treatment, along
with any personal information, including relevant
previous medical and dental experiences.

All the history data are preferable to be

collected in a Screening Questionnaire
Form that filled by the patient himself as
much as possible.
 I. History
1. Personal Data.
2. Medical History.
3. Dental History.
 1. Personal Data
⚫ Patient’s Name.
⚫ Age.
⚫ Sex.
⚫ Address.
⚫ Phone Number.
⚫ Marital Status.

⚫ Occupation.
 2. Medical History
 Importance:
⚫ To determine any special precautions before
treatment.

⚫ To pre–medicate some patients before treatment.

⚫ To eliminate or postpone prosthodontic treatment due

to patient’s psychological or physical health.
 Classification of the Medical History
Conditions:
A. Conditions affecting the treatment methods.
B. Conditions affecting the treatment plan.
C. Systemic conditions with oral manifestations.
D. Systemic conditions that have risk factors to
the dentist and his auxiliary personnel.
A. Conditions Affecting the Treatment Methods

• Disorders that necessitate the use of Antibiotic pre-

medication.
• Patients under Steroid therapy.
• Patients receiving Anticoagulant drugs.
• Patients suffering from Allergic reaction.
• Patients with Cardiac Pacemakers.
• Patients with a history of Hypertension or Coronary heart
disease.
• Epileptic patients.

• Uncontrolled Diabetic patients.

B. Conditions Affecting the Treatment Plan

◼ Patient receiving previous Radiation Therapy at the head and

neck region. (hyperbaric oxygen to prevent serious
complications).

• Patients with prolonged presence of Xerostomia or dry

mouth.

• Patients with Hemorrhagic Disorders.

• Extremes of age and Terminal illness.

C. Systemic Conditions with Oral Manifestations

1. Periodontally affected patients due to diabetes, menopause,

pregnancy or the use of some drugs as; cyclosporine or
anticonvulsant as; Dilantin.

Pregnancy Tumor. Gingival Hyperplasia due to Dilantin..

2. Patients with Teeth Erosion that is due to stomach
acid regurgitation as in cases of gastro–esophageal
reflux disease, bulimia and anorexia nervosa.

Enamel Loss due to Erosion.

3. Patients suffering from Xerostomia or Dry Mouth
that may be due to large doses of radiation in the
head and neck region or due to drugs such as
antihistaminic, antihypertensive or anticholinergic.
D. Systemic Conditions that have Risk Factors
to the Dentist and Auxiliary Personnel
⚫ The possible Infectious Diseases are hepatitis B & C
viruses, HIV, syphilis, herpes simplex, varicella
zoster and mycobacterium T.B. that are mainly
transmitted through; direct contact, saliva, blood
and respiration.

⚫ The universal infection control precautions should be

practiced for every patient either carrier to an
infectious disease or normal one to ensure the full
infection control.
 3. Dental History
A. The patient’s Previous Dental Treatments.

B. The patient’s Attitude and Expectations.

C. The patient’s Chief Complaint.

A. The Patient’s Previous Dental Treatments

 It includes:
Periodontal, Restorative, Endodontic, Orthodontic,
Removable Prosthodontic, Oral Surgery,
Radiographic and Temporo-mandibular Joint
Dysfunction History.

It gives an idea about patient’s level of dental awareness

and the expected patient’s cooperation.
DENTAL HISTORY

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 ORAL SURGICAL HISTORY

◼ Information about missing teeth

and any complications.

◼ Patients who require prosthodontic

care subsequent to orthognathic
surgery.

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 PERIODONTAL HISTORY

◼ The patients oral hygiene is

assessed, current plaque control
measures.

◼ The frequency of any previous

debridement should be recorded.

◼ Dates and nature of any previous

periodontal surgery should be noted.

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 RESTORATIVE HISTORY

◼ Simple composite resin or dental

amalgam fillings may involve
crowns and extensive fixed partial
dentures.

◼ The age of previous existing

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

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 ORTHODONTIC HISTORY

◼ Occlusal analysis should be an integral part of

the assessment of a post orthodontic dentition.

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 REMOVABLE PROSTHODONTIC
HISTORY

◼ The patients experiences with removable prostheses

must be carefully evaluated.

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 RADIOGRAPHIC HISTORY

◼ Previous radiographs may be helpful

in judging the progress of dental
disease.

◼ Avoid exposing the patient to

unnecessary ionizing radiation.

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 TMJ DYSFUNCTION HISTORY

A history of pain or clicking tenderness to palpation should

be treated and resolved before fixed prosthodontic treatment
begins.

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B. The patient’s Attitude and Expectations

♥ The patient’s expectation and desires for esthetic

should be considered but, within the compatibility
of his past dental history.
 C. The Patient’s Chief Complaint

 The patient should express in his Own Words

the exact nature of his Chief Complaint.
 The Chief Complaints mainly are one of the
following:

i. Comfort; Pain, Sensitivity and Swelling.

ii. Function; difficulty in Speech or Mastication.
iii. Social aspects; bad Taste or Odor.
iv. Appearance; Missed, Crowded, Fractured, Mal–
Positioned, Discolored teeth and or teeth with
Developmental Defects.
 II. Clinical Examination
1. General Examination.

2. Extra Oral Examination.

3. Intra Oral Examination.

 1. General Examination
 It includes:
General Appearance, Gait, Weight, Skin Color and
the Vital Signs as; Pulse, Temperature, Blood
Pressure and Respiration.
 2. Extra Oral Examination

 It includes:

Facial Asymmetry, Cervical Lymph Nodes,

Tempro–Mandibular Joints, Occlusal Evaluation,
Muscles of Mastication and Lips.
 Tempromandibular joints
⚫ Bilaterally palpation of the joints anterior to the auricular
tragi as the patient opens and closes his mouth reveals the
existence of any signs of dysfunction.

Bilateral palpation of TMJs

Maximum opening of the jaw
must be measured
( more than 50 mm) .

- If less than 35 mm
it is an indication of
jaw restriction.
◼ The maximum mandibular lateral movement of
about 12mm. is considered normal.
 Muscles of mastication

⚫ Muscle’s pain and spasm is usually associated

with Para-Functional habits as; Clenching,
Bruxism, Continuous Biting, Stresses and Faulty
Occlusion.
Muscles of mastication
⚫ Muscles of mastication are examined by Palpation.

Masseter Temporalis

Trapezius Sterno-mastoid
Palpation sites for assessing muscle tenderness. A, TMJ capsule: lateral
and dorsal. B, Masseter: deep and superficial. C, Temporal: anterior and
posterior. D, Vertex. E, Neck: nape and base. F, Stern ocleidomastoid:
insertion, body, and origin. G, Medial pterygoid. H, Posterior digastric.1,
Temporal tendon. J, Lateral pterygoid
 Examination of Lips
⚫ External and Internal aspects of lips should be
examined.

⚫ Evaluates the patient’s normal and exaggerated

smiling considering teeth exposure.
 3. IntraOral Examination
 It includes:
⚫ Oral Hygiene, Caries Index, Abnormal Habits, Soft
and Hard Tissues, Supporting Structures, Occlusion
and finally the Prospective Abutment.
  Diagnostic Aids
• Dental Charting: • Digital IntraOral Camera:
 Gingival Examination

Healthy gingival Chronic gingivitis

 Periodontal Examination

Periodontal Examination using the Periodontal Probe.

 Abnormal habits

 It includes:
Bruxism, Pipe Smoking and Pencil Biting. They
increase the lateral forces and occlusal trauma, which
will affect the type of the prosthesis.
 Soft Tissues
 It includes the Form, Texture and Color of;

⚫ External and internal aspects of lips.

⚫ Dorsal and lateral borders of the tongue.

⚫ Floor of the mouth.

⚫ Vestibule.

⚫ Cheeks.

⚫ Hard and soft palate.

⚫ Throat & tonsillar region.

Hard Tissues

• The number and length of the edentulous spans.

 Occlusion
⚫ Occlusal Evaluation:
It should be carried out for; Wear Facets, Premature
Contacts, Cuspal Interference either in centric or in
eccentric movements.

⚫ Teeth General Alignment:

It should be evaluated for; Crowding, Rotation,
Spacing, Supra–Eruption, Vertical and Horizontal
Overlap as well as Malocclusion.
Types of bites

Normal Occlusion

Open Bite

Deep Over Bite

Types of bites

Posterior Cross bite Cross bite

 Proposed Abutment
♣ It should be examined for;
i. Carious Lesions.
ii. Pulp Conditions, Vitality.
iii. Mobility.
iv. Periodontal Conditions.
v. Coronal Defects.
i. Carious Lesions
⚫ Carious lesions can be early detected by; Caries
Detection Dyes, Fiber–Optic Trans–illumination
or Laser Fluorescence ‘‘Diagodent’’.

♣ Diagodent:
It is a new laser fluorescence system that used for
early detection and diagnosis of tooth decay.

Diagodent with hand piece. Pen-like device.

 Carious Lesions
⚫ After excavation of the ⚫ The old filling in the
carious lesion, the amount prospective abutment
of remaining tooth should be removed to
structure is evaluated. detect any recurrent caries
underneath.
ii. Pulp Conditions and its Vitality
♣ Available testing techniques either:
1. Electrical pulp tester.

2. Thermal testing;
a. Cold …… ethyl chloride, ice.
b. Hot …… gutta percha, impression
compound.
♥ N.B.:
⚫ Vital pulp……… suitable abutment.
⚫ Non-vital pulp… … brittle, weak abutment,
→ full coverage retainers.
⚫ Doubtful pulp condition or pulp capped tooth
should not be used as abutment for fixed
prostheses. → endodontic ttt.
 iii. Mobility
 Miller’s classification for tooth mobility
⚫ Grade 1 = first distinguishable sign of movement greater
than normal.

⚫ Grade 2 = total movement of 1mm ..... add abutment.

⚫ Grade 3 = total movement > 1mm in any direction and

/or is depressible … …extraction.
iv. Periodontal conditions
 It should be examined for;
Gingival Condition, location of the Epithelial
Attachment, Pocket Depth, Gingival Recession and
Furcation Involvement.
v. Coronal Defects
 It should be examined for;
1. Areas of Attrition, Erosion, Abrasion.
2. Discoloration either; Extrinsic, Intrinsic.
3. Fracture.
4. Defect in Crown Morphology.
5. Malposition.
1. Attrition, Abrasion and Erosion
⚫ Attrition: Physiologic loss occurs with age due to tooth
contact during normal function.
⚫ Abrasion: Mechanical loss due to incorrect tooth
brushing.
⚫ Erosion: Chemico–Mechanical loss due to chemicals as
lemon and alcohol or gastric vomiting.

Attrition Abrasion Erosion

 2. Discoloration
⚫ Intrinsic Discoloration:
Pulp Death.
Improper Root Canal treatment
Dental Flourosis.
Internal Resorption pink tooth.
Tetracycline. Non–Vital Pulp. Dental flourosis.

⚫ Treatment:
Bleaching,
Porcelain Laminate Veneers
Full Coverage Restoration
Internal resorption Tetracycline stain
⚫ Extrinsic Discoloration:

Smoking
Coffee, Tea
Calculus, Tarter.

⚫ Treatment:
Scaling.
Polishing.
Extrinsic Stains
3. Fracture
⚫ According to the extent of tooth fracture, the
type of restoration will de determined.
4. Defects in Tooth Crown Morphology
⚫ Defects in the Form and Size:
i. Hutchinson Teeth in case of syphilis.
ii. Moon’s Molar ‘congenital anomaly’.
iii. Peg Shaped Lateral ‘congenital anomaly’.

Peg shaped lateral

⚫ Treatment: Hutchinson teeth

Full Coverage Restoration.

Defects in Tooth Crown Morphology
⚫ Short Teeth:
When used as abutment……maximum retention
through……
Preparation with least occlusal taper.
Extension of preparation subgingivally.
Using retainers with metal occlusal surface.
Preparation with retentive grooves.
5. Malposition
⚫ Severely Tilted:
No common path of insertion without over
reduction and endangering its pulp.
The tooth distal to the abutment may interfere with
the insertion bridge.

Severely tilted
⚫ Super Erupted Tooth:
Aim: to restore normal level of occlusal plane.

It is achieved through:
• Enameloplasty ……followed by fluoride application.

• If dentin is exposed ……a full coverage restoration.

• Intentional root canal treatment……full coverage

restoration.

• Tooth extraction is the only choice.

⚫ Infra Erupted Tooth (Ankylosis)

Use full coverage restoration to regain its normal

level in the occlusal plane.
 III. Diagnostic Cast Analysis
 Criteria of Good Diagnostic Casts:
• Accurate reproduction of both arches.

• No bubbles or nodules on the occlusal surface.

• Mounted in Centric Occlusion on a Semi Adjustable

Articulator by means of a Face Bow and Occlusal
Wax Records.
 Functions of Diagnostic Cast
1. Distribution ,Dimensions of
Edentulous Span:

Allow an unobstructed view of the edentulous spans

i. Mesio-distal width …… to assess liability to
flexibility.
Short span → no problem.
Long span → add more abutments.
use hard alloy
ii. Occluso-gingival dimension …… for pontic
design, Material.

iii. Arch curvature ……to assess whether the

pontics will act as lever arm on the abutment.
Maxillary pointed anterior arch … add more abutments.
iv. Distribution and extent of edentulous areas
Single short span…… fixed partial denture.
Multiple edentulous spaces…… removable partial
denture.
2. Occlusal Analysis:
• Permit analysis of occlusion without influence of
patient's neuromuscular system.

• Type of bite whether being normal or anterior or

posterior cross bite, deep over bite or over jet.

• Occlusal Prematurities as well as the wear facets,

their number, size and location could be evaluated.
3. The Occlusal Discrepancies and the Need
to Establish a New Occlusal Plane:

They can be easily spotted, evaluated by the aid of

radiographs. The amount of the occlusal reduction can be
previously determined.
4. Changes in Teeth Axial Inclination for
a Common Path of Insertion:

With the aid of Surveyor and Radiographic

Evaluation.
5. Abutment Teeth Form, Size and Mal-
position:

The type of retainer and the retentive features

needed are determined according to the length,
size and form of the abutment teeth.
6. Planning for Suitable Bridge Design.
7. Tooth Preparing and Waxing prior Initiating
the Treatment:

It helps to visualize possible problems to be encountered

in the clinical treatment.
Through diagnostic wax–up, the final shape, form of the
prosthesis could be properly assessed.
Diagnostic Wax–Up

Diagnostic Wax–Up
IV. Full Mouth Radiographs
The Radiographic examination necessitates:
1. Extra–Oral Radiographs
Panorama.
Trans–cranial. Tempromandibular joints
Cone beam implant placement
2. Intra–Oral Radiographs
Periapical (14).
Bitewing (4).
 1. Extra–Oral Radiographs
A. Panoramic Radiographs:
Evaluation of bone before implant placement.
Assessment of the third molars.
Presence or absence of teeth.
Screening edentulous arches for root fragments.
B. Trans–cranial:
Examination of the Tempromandibular joints.
If more information is needed………use

Computed Tomography ‘‘CT’’ Scanning.

Magnetic Resonance Imaging ‘‘MRI’’.

CT. MRI
C. Cone beam
2. Intra–Oral Radiographs
Periapical Bitewing

Full–Mouth Radiographs
 Digital Radiography:

Is an electronic detection of an X-Ray

generated image that is electronically
processed to produce an image on a computer
screen.
 Intra–Oral Radiographs
They are used to evaluate:

A. Teeth and their investing structures.

B. Edentulous areas.

C. Remote areas.
A. Teeth and their investing structures
Sequential evaluation of the abutment, which is;

1. Coronal Portion.

2. Pulp Space.

3. Root Portion.

4. Thickness of Periodontal Membrane Space.

5. Periapical Area.
 1. Coronal Portion
i. Carious Lesions:
Carious Lesions on the
proximal surfaces

Any Recurrent Caries

around the previous
restorations.
ii. Local formative defects:
As the Hypo–Plastic Pits and the Amelogenesis
Imperfecta.
2. Pulp space
i. Size, form, shape and location of the
pulp chamber:

It is necessarily especially in cases of:

Over–Eruption.
Mesial Tiling.
Pinhole preparation.
ii. Pulp:

Non–Vital tooth with

endodontic treatment.

Non–Vital tooth without

endodontic treatment
(periapical lesion).
3. Root Portion
Evaluation of roots, supporting tissues revealing:
i. Crown Root ratio (C / R).

ii. Root Configuration.

iii. Periodontal Surface Area.

i. Crown Root Ratio (C / R).
It is the ratio between the linear length of the part
of tooth above the level of alveolar crest of bone
to that part of root embedded in bone.
 Optimum Crown Root Ratio(C/R) is (2/ 3).
 N.B.:
The (1 / 1) Crown Root ratio is accepted in:

• Highly motivated Patient.

• Good Oral Hygiene Patient.
• Favorable Opposing Occlusion.
• Normal Occlusal Pattern.
• Favorable Root Configuration.
 Factors Affecting Crown/Root Ratio:

• Attrition, Wear of the Occlusal Surface

• Alveolar Bone Resorption.

• Periapical Pathosis

• Reduction of the Root Length due to apex–ectomy,

Root Fracture.

• Root Form, Shape as Stunted, Dilacerated Root.

ii. Root Configuration:
• Broader roots Labio-Lingually are preferable than
those Rounded cross section.

• Multi Widely Separated roots provide better support

than Converging Fusing roots.
iii. Periodontal surface area:

 Ante's Law:
‘‘The sum of the periodontal membrane
surface area of the abutment teeth should be
equal or larger than the tooth or teeth to be
replaced’’.
4. Thickness of Periodontal Membrane
Space:
• It is checked for continuity, uniformity in width of
Lamina Dura.

• Any Widening of periodontal membrane correlated

with either occlusal prematurities or occlusal
trauma.
5. Periapical area
• It is checked for the continuity of the
Lamina Dura and Periapical Pathosis.
 B. Edentulous areas
It is examined to detect any Remaining Roots,
Residual Infection, Existing Lesions.
 C. Remote area
• It is examined to detect any Existing Slow
Growing Infection, as Cyst, any Impacted Tooth.