FIXED PROSTHODONTIC

(CROWN & BRIDGE)

‫ الكتب المقررة‬Assigned Texts:
1- Fundemental of prosthodontics (Shillinburg latest edition.)
2- Contemporary Fixed prosthodontics (Rosenstiel et al.).
3- Planning and Making Crown and Bridges (Smith et al)

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 – 4 ( ‫محاضرة رقم‬

DIAGNOSIS AND TREATMENT PLANNING OF FIXED
PROSTHODONTIC

Diagnosis
There are five elements to a good diagnostic work up in preparation for
fixed prosthodontic treatment :
1-History 2-Intraoral examination 3- Occlusal/ TMJ Evaluation
4-Diagnostic cast 5-Full mouth radiograph.
1-History:
A good history that should be taken before the initiation of treatment is
important in order to determine what special precaution must be taken and
to correct any mistakes.
Medical history:
1-If a patient reports previous reaction to drugs, as local anesthetic and
antibiotic .
2-Patient who present with a history of ; Cardio-vascular problem
Uncontrolled hypertension ; Rheumatic fever ; Hyperthyroidism and other
relevant conditions.
Note: The patient’s physician should be consulted before treatment the
most previous condition.
Chief complaint:
It is the problem that has brought the patient to the dental office ,for
treatment:
1-Comfort ( pain; sensitivity; swelling ).
2-Function ( difficulty in mastication or speech )
3-Social ( bad taste or odor )
4-Appearance ( fracture teeth or restoration; discoloration …etc )
2-Intraoral Examination
1-General oral hygiene (plaque ; periodontal condition with attention to
potential abutment teeth.)
2- Presence and location of caries ; previous restorations and prostheses
that may need to be replaced.
3- Examine edentulous ridges. 4- Evaluation the occlusion .

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

3- Occlusal/ TMJ Evaluation.
Before to the start of fixed prosthodontic procedures, the patient occlusion
must be evaluated to determine if it is healthy , and within normal limits,
then all treatment should be designed to maintain that occlosal relationship.
If the occlusion is dysfunction, further evaluation is necessary to determine
is the new relation can be correct of the occlusal problem or may increase
it.
Assessment of tempromandibular joints and muscular system should be
done.
4- Diagnostic Casts:
Diagnostic cast are an integral part of the diagnostic procedures. It is
necessary to give the dentist as complete a perspective as possible of the
patient’s dental needs.
Some advantages of having accurately articulated diagnostic cast are:
1. Proposed treatment procedures can be rehearsed on the stone cast
prior to making any irreversible changes in the patient’s mouth.
2. It allow an view of the edentulous spaces and accurate assessment of
the span length as well as its occluso-gingival dimension .
3. It is determine what type of pontic that can be used.
4. The length of abutment teeth, and what preparation designs will
provide adequate retention and resistance.
5. The path of insertion can be anticipated.
6. The provisional restoration can be made

5-Full Mouth Radiograph:

The radiographs provides the dentist with information which helps to

complete the diagnosis.
1. Caries on proximal surfaces and recurring caries around previous
restoration .
2. The presence of periapical lesions should be noted as well as the
extent and quality of previous endodontic treatments.
3. Alveolar bone level particularly of abutment teeth.
4. The crown root ratio of abutment teeth.
5. The length , configuration and direction of the root .
6. Any widening of the periodontal membrane should be corrected
with occlusal premature contacts or occlusal trauma.
7. The presence of retained root tips or other pathology in the
edentulous areas.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 FIXED PROSTHODONTIC
(CROWN & BRIDGE)

Lec:2 )2 ( ‫محاضرة رقم‬ ‫مستوى رابع طب االسنان‬ ‫ محسه الحمزي‬/‫د‬

Treatment Planning
Treatment planning consist of formulating a logical sequence of treatment
in steps to restore the patient’s teeth to good health, with optimal function
and appearance good treatment plan informs the patient about the present
condition, the extent of dental treatment proposed, the time and cost of the
treatment, and the level of home care and professional follow-up that will
be required to achieves success. Treatments is required, identification of
patient needs, correct existing disease, prevent future disease, restore
function, and improve appearance.
Indications for Fixed Bridges
To replace the missing teeth for:
Maintained the integrity of the dental arch. (Fig 1)
Prevent the adjacent teeth that often migrate into the vacated space.
Prevent the opposing teeth from supereruption, if it is occur should
corrected. Restore the mouth to complete function, good appearance, and
speech.
The most usual configuration of an ideal bridge utilize an abutment tooth
on each end of the edentulous space to support the bridge, and if the
abutment teeth are:
Periodontally sound, the edentulous span is short and straight

Fig: (1) The complications of non replacing missing tooth.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

Selection the type of Prosthesis:
Missing teeth may be replaced by one of three prosthesis types:
1- Removable partial denture ( RPD ).
2- Fixed partial denture ( FPD ).
3- Implant-supported fixed partial denture.
The choosing of any type depended on the several factors:
Biomechanical, Periodontal, Esthetic, financial factors, and the
Patient’s wishes. It is not uncommon to combine to types in the same
arch.

1. Removable Partial Denture ( RPD )

It is indicated for:
1. Edentulous spaces greater than two posterior teeth.
2. Anterior spaces greater than four incisors or canine and
contiguous teeth.
3. An edentulous space without distal abutment.
4. Multiple edentulous spaces because the FPD may expense and
complexity.
5. Bilateral edentulous spaces with more than two missing teeth on
one side.
6. When there are unsuitable Abutments for the FPD.
7. Periodontally weakened primary abutments may serve better in
RPD rather than in FPD.
8. Severe loss of tissue in the edentulous ridge.

2. Bridge or Fixed Partial Denture ( FPD )

When a missing tooth is to be replaced, a fixed partial denture is preferred
by the majority of patients. There are different types of FPD that include:
Fixed- Fixed Bridge.
Fixed-movable Bridge.
Simple Cantilever-Fixed Bridge.
Spring-Cantilever Bridge.
Resin-Bonded Bridge.
Movable Bridge.
Combination and Complex Bridges.
Each type of the previous FPD has indications, contraindications,
advantages and disadvantages.
We Discuss Them in The Future.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 3. Implant-supported Fixed Partial Denture:
The Indications :
Fixed partial dentures supported by implants are indicated to the
following:
1. The choice where there are insufficient abutments to support a
conventional FPD.
2. Patient attitude and /or a combination of intraoral factors make a
removable partial denture a poor choice.
3. Implants may be a better choice for FPD abutments if
prospective tooth abutments will require endodontic therapy,
periodontal surgery, and possibly root resections to support a
long-span, complex, and expensive prosthesis.

The Advantages:
1. A single tooth can be replaced by a single implant saving defect-
free adjacent teeth from destructive effect of retainer crown
preparations.
2. A span length can be replaced by multiple implants, either as
single-unit restorations or as implant-supported fixed partial
dentures.

Especial considerations for implant supported FPD:

1. The retainers used for most implant systems require a greater
degree of abutment alignment precision than the natural teeth.
2. The abutments should be positioned so that the occlusal forces
will be as nearly vertical to the implants as possible to prevent
destructive lateral forces.
No Prosthetic Treatment:
If the patient presents with long-standing edentulous space into which
there has been little or no drifting or elongation of the adjacent or
opposing teeth the question of replacement should be left to the
patient’s wishes. Fig 2.

Fig 2.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 FIXED PROSTHODONTIC
(CROWN & BRIDGE)

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬3( ‫محاضرة رقم‬

Selection Of Abutment Teeth

It is the natural tooth or root, which support the bridge from one or
both sides.
The forces, which normally absorbed by missing tooth, are
transmitted, through the pontic, connectors, and retainers, to the
abutments.
X-ray, study cast and clinical examination evaluate the abutment.

Factors Affecting the Selection Of Abutment Teeth

A. General Factors.

1- Age of the patient:

The suitable age for fixed prosthesis work is 18 – 50 years.

Before 18 years:
Large pulp with high pulp horns and no secondary dentin, so the reduction
of the tooth may cause pulp irritation or exposure.
High epithelial attachment. If the finishing line is positioned subgingivally,
gingival recession is developed by the age, which gives poor esthetics.
After 50 years:
Senile gingival recession and exposure of the root.
The crown-root ratio will be affected.
Patient in this age usually suffer from periodontal diseases

2- Oral Hygiene and Caries Index.

Bad oral hygiene is contraindicated for FPD
High caries index patient require full coverage retainers.
Low caries index patient, the partial coverage retainers are indicated.

B. Local Factors :
1- Amount of Existing Caries, and Condition of the Pulp:
Simple, and compound caries should be removed and an adequate
restoration is applied. The tooth must have some sound, surviving coronal
tooth structure to insure longevity. Even then, some compensation must be
made; this can be accomplished through the use of a dowel core, or a pin-
retained amalgam or composite resin core.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

Whenever possible, an abutment should be a vital tooth. However, a tooth
that has been endodontically treated and is asymptomatic, with
radiographic evidence of a good seal and complete obturation of the canal,
can be used as an abutment.
Teeth that have been pulp caped in the process of preparing the tooth
should not be used as FPD abutments unless they endodontically treated.

2- The Roots and Supporting Tissues:

The supporting tissues surrounding the abutment teeth must be healthy and
free from inflammation before any prosthesis can be contemplated.
Normally, abutment teeth should not exhibit mobility since they will be
carrying an extra load. The root and supporting tissues should be evaluated
for four factors:
1.Crown-root ratio. 2.Root configuration. 3.Periodontal ligament area.
4.Span length

1. Crown – Root Ratio. (Fig. 3):

This ratio is a measure of the length of tooth occlusal to the alveolar
crest of bone compared with the length of root embedded in the bone.
The ideal C / R ratio is 1:2.
The optimum C / R ratio is 2:3.
The minimum C / R ratio is 1:1.
However the C/R ratio alone is not an adequate criteria for evaluating
a prospective abutment tooth

(Fig. 3) Crown Root Ratio.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 2. Root Configuration. (Fig. 4 , 5 ).
Roots that are broader labiolingually than they are mesiodistally are
preferable to roots that are round in cross section (Fig. 4 ) .
Multirooted posterior teeth with widely separated roots will offer better
periodontal support than roots that converge, fuse, or a conical
configuration.( Fig. 5 ).
The tooth with irregular configuration or with some curvature in the apical
third of the root is preferable than a perfect taper.

Fig. 4 Fig. 5

3. Root Surface Area or Periodontal Ligament Area:

If the root surface area is large, the tooth will be better equipped to handle
added stress.
The root surface area of the abutments teeth must be assessed when
planning treatment for FPD
This factor depend on the (Ante’s Law).
Ante’s Law: The root surface area of the abutment teeth should
equal ore more than that of missing teeth.
As an example of Ante’s law, considered the patient who has lost a first
molar and second premolar. In this case, a four-unit FPD is acceptable risk
, as long as there has not been bone loss, because the second molar and first
premolar abutments have surface areas approximately equal to those of the
missing teeth. If the first molar and both premolars are missing are missing,
This should be considered a high risk FPD, because the missing teeth have
a greater total root surface area than the abutments.(Fig.6).

Fig.6 Root surface area.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 4. Span Length
Excessive flexing under occlusal loads may cause failure of a long span
FPD.
It can lead to fracture of a porcelain veneer ( Fig 7) breakage of a
connector, loosening of a retainer, or an unfavorable soft tissue response
and thus render prosthesis useless.

Fig 7
The relationship between deflection and length of span is not simply linear
but varies with the cube of the length of the span and inversely with the
cube of the occlusogingival thickness of the pontic. If a span of single
pontic is deflected a certain amount (Fig.8- A), a span of two similar
pontics will move 8 times as much. (Fig. 8- B) and three will move 27
times as much. (Fig.8 - C). A pontic with a given occlusogingival
dimension will bend times as much if the pontic thickness is halved. When
along span FPD is fabricated, pontics and connectors should be made as
bulky as possible to ensure optimum rigidity without jeopardizing gingival
health. In addition, the prosthesis should be made of a material that has
high strength and rigidity.

Double abutments are sometimes used as a means of overcoming problems

created by unfavorable C/R ratios and long spans.
A secondary abutment (remote from the edentulous space) is sometimes
used to strengthen the FPD
However a secondary abutment must has at least as much root surface area
and favorable C/R ratio as a primary abutment (adjacent to the edentulous
space). As an example, a canine can be used as the secondary abutment to a
first premolar primary abutment, but it is unwise to use a lateral incisor as a
secondary abutment, to a canine primary abutment.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

Fig 8- The deflection of a fixed partial denture is proportional to the cube of the
length of its span. A, A single pontic will deflect a small amount (D) when
subjected to a certain force (F). B, Two pontics will deflect 23 times as much (8 D)
to the same force. C, Three pontics will deflect 33 times as much (27 D).

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 FIXED PROSTHODONTIC
(CROWN & BRIDGE)
‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬4( ‫محاضرة رقم‬

Spacial problems
Replacing multiple anterior teeth.
The four mandibular incisors
They can usually be replaced by a simple FPD with retainers on each
canine. Mandibular incisors, because of their small size, generally make
poor abutment teeth.
Thus the dentist may have to make one of the following choices:
Compromised esthetics from too thin a ceramic veneer.
Pulp exposure during tooth preparation.
Other alternative would be selective tooth removal.
The loss of maxillary incisors:
Presents a much greater problem to restoring appearance and providing
support. Because of the curvature of the arch, forces directed against a
maxillary incisor pontic will tend to tip the abutment teeth. Unlike the
mandibular incisors, the maxillary incisors are not positioned in a straight
line. Tipping forces must be resisted by means of two abutment teeth at
each end a long span anterior FPD. Thus, when replacing the four
maxillary incisors, the canines and first premolars as abutment teeth.
Pier Abutments.
An edentulous space can occur on both sides of a tooth, creating alone pier
abutment. The stresses that created by a long span fixed – fixed bridge are
too destructive to the pier abutment. The non-rigid fixed partial denture
(fixed – movable bridge) transfers the stress to supporting bone rather than
concentrating it in the connectors.
The non-rigid connector is a broken – stress mechanical union of retainer
and pontic instead of the usual rigid connector.
The most commonly used non-rigid design consists of a T – shaped key
that is attached to the pontic, and a dovetail key-way placed within a
retainer. (Fig. 9 ).
Special considerations:
Prosthesis with non-rigid connectors should not be used if prospective
abutment teeth exhibit significant mobility.
If the key-way of the connector is placed on the distal side of the pier
abutment, mesial movement seats the key into the key – way more solidly
Placement of the key – way on the mesial side of the pier abutment, causes
the key to unseat during its mesial mobility; this could produce a
pathologic mobility in the canine or failure of the canine retainer. (Fig. 9,D)

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

Fig 9- A, A five-unit FPD replacing the maxillary first molar and first premolar. The
middle abutment can act as a fulcrum during function, with possible unseating of one of
the other abutments. To be successful, this type of FPD needs extremely retentive
retainers. B, An alternative approach is a nonrigid dovetail connector between the molar
pontic and the second premolar. C, Where periodontal support is adequate, a much
simpler approach would be to cantilever the first premolar pontic

Fig. 9 - D

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

 Tilted Molar Abutments.

The common problem that occurs with some frequency is the mandibular
second molar abutment that has tilted mesially into the space of first molar.
It is impossible to prepare the abutment teeth for FPD along the axes of the
respective teeth achieve a common path of insertion. (Fig10 - A). There is
further complication if the third molar is present, because the FPD will not
seat. (Fig. 10 - B).

The alternative treatments are one of the following:

The treatment of choice is the uprighting of the molar by orthodontic
treatment. Inanition to placing the abutment tooth in a better position for
preparation and for distribution of forces under occlusal loading, uprighting
the molar also helps to eliminate bony defects along the mesial surface of
the root. ( Fig.10 - D).
Proximal half crown can be used as a retainer on the abutment, if the distal
surface of the abutment is sound, and the oral hygiene of the patient is
good. (Fig. 10 - C).
A telescope crown and coping can be used as a retainer on the distal
abutment. A full crown preparation with heavy reduction is made to follow
the long axis of the tilted molar. An inner coping is made to fit the tooth
preparation, and the proximal half crown that will serve as retainer for the
FPD is fitted over the coping. ( Fig. 10 - E ).
The non-rigid connector is another solution to this problem; a full crown
preparation is done on the molar, with its path of insertion parallel with the
long axis of that tilted tooth. A box form is laced in the distal surface of the
premolar to accommodate a key-way in the distal surface of premolar
crown. (Fig. 10 - F).

Fig. 10. A, Early loss of a mandibular first molar with mesial tilting and drifting of the second and
third molars. B, A conventional three-unit FPD will fail because its seating is prevented by the third molar.
C, A modified preparation design can be used on the distal abutment. D, A better treatment plan would be
to remove the third molar and upright the second molar orthodontically before fabricating an FPD.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

Canine replacement Fixed Partial Denture

FPD replacing canines can be difficult because the canine often lies
outside the interabutment axis. The prospective abutments are the
lateral incisor, and the first premolar. A fixed partial denture replacing
maxillary canine is subjected to more stresses than that replacing a
mandibular canine, since forces are transmitted outward (labially) on
the maxillary arch, against the inside of the curve . On the mandibular
canine the forces are directed inward (lingually) against the outside of
the curve.

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬

Cantilever Bridge or Fixed Partial Denture:

It has an abutment or abutments at one end, with the other end of the
pontic remaining unattached.
Forces applied to the pontic of a conventional FPD are transmitted to
both abutments.
While the cantilever FPD, the forces applied to the pontic, the pontic
acts as a lever that tend to be depressed under forces, with a strong
occlusal vector.
A cantilever can be used for replacing a maxillary lateral incisor on
the canine.
There should be no occlusal contact on the pontic in either centric or
lateral excursions and the abutment must be has a long root, and good
bone support. There should be a rest on the mesial of the pontic,
against a rest preparation in an inlay or other metallic restoration on
the distal of the central incisor to prevent rotation of the pontic and
abutment.
The mesial aspect of the pontic can be slightly “wrapped around” the
distal portion of the uninvolved central incisor to stabilize the pontic
faciolingually.
The cantilever FPD can also be used to replace a missing first
premolar, if the occlusal contact is limited to the distal fossa. Full
veneer retainers are required on both the second premolar and first
molar.
The cantilever FPD can also be used to replace missing molars when
there is no distal abutment present, and to prevent supereruption of
opposing teeth.
When the pontic is loaded occlusally, the adjacent abutment tends to
act a fulcrum, with a lifting tendency on the farthest retainer.
To minimize the leverage effect, the pontic should be kept as small as
possible.

More information:
1- Fundemental of prosthodontics (Shillinburg latest edition.)
2- Contemporary Fixed prosthodontics (Rosenstiel et al.).
3- Planning and Making Crown and Bridges (Smith et al)

‫ محسه الحمزي‬/‫د‬ ‫) مستوى رابع طب األسنان‬1 - 4( ‫محاضرة رقم‬