DESIGNING OF

FIXED
PROSTHODONTICS
Presented by
Marwa Wahsh
Associate professor of fixed prosthodontics
Treatment Of Tooth Loss

 Decision to remove
a tooth
 Consequences of
removal without
replacement
Treatment Of Tooth Loss
Factors affecting the
selection of restoration
 Biomechanics
 Periodontal condition
 Esthetics
 Financial factors
 Patient´s wishes
Selection Of The Type Of
Prosthesis
 Implant Supported Fixed Partial
Denture
 Resin Bonded Tooth-Supported
Fixed Partial Denture
 Conventional Tooth-Supported
Fixed Partial Denture
 Removable Partial Denture
Conventional Tooth-Supported
Fixed Partial Denture
Resin Bonded Tooth-Supported Fixed
Partial Denture
Resin Bonded Tooth-Supported
Fixed Partial Denture
Implant Supported Fixed
Partial Denture
Implant Supported Fixed
Partial Denture
Implant Supported Fixed Partial
Denture
Indications for Implants:

1. Single or multiple tooth replacement up to

full arch.
2. Sufficient bone.
3. Broad flat ridge.
4. Inadequate number or strength of abutments.
5. Dry mouth.
6. No distal abutment to the edentulous space.
7. Abutments present requiring extensive
treatment of questionable prognosis.
Removable Partial Denture
Indications for a RPD:
RPD replace missing teeth and supporting
structures.
1. Bilateral free end saddle i.e. no distal
abutment.
2. Long span edentulous area.
3. Anteriorly missing more than 4 incisors or
canine and two teeth.
4. Posteriorly missing more than 3 teeth
5. Considerable bone loss.
Residual ridge defects
Combination of fixed & removable
prosthesis
Combined removable and fixed appliance
 Free
end
saddle
 Bridge Designs
 For beginners it is helpful to write down a
list of all the likely designs for a bridge in
the case being considered.
 This should include:
• Basic design
• Potential abutment teeth
• Retainers
• Pontics
• Connectors
Bridge Designs
 All possible designs should be
weighed for their advantages and
disadvantages.
 In sophisticated conditions further
investigations may be needed:
• Study casts modification
• Intra-oral trials
• Provisional bridges
Study cast modification: Waxing up
Bridge Designs
 Four basic designs
1. Fixed-fixed bridge
2. Fixed-supported bridge
3. Cantilever bridge
4. Spring cantilever bridge
 Combination designs
Fixed-fixed bridge
Fixed-fixed bridge
Fixed-movable (Fixed-
supported) bridge
Fixed-supported bridge
Cantilever bridge (Fixed
free)
 Spring cantilever bridge

Now replaced by resin-bonded bridges or

single tooth implant.
 DESIGNING OF
FIXED
PROSTHODONTICS
Presented by
Marwa Wahsh
Associate professor of fixed prosthodontics
Compound designs
Removable Bridge
Inner crowns Outer crowns

(Cylindrical)
Telescopic Crowns
as macro-attachments

Parallel walls provide friction fit between inner

and outer crowns
Choice Of Material

 Metal
Choice Of Material

 Metal-ceramic
Choice Of Material

 Non-metallic:
All-ceramic
- All-ceramic bridges
 Assessment Of
Abutment Teeth
 Endodontically treated
abutments:
 Asymptomatic- Good apical seal-
Amount of remaining tooth
structure
 Pulp capping:
 Should be endodontically treated
prior to fixed partial denture
construction
 Healthy supporting tissues
and free from inflammation
Assessment Of Abutment
Teeth
1. Crown-root ratio
1:1 ratio can be used in
cases of:
A. Opposing artificial teeth or mobile
periodontally affected teeth
B. Normal occlusion
C. Favorable root configuration
D. Patients with excellent hygiene and
plaque control
Assessment Of Abutment
Teeth
2. Root Configuration

Broad Rounded Divergent Fused

Assessment Of Abutment
Teeth
3. Periodontal membrane surface area
•Ante’s law:
 Assessment Of Abutment Teeth
 Biomechanical considerations:
• Span dimension: D3
Assessment Of Abutment Teeth

 Biomechanical considerations
Failure of a long-span fixed
partial denture
 Fracture of porcelain veneer
 Breakage of a connector
 Gingival impingement
 Retainer loosening /cement breakage.
How to overcome
1.Grooves on the buccal and lingual surfaces
2.Double abutments
3.Use materials of high yield strength & rigidity
e.g. Ni-Cr
4.Connectors should be bulky as much as possible
 Straight Connection
2. Inter-abutment axis

Load distribution in the No lever effect

periodontal ligament
Arched Connection

Lever effect causes

unfavorable loading
 Factors affecting retainer
selection:
I. Retention:
Full veneer retainers provide more retention than
partial coverage
 Factors affecting retention:
1. Remaining tooth structure
2. Extensively damaged teeth: Endodontic ttt + post
+core to improve retention
3. Crown morphology and available enamel
4. Pins and grooves improve retention
Factors affecting retainer
selection:
II. Esthetics:
Factors affecting esthetics:
1. Position in the arch
2. Esthetic demands
3. Tooth form
4. Coronal defects
5. Replacement of unsightly clasps of RPD with
precision attachment
 If thin or translucent teeth →grey
shadow of the metal will show →
poor esthetics
Factors affecting retainer
selection:
III. Age:
Minimum age 18-20 years due to:
1. Large pulp size (However resin bonded
restorations may be used in young age)
2. High gingival attachment which may
lead to restoration margin exposure due
to passive eruption
 Adhesive
(Resin bonded bridge)
Factors affecting retainer
selection:
IV. Caries:
Retainer selection should allow protection and
strengthening of abutments weakened by
caries
V. Opposing occlusion:
Prostheses whether fixed or removable create
less forces than natural teeth thereby
influencing retainer choice
Factors affecting retainer
selection:
VI. Size and alignment of abutments:
Partial coverage or minimal preparation retainers
require well developed teeth with proper
alignment
VII. Abutment condition:
1. Intact: partial coverage or minimal preparation
2. Caries or restorations
3. Discoloration
4. Malalignment
5. Class II restorations: Inlay
Factors affecting retainer
selection:
VIII. Caries index and oral hygiene:
 Patients with high caries index and bad
oral hygiene are indicated for full
coverage retainers
VIII. Patient musculature:
 Patients with abnormal habits are
contraindicated for partial coverage
retainers
Pontics

1. Sanitary (Hygienic or wash-through)

Broad residual ridge

Pontics

2. Saddle (Ridge lap)

Concave gingival surface: Inaccessible for

cleaning which leads to plaque accumulation
Pontics

3. Modified ridge lap

Universal pontic: To provide good esthetics

in anterior and posterior regions
Pontics

4. Conical (Dome-
shaped or bullet)

For narrow residual ridge

 Pontics
5. Ovate pontic

5. Ovate

Most esthetically appealing design: The pontic appears

as if a tooth is emerging from the gingiva
Connectors

 Rigid connectors:
Cast
Soldered
Loop connectors
 Connectors
 Non-rigid connectors
 Key and key way

Support must be derived from the anterior

restored abutment.
Guidelines in design selection:

1. Implant is the treatment of choice if

indicated in any situation if feasible.
2. Under ideal conditions, maximum number of
missing posterior teeth to be replaced is 3 in
the maxilla & 2 in the Mandible.
3. Edentulous spaces resulting from the loss of
4 adjacent teeth other than 4 incisors are
better replaced with a partial denture or
implant supported FPD.
Guidelines in design selection:
4. Multiple edentulous spaces in the same
arch are better replaced with implant
retained FPD or a removable partial
denture.
5.If the main abutments are weak add
secondary abutments.
6.It is better to end bridges on strong
abutments . It is not preferred to use a
root canalled tooth as terminal
abutment.
7. Cantilevering requires a stable arch form.
Rotated, overlapped, misaligned teeth should
be excluded.
8. Missing maxillary lateral maybe restored by
cantilever bridge on maxillary central or
canine but not mandibular laterals.
A certain risk is always present in cantilever
designs since the potential for failure
cannot be excluded. Forces applied to the
pontic may cause canines to rotate allowing
the pontic to slip out of contact with the
central causing collapse in the arch.
9. A rest maybe extended from the pontic to
the lingual surface of the central to improve
stability. ( Fixed -supported)
10. In case of using a additional secondary abutment,
the secondary abutment should possess at least as
much root surface as the 1ry abutment. A canine
maybe added to a first premolar abutment but a
lateral may not be added as a 2ry abutment to a
canine.
 In case of upper laterals, lower centrals as
terminal abutments add secondary abutments
especially in case of gingival recession.
 Lower first premolar is a weak abutment
(short lingual wall), if used as a terminal
abutment canine maybe added as secondary
abutment.
MAXILLARY DESIGNS
MAXILLARY DESIGNS

 Missing maxillary
central incisor:
1. Fixed-Fixed
2. Fixed-Supported
3. Cantilever
In cases of missing central
or lateral incisor with
diastema; implant retained
FPD is usually selected, or
palatal loops maybe used
with tooth supported FPD.
 Missing both
maxillary central
incisors:
Fixed-Fixed
Cantilever Resin bonded bridge
 Lithium disilicate glass-
ceramic veneer-fixed dental
prostheses
 Missing maxillary
lateral incisor:
1. Cantilever
2. Fixed-Supported
3. Fixed-Fixed
 Missing maxillary
central & lateral
incisors:
Fixed-Fixed
 Missing both
maxillary central
incisors & one lateral
incisor:
Fixed-Fixed
 Missing all maxillary
incisors:
Fixed-Fixed
According to arch
curvature
 Arch form and curvature

When pontics lie outside the inter-abutment

axis line, they act as a lever arm causing a
torque effect (Tipping)
 Arch form and curvature
Additional abutments must be taken in the
opposite direction at a distance equal to the
lever arm
i.e., we take the first premolars as added
abutments in cases of v-shaped arch

The resistance arm should be at least

equal to the lever arm
 Secondary retention (R) must extend a
distance from the primary interabutment
axis equal to the distance that the lever arm
(P) extends in the opposite direction
 Missing maxillary
canine
Fixed-Fixed
 In old patient or
short span:
Cantilever or fixed-
supported
 Missing maxillary
canine & lateral
incisor
Fixed-Fixed
 Missing maxillary first
premolar
Fixed-Fixed
Cantilever (Canine-
guided occlusion)
Use partial coverage
in complex bridges
to prevent labial
over reduction.
 The initial choice in  N.B.: Missing
replacing maxillary maxillary or
mandibular first
premolars and premolar maybe
molars is fixed-fixed restored using 5 and 6
bridges while fixed- in cantilever bridges if
supported maybe a the span is short and
the abutments are
secondary choice. restored and the
patient is old.
 Missing maxillary
canine & first
premolar
Fixed-Fixed
 Missing maxillary
second premolar
Fixed-Fixed
 Missing maxillary
first & second
premolar
Fixed-Fixed
 Missing maxillary
first molar
Fixed-Fixed
Fixed-Supported
 Missing maxillary
second premolar &
first molar
Fixed-Fixed
 Missing maxillary first &
second premolar & first
molar:
If Canine and second
molar are strong and
opposing partial denture
can provide good
prognosis
N.B.: Canine guidance
Prognosis is good in case of
opposing RPD and
collapsed edentulous
span.
 Missing maxillary second molar:
The same as first molar
 Cantilever bridge can be used to restore upper
last molar : Pontic acts as an occlusal stopper
to prevent overeruption of the opposed lower
molar.
MANDIBULAR DESIGNS

 Missing
mandibular central
incisor:
Fixed-Fixed
 Missing both
mandibular central
incisors
Fixed-Fixed
 Missing
mandibular lateral
incisor
Fixed-Fixed
 Missing
mandibular central
& lateral incisors
Fixed-Fixed
 Missing all
mandibular incisors
Fixed-Fixed
 Missing mandibular
canine
Fixed-Fixed (If the
lateral is very weak
remove it and use 2
central incisors)
 Missing
mandibular lateral
incisor & canine
Fixed-Fixed
 Missing
mandibular first
premolar
Fixed-Fixed
Cantilever ( If 5 & 6
are restored)
 Missing
mandibular canine
& first premolar
Fixed-Fixed
 Missing
mandibular second
premolar
Fixed-Fixed
Fixed-Supported
Inlay-retained bridge
 Missing
mandibular first &
second premolar
Fixed-Fixed
 Missing
mandibular first
molar
Fixed-Fixed
 Missing
mandibular second
premolar & first
molar
Fixed-Fixed
 Missing mandibular second molar:
The same as first molar
 Important considerations

1. Treatment simplification.
2. Implants are preferred if indicated.
3. Secondary abutments are indicated in cases
of unfavorable Crown /Root ratio and long
spans.
 Important considerations

4. Cantilevers are contraindicated to restore

lower incisors
5. Support must be done on the anterior
RESTORED abutment
6. It is preferable to end the FPD on a strong
tooth
SPECIAL PROBLEMS
Disruption of the dental arch
Speech , TMJ
Loss of dynamic equilibrium
(balance of forces):
supra eruption , tilting ,
drifting
Correction of over-erupted
opposing tooth to establish
balanced occlusion
1. Simple contouring of plunger cusp and topical
application of fluoride
Courtesy of dr. Mohammed Rayan
2. Orthodontic intrusion.

Courtesy of dr. Mohammed Rayan

2. Orthodontic intrusion.

Courtesy of dr. Mohammed Rayan

2. Orthodontic intrusion.

Courtesy of dr. Mohammed Rayan

3. Onlay or occlusal veneer

Courtesy of dr. Mohammed Rayan

4. Crowning of over-erupted tooth.

Courtesy of dr. Mohammed Rayan

5. Endodontic treatment and crowning of over-
erupted tooth.
Courtesy of dr. Mohammed Rayan
 6. Extraction.
Courtesy of dr. Mohammed Rayan
Intrusion of groups of teeth
 Special problems
Mesially tilted second molar
B- super erupted tooth :
The aim in dealing with super erupted is to regain the
normal level of occlusal plane and this may be achieved
through :
1- Enameloplasty followed by fluoride
application.
2- If dentin is exposed occlusal veneer or overlay or full
coverage crown.
restoration is needed.
3- Intentional root canal treatment may
be needed followed by full coverage
restoration.
4- Tooth extraction in some times the only
possible choice to correct the occlusal plane.
 Badly Tilted:
No common path of insertion without over
reduction and endangering its pulp.
The tooth distal to the abutment may interfere with
the insertion of the bridge.

Badly tilted
• Malposition e.g.; Badly Tilted abutment:
Mesial drifting will present problem in attaining a
common path of insertion without over reduction of the
abutment without endangering its pulp .
Moreover the tooth distal to the abutment may interfere
with bridge insertion.
 Management of badly tilted tooth can be
achieved through one of the following line of
treatment :
1- Orthodontic uprightening :
2- Recontouring and fluoride
application to allow seating of the
fixed partial denture
2- The use of mesial one half crown as a
retainer on the second molar
3- the use of non- rigid connector at
the distal of the anterior retainer
4- Use of telescopic crown.
Crowning of abutments to compensate the narrow space
without constructing a pontic.
 Special problems

 Cantilever bridges
The pontic would act as a
lever that tends to be
depressed under forces:
1. Inducing harmful
lateral forces on the
supporting abutments.
2. Leads to tipping,
rotation or drifting of
abutment.
Missing first molar
 Cantilever bridge can be used to restore
first molar : Pontic acts as an occlusal
stopper to prevent overeruption of the
opposed molar.
Special problems

 Cantilever bridges:
1. Abutments must offer more than
average support
2. Extremely retentive tooth preparations
3. Ideal occlusal scheme
 Pier Abutment

stress
concentration
around the
abutments.

A non rigid
connector (broken The pier act as a fulcrum
stress attachment) causing unseating effect on
terminal abutments, bone
is used to minimize resorption, mobility, bridge flexing
stress. & fracture of cement seal
Non-rigid connector
 Provide stress breaking effect:
1. Transfer shear stresses to bone rather than
connectors
2. Minimize M-D torquing of the abutment
by allowing them to move independently
Special problems
 Pier abutment

Pathologic mobility or
fracture of its retainer
Compound bridge
Pier abutment
Some designs for cases with multiple
missing teeth & an intermediate
abutment (Pier abutment)
 Missing maxillary
central incisor &
opposite-side lateral
incisor
 Missing
mandibular central
incisor & opposite-
side lateral incisor
No need for non-
rigid connector due
to short span and
small teeth
 Missing maxillary
lateral incisor &
first premolar
Use non-rigid
connector or
cantilever the
lateral
 Special problems
 Canine replacement
bridges:
Canine often lies outside the
inter-abutment axis (Induces
high lateral forces)
Upper is subjected to higher
stresses than lower since forces
are transmitted outward (due
to labial direction of force) in
the maxilla against inside of the
curve (Its weakest point)
 Special problems

 Canine replacement bridges

Prospective abutments are the
lateral incisor usually the
weakest tooth in the entire
arch and first premolar the
weakest posterior tooth
 Special problems

 Canine replacement bridges

considered a complex bridge
No bridge replacing the canine should
replace more than one additional tooth
 Restore the occlusion to group
function
 Special problems
 Problems encountered with replacement of
missing maxillary incisors
Residual ridge defects
Bridge Designs

Residual ridge defects

Deformed residual
ridge, ten weeks post Flap reflected
extractions.

Connective tissue Connective tissue graft

graft sutured over labial
defect
Occlusal view showing Interim fixed prosthesis is
good fill of the relieved for post-surgical
buccolingual defect. oedema.

Final healing at 12 weeks.

Andrew’s bridge design
Andrew’s bridge design
Andrew’s bridge design
Andrew’s bridge design
Congenitally missing lateral
incisor
Missing lateral replaced by implant
Congenitally missing lateral
incisor
 Congenitally missing lateral
incisor

 Resin-bonded bridge
Special problems

 Spacing problems: Diastema

All ceramic cantilever FDPs

 M. Kern et al. Ten-year outcome of zirconia ceramic cantilever

resin-bonded fixed dental prostheses and the influence of the
reasons for missing incisors. Journal of Dentistry 65 (2017) 51–55
 Special problems

 Spacing problems: Reduced mesio-distal width

• Alteration of the shape of natural teeth
.Alterations of the shape.

.Peg shaped laterals.

 .Correction of diastemas.
a. Orthodontic ttt.
b. Direct composite restoration.
c. direct/indirect laminate veneer.
d. Full coverage
 Crowded teeth
 Cosmetic contouring

 Orthodontic ttt.

 Crowns.
Laminates

Crowns
Reduced space for
missing central
incisor
Reduced space for Orthodontic
missing central treatment to restore
incisor the space.

Space restored Completion of

treatment.
 Pontic

Pontic

Duplication of line angels with narrow anterior

space result in slight overlapping
 Pontic

Pontic

Duplication of line angels with wide anterior space

Spacing problems: Diastema
Spacing problems: Diastema
When replacing a posterior tooth, we
duplicate the dimension of the more
visible mesial half of the adjacent
tooth
Wider space: same mesial half and
larger distal
Narrow space: same mesial half and
smaller distal
.Short clinical crown
High Lip lines, “gummy” Smiles
 Periodontal surgery combined with dermal fillers
Overall increase in occlusal
vertical dimension
Diagnostic Phase
Diagnostic Wax-up
•Periodontal surgery including
gingevectomy and ostectomy.
Mouth Preparation
Provisional
Final restoration