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What is FPD?

Fixed partial denture is a prosthetic appliance


that restore and replace natural dentition by
artificial substitutes that are not readily
removable from the mouth
Aim

Fixed partial denture can transform an unhealthy,


unattractive dentition with poor function into a
comfortable healthy occlusion and enhance
esthetics
Coverage of Treatment Planning

Treatment planning defined as logical sequence of


treatment designed to restore the patients dentition to
good health, with optimal function and appearance

It should be presented in written form and should be


discussed in detail with the patient
Variations of FPD
Conventional tooth supported FPD

 Utilizes an abutment tooth on each end or only one end (cantilever)


 If abutment teeth are periodontally sound, the edentulous span is
short, straight, the retainers are well designed and executed, the FPD
can be expected to provide a long life and function for the patient.

Exclusions
 Gross soft tissue defect
 Dry mouth
Resin Bonded FPD

A prosthesis that is luted to tooth structure,


primarily in enamel, which has been etched to
provide mechanical retention for the composite
resin
Indication

 Replacement of missing anterior teeth


 Abutments with sufficient enamel to etch
 Short span bridge
Splinting periodontally compromised tooth
Medically compromised patients
Implant Supported FPD

 When there are insufficient abutment teeth, inadequate


strength in abutments, no distal abutment present

- Single missing tooth – replaced by single implant – therefore


no destruction of adjacent abutments
- 2-6 missing teeth – replaced by multiple implants either as
single units or implant supported FPD’s
Fiber Reinforced Composite FPD
 Fiber reinforced composite fixed partial denture is an
innovative alternative to traditional metal ceramic
restorations.
It is indicated :
 For a restoration with excellent appearance.

 The need to decrease wear of opposing natural teeth.

 The use of conservative intra coronal abutment tooth


preparation.
 The desire for a metal free restoration and rapid
chairside procedure.
Treatment Planning

I - Identification of patients needs


a) Correction of existing disease - By identification and
reduction of the initiating factors and improvement of the
resistive factors or Both
b) Prevention of future disease - by evaluating the patients
disease experience & knowing the prevalence of the disease in
general population. Treatment should be proposed if future
disease seems likely in the absence of such intervention.
c) Restoration of Function – level of the function is assessed
during examination and treatment may be proposed to correct
impaired function (e.g. speech &
mastication).
d) Improvement of appearance – listen carefully to the
patient’s views and if the appearance is far outside socially
accepted values, the feasibility of corrective procedures should
be brought to the patients attention. Long term dental health
should not be compromised by unwise attempts to improve
appearance and patients should always be made aware of the
possible adverse consequences of treatment.
II- Available materials and techniques

Clinician should understand the limitations of appropriate materials


and procedures & this will help prevent experimental approach
to treatment.
a) Plastic materials (e.g. AgAm & Composite)
b) Cast Metal – intracoronal restoration & extracoronal restoration
c) Metal ceramic
d) Resin Veneered
e) Fiber-reinforced resin
f) Complete ceramic
g) Fixed partial denture
h) Implant supported prosthesis
i) Removable partial dentures
III-Treatment of tooth loss
Causes- caries, periodontal disease, trauma, neoplasm,
congenitally absent

a) Decision to remove a tooth – poor/hopeless teeth should be


removed. A decision about replacing a missing tooth is best
made at the time of its removal rather than months or years
after the fact.
b) Consequences of removal without replacement –
- supraclusion/ supraeruption of opposing tooth/teeth.
- tilting of the adjacent teeth
- loss of proximal contact
Extended treatment plans like orthodontic repositioning and
additional cast restoration may be needed to compensate for
the lack of treatment at the time of tooth removal
Fig 1 –Tooth position and alignment are Fig 2 – shows the typical consequences
maintained, in part by the interaction 1- supraclusion of opposing teeth
between teeth. 2- tilting of adjacent teeth
3- loss of contact
IV-Selection of Abutment teeth/ Abutment Evaluation

-Whenever possible an abutment should be a “VITAL TOOTH”


-The forces that would normally be absorbed by the missing
tooth, are transmitted through the pontic, connectors and
retainers to the abutment teeth therefore the abutment teeth
should be able to withstand the forces normally directed to
the missing teeth in addition to those usually applied to the
abutments.
-An FPD should be designed as simply as possible
A) REPLACEMENT OF SINGLE MISSING TOOTH
Unless bone support has been weakened by periodontal
disease, a single missing tooth can almost always be
replaced by a 3 unit FPD having one mesial and one distal
abutment tooth.
Factors to be considered
i) Cantilever FPD - this is a potentially destructive design
with the lever arm created by the pontic.
Fig A – the pontic of a cantilever bridge acts Fig B – the forces that are applied to the pontic
as a lever arm that tends to cause tipping of a 3 unit FPD is distributed equally to
and rotation under strong occlusal vector. the abutment teeth and less leverage is
applied to the teeth or the retainers than
with the cantilever bridge.
Uses of Cantilever Bridge
a) Replacing Maxillary lateral
incisor
- There should be no occlusal
contact on either centric or
lateral excursions.
- Canine must be the abutment
& must have long root and
good bone support.
- To prevent rotation of pontic
and abutment , a rest can be
placed on the mesial of pontic
against a rest preparation on
the distal of the central incisor.
b) Replacing Mandibular first
premolar
- Occlusal contact should be
limited to the distal fossa.
- Full veneer retainers on both
the second premolar and
molar.
- There should be excellent
bone support around the
abutment teeth.
c) Replacing mandibular molars
when there is no distal
abutment present
- Pontic should be kept as small
as possible (like a premolar)
with light occlusal contact in
centric and absolutely no
contacts in any excursions
because the adjacent abutment
acts as a fulcrum with a lifting
tendency on the farthest
retainer.
- Pontic should possess
maximum occlusogingival
height to ensure a rigid
prosthesis
d) Used with implant
supported prosthesis
- The actual length of
cantilever depends on
stress factors.
E.g. Parafunction, arch
position, masticatory
dynamics, opposing arch,
crown height, direction of
force, bone density,
implant number, implant
width, implant design.
ii) Assessment of abutment teeth
- Thorough investigation of each abutment with radiographic
examination
- Pulp health should be assessed & if doubtful, endodontic
treatment should be carried out
- Existing restorations, cavity liners and residual caries should
be removed and checked for possible pulpal exposure
iii) Endodontically treated abutments
- If properly treated it can serve well as an abutment, with the
post and core foundation for retention and strength.
- Usually failure occurs in teeth with short roots and little
coronal tooth structure.
- If badly damaged tooth, it is better to remove than to attempt
endodontic treatment.
iv) Unrestored abutments
- Ideal – Unrestored, caries free

- Can be prepared conservatively for a strong retentive


restoration with optimum esthetics
- For patients who are reluctant to have a perfectly sound tooth
cut down to provide anchorage for a FPD , the overall dental
health of the patient should be emphasized rather than looking
at each tooth individually.
v) Tilted molar abutments / Mesially tilted second molars
- Common problem occurs when the mandibular 2nd molar
abutment gets tilted into the space formerly occupied by the
first molar. Further complication occurs if the 3rd molar is
present and has drifted and tilted with the second molar. In
such case the mesial surface of the tipped third molar will
encroach upon the path of insertion of the FPD.

If encroachment is slight - solved by restoring or recontouring


the mesial surface of 3rd molar
- - addtion of facial and lingual grooves on 2nd molar for
better retention
If tilting is severe – uprighting of the molar by orthodontic
treatment.
- also helps in distribution of forces under occlusal loading
and even helps to eliminate bony defects along the mesial
surface of the root.
- usually 3rd molars are extracted to facilitate movement of
2nd molar.
- Average treatment time – 3 months.
-to prevent post treatment relapse, a temporary FPD is
fabricated immediately after removal of orthodontic
appliance.
If orthodontic correction is not possible , a FPD can still
be fabricated

Hood, Farah and Craig (1975) and Yang and Thompson


(1991)
- A molar which has tipped mesially will actually exhibit less
stress in the alveolar bone along the mesial surface of its
mesial root with a fixed partial denture than without it.
However, there will be an increase in stress along the
premolar.
Smith (1993)
- Proximal half crowns can be used as a retainer on distal abutment. This is
simply a three –quarter crown that has been rotated 90 degrees so that the
distal surface is uncovered.
- Possible only if – the distal surface is caries free
- the distal surface is not decalcified
- there is a very low incidence of proximal caries
throughout the mouth
- the patient is able to keep the area exceptionally clean.
- Contraindicated - where there is severe marginal ridge height discrepancy
between the distal of the 2nd molar and the mesial of 3rd molar as a result of
tipping.
Shillingburg HT (1972)
- A telescope crown and coping can be used as a retainer on the distal
abutment i.e. full crown preparation with heavy reduction is made to
follow the long axis of tilted molar. An inner coping is made to fit the
tooth preparation and a proximal half crown that will serve as a retainer
for the FPD is fitted over the coping.
Advantages- allows total coverage of the clinical crown while
- compensating for the discrepancy between the path of insertion
of the abutments
- the marginal adaptation is provided by the coping.
Another alternative treatment for mesially tilted 2nd molar
Use of a Non-rigid connector
- A full preparation is done on the molar with its path of insertion

parallel with the long axis of the tilted tooth.


- A box form is placed on the distal surface of the premolar to

accommodate a keyway in the distal aspect of the premolar.

Reasons for not placing the non-rigid connector on the mesial


aspect of the tipped molar is that it can lead to even greater tipping
of the tooth.
Uses – when molar exhibits marked lingual as well as mesial
inclination because the routine FPD in such cases will lead
to drastically over tapered preparation with no retention.

Because telescope crowns and non-rigid connectors both


require tooth preparations that are more destructive than
normal, the selection of one of these would be influenced by
the nature of previous restorations on the tilted molar would
call for the use of a telescope crown.
Factors for multiple missing teeth replacement:

a) Direction of Forces.
- a well fabricated FPD can distribute applied force in the most favorable way
by directing them in
the long axis of the abutment teeth.
- The dislodging forces on a FPD retainer tend to act in a mesiodistal direction
as opposes to the more common buccolingual direction of forces in a
single restoration.
- Preparations should be modified accordingly to produce greater resistance &
structural durability
- Multiple grooves, including some on the buccal and lingual surfaces are
commonly employe for this purpose.
b) Root surface area / Area of periodontal attachment of the root to the bone
- When supporting bone is lost , the involved teeth have lessened capacity to serve as abutments,

Tylman (1970) - stated that two abutment teeth could support two pontics.

Irvin H Ante (1926) – suggested that in fixed partial prosthodontics for the observation that, the
combined pericemental area of the abutment teeth supporting a fixed partial
denture should be equal or greater in pericemental area than the tooth or teeth to
be replaced.

Johnson et al (1974) – designated “ ANTE’S LAW “ which states that the root surface area of the
abutment teeth had to equal or surpass that of the teeth being replaced with pontics
Therefore according to this premise :
 One missing tooth can be successfully replaced
if abutment teeth are healthy .

 If two teeth are missing, a FPD can probably replace


the missing teeth but the limit is being approached.

 When the root surface area of the teeth to be replaced


by pontics surpass that of the abutment teeth ,then a
high risk or an unacceptable situation exists.
As a clinical guideline there is some validity in the concept of “Ante’s Law”.
- i.e. FPD’s with short pontic spans have a better prognosis than do those with extremely long spans.
However,
Nyman and Ericsson - have demonstrated that even teeth with very poor periodontal support
can serve successfully as FPD abutments in carefully selected cases.

ii) shape and angulation / Root configuration.

Roots that are broader labiolingually than mesiodistally or elliptical


cross-section roots will offer better support than circular cross section
roots. A single rooted tooth with evidence of irregular configuration
or with some curvature in the apical third of the root is preferred
to the tooth that has nearly perfect taper.

Multirooted posterior teeth with widely separated roots will offer better
periodontal support than roots that converge, fuse or generally present a
conical configuration. Teeth with conical roots can be used as an
abutment for a short span FPD if all other factors are optimal.
iii) Crown - root ratio.
- This ratio is a measure of the length of the tooth occlusal to
the alveolar crest of bone compared with the length of
root embedded in the bone.
- Optimum crown-root ratio for a tooth to be utilized as
a FPD abutment is 2:3
- A ratio of 1:1 is the minimum ratio that is acceptable
for a prospective abutment under normal circumstances.

If the occlusion opposing a proposed fixed partial denture is composed of artificial teeth, the
occlusal force will be diminished with less stress on the abutment tooth.
 Because of the conical shape of most roots, when one third of the
root length has been exposed half of the supporting area is lost.
In addition, the forces applied to the supporting bone are magnified because
of the greater leverage associated with the lengthened clinical crown.

Healthy periodontal tissues are prerequisites for all FPD’s and it is important that excellent plaque
removal techniques be implemented and maintained at all times.
iv) Span Length
- All FPD’s flex slightly when subjected to load.
- In addition to the increased load placed on the periodontal ligament by a long span FPD , longer
spans are less rigid and therefore flex more.
Criteria for double Abutments.
- Secondary abutments (remote from edentulous space) must have –
as much root surface area and as favorable a crown root ratio as
the primary abutment.
- The retainers on secondary abutments must be at least as retentive
as on primary abutments because when the pontic flexes tensile
forces will be applied on the retainers on the secondary abutments.
- There must also be sufficient crown length and space between
adjacent abutments to prevent impingement on the gingiva under
the connector
v) Pier Abutments

An edentulous space can occur on both sides of a tooth creating a lone ,


free standing pier abutment.
Shillingburg and Fisher (1973) – forces are transmitted to the
terminal retainers as a result of the middle abutment acting as a
fulcrum causing failure of the weaker retainer.
Because of the forces :-
- the retainers or the casting will get loosened
- Leakage will be caused around the margin leading to extensive
caries.
iii) Replacing multiple anterior teeth
Special considerations - problems with appearance
- need to resist laterally directed tipping forces when pontics lie
outside the
intrabutment line axis (pontics acts as a lever arm which can produce torquing
movement)
This is a common problem while Replacing four maxillary incisors
solved by - gaining additional retention in the opposite direction from
the lever arm and at a distance from the interabutment axis
equal to the length of the lever arm. Therefore the first
premolars are sometimes used a secondary abutments for
better retention because the tensile forces will be applied to
the premolar retainers.
. Replacing four madibular incisors
-Can be replaced by simple FPD with retainers on each canine
-Not usually necessary to include the first premolars
-Lone standing incisors should be removed because its retention can
complicate & further jeopardize
long term results
Mandibular incisors because of small size make poor abutment teeth &
plaque control difficult
Therefore, a clinician must make a choice between
i) compromised esthetics from too thin a ceramic veneer

ii) pulpal exposure during tooth preparation or

iii) selective tooth removal


C) INDICATIONS FOR REMOVEABLE PARTIAL DENTURE

Whenever possible edentulous spaces will should be restored with FPD than RPD,
however under the following circumstances RPD is indicated.
 Where vertical support from the edentulous ridge is needed .
E.g. in the absence of a distal abutment.
 Where resistance to lateral movement is needed from contra-lateral teeth and
soft tissues.
E.g. to ensure stability with a long edentulous space
 When there is a considerable bone loss in the visible anterior region and an FPD
would have an unacceptable appearance.
V) Sequence of treatment
Includes :
a) Treatment of symptoms
Relief of discomfort accompanying acute conditions
Urgent treatment of non-acute problems
b) Stabilization of deteriorating factors
Dental caries
Periodontal disease
c) Definitive therapy
Oral surgery, Periodontics, Endodontics, Orthodontics,
Fixed Prosthodontics – Occlusal adjustments
- Anterior restorations
- Posterior Restorations
- Complex Prosthodontics
d) Follow up specific program of follow up care & regular recall visits.
References
1) Contemporary Fixed Prosthodontics – Rosenstiel, Land & Fujimoto
2) Fundamentals of Fixed Prosthodontics – Shillingburg
3) A preliminary diagnostic and treatment protocol – J Bowley et al
DCNA.July 1992,36(3) 551-567.

4) Decision making in Dental treatment planning – Hall, Roberts and


LaBarre
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