evaluation of patient in fpd

8/12/2019 Evaluation of Patient in Fpd

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FIXED PARTIAL DENTURES

PATIENT EXAMINATION

The scope of fixed prosthodontic treatment can range from the

restoration of a single tooth to the rehabilitation of the entire occlusion. It can

transform an unhealthy, unattractive dentition with poor function into a

comfortable, healthy occlusion capable of giving years of further service while

greatly enhancing esthetics. To achieve that success, however, requires

meticulous attention to every detail from initial patient interview through the

active treatment phases to a planned schedule of follow - up care

Diagnosis

A thorough diagnosis first must be made of the patients dental condition

,consider ing both hard and soft tissues. This must be correlated with

individuals overall physical health and psychological needs.

There are 5 elements to a good diagnostic wor up in preparation for a fixed

prosthodontic treatment.

!. "istory

#. T$%&occlusal evaluation'. Intraoral examination

(. )iagnostic casts

5. *ull mouth radiographs

History

It is important to tae a good history before the initiation of treatment to

determine if any special precautions are necessary. +ome elective treatment

might be eliminated&postponed because of patients physical&emotional health.

It may be necessary to premedicate some patients for certain conditions or to

avoid medication for others.

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A history of infectious diseases such as serum hepatitis&aids must be

nown so that protection can be provided for other patients as well as office

personnel.

If a patient reports of a previous reaction to a drug it should be

determined whether it was an allergic reaction&syncope resulting from anxiety

in the dental chair. If there is any possibility of true allergic reaction, offending

medication should never be administered&prescribed. ocal anaesthetic and

antibiotics are the most common offenders.

The patient might also report a reaction to a dental material. Impression

materials and nicel containing alloys are leading candidates.The patient should be ased about medication currently being taen. All

medications should be identified and their contraindications noted before

proceeding with treatment.

atients who present with a history of cardiovascular problems may

require special treatment. o patient with uncontrolled hypertension should be

treated until the blood pressure has been lowered. /enerally, a systolic reading

above !01mm "g or a diastolic reading above 25 mm"g should not be treated

and should be referred to his&her physician for examination and treatment.

atients with a history of hypertension &coronary artery disease should not

receive 3I3"4I3, since this drug has a tendency both to increase heart

rate and elevate ..

An individual with a, prosthetic heart valve, a history of previous

bacterial endocarditis

6 4heumatic fever with valvular dysfunction.

6 7ongenital heart malformation.

6 $itral valve prolapse with valvular regurgitation.

+hould be premedicated with Amoxycillin 8or9 in the case of allergy

3rythromycin&7lyndamycin should be given. Tetracyclines and sulfanamides

are :T recommended for patients with recurrent rheumatic fever and

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bacterial endocarditis. $any patients with prosthetic heart valves are on

7oumadin, an anticoagulant. These patients physicians should be consulted

before beginning any procedures that will cause even minor bleeding.

Epilepsyis another condition where it has to be recogni;ed and steps to be

taen to control anxiety in these patients. ong fatiguing appointments should

be avoided to minimi;e the possibility of initiating a sei;ure.

Diabetic patients are prone to periodontal breadown& abscess formation.

Those patients who have poorly controlled diabetes tending towards elevatedblood sugar or hyperglycemia, could be adversely affected by stress of a dental

appointment to a point of falling into a diabetic coma. "yperglycemia can also

cause problem.In hypoglycemia patient feels light - headed and appear

intoxicated. These patients usually carry some quic source of sucrose and

also the patients stress level has to reduced.

Xerostomia The prolonged presence of xerostomia&dry mouth < !9 leads to

greater caries activity and is therefore extremely susceptible to the margins of

cast metal&ceramic restoration. #9 atients who have had large doses of

radiation in the oral region may have drastically diminished salivary flow. '9 It

can also occur as a component of s=ogrens syndrome an autoimmune collagen

disease. It is frequently seen in con=unction with other autoimmune disease,

such as rheumatoid arthritis, lupus erythematosus, antihistamines and

scherodermia.(9anticholinergics, anorectics, and antihypertensives may

produce xerostomia.

An effort should be made to get an accurate description of the patients

expectations of the treatment results particular attention should be paid to the

cosmetic effect anticipated.

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II TMJ/OCCL!AL E"ALATION

rior to the start of fixed prosthodontic procedures the patient occlusion

must be evaluated to determine. If the occlusion is within normal limits, then all

treatment should be designed to maintain that occlusal relationship. "owever, if

the occlusion is dysfunctional in some manner. It has to be determined

whether, the occlusion can be improved prior to the placement of the

restoration 8or9 whether the restoration can be employed in the correction of the

occlusal problem.

It should be checed, if the patient has had frequent occasions of head,

nec&shoulder pain. If so an attempt must be made to determine the origin ofsuch pain.

TMJ

!. The temperomandibular =oints have to be assessed. "ealthy T$%>s function

quietly with no evidence of clicing crepetition, or limitation of movement on

opening.

#. The clinician locate the T$%>s by palpating bilaterally =ust anterior to

articular tragi while having the patient open and close. ?ith light anterior

pressure helps identifying any potential disorder in the posterior attachment

of the dis.

'. $aximum =aw opening of less than average opening is greater than 51mm.

Any deviation from the midline is also recorded. $aximum lateral movement

can then be measured 8normal being about !#mm9.

M!CLE! O# MA!TICATION

!. A brief palpation of the masseter, temporalis medial pterygoid and lateral

pterygoid is done. ight pressure must be used and the patient ased to

report any discomfort and to classify it as mild, moderate, severe.

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#. alpation is best accomplished bilaterally and simultaneously. This allows

the patient to compare and report any differences between right and left

side to the clinician.

'. 3vidence of pain&dysfunction in either the T$% or the muscles associated

with the head and nec region is an indication for further evaluation prior to

starting any fixed prosthodontic procedure.

LIP!

!. !.The clinicians should next observe the patient for tooth exposure during

normal and exaggerated smiling.#. This may be critical in treatment planning and particularly for margin

placement of metal-ceramic crowns.

'. The extent of the smile depends on the length and mobility of the upper lip

and the length of the alveolar process.

(. ?hen the patient laughs the =aw opens slightly and a dar space is visible

between the maxillary and mandibular teeth. This is called the @egative

+pace@. $issing teeth, diastemas and fractured poorly restored teeth will

disrupt the harmony of the negative space and often requires correction.

III INT$AO$AL EXAMINATION

The intraoral examination should provide information about the condition

of the soft tissues teeth and supporting structures. The tongue, floor of the

mouth vestibules, chees, and hard and soft palate are examined and any

abnormalities are noted.

A% Perio&ontal e'amination

A periodontal examination should provide information about the status of

acterial accumulation

7alculus deposits&stains

4esponse of the host tissue

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ocets&4ecession

)egree of irreversible damage

This gives us the information about patients attitude towards

his&heroral hygiene 3xisting periodontal disease must be corrected before any

definitive prosthodontic treatment is undertaen.

(ingi)a

The gingiva has to be lightly dried before examination so that moisture

does not obscure subtle changes or detail.

7olor, texture, si;e, contour, consistency and position are noted and

recorded. The gingiva is then carefully palpated to express any exudate or pus

that may be present in the sulcular area.

"ealthy gingiva is pin, stippled and firmly bound to the underlying

connective tissue. The gingival margin is nife edged and sharply pointed

papilla fill the interproximal spaces. pon examination any deviation from these

normal findings should be noted.

The width of the band of eratini;ed attached gingiva around each toothcan be assisted by gently depressing the marginal gingiva with the side of a

periodontal probe&explorer.It is generally greatest in incisor region8'.5-(.5mm

in the maxilla and '.'-'.2mm in the mandible9 and less in posterior segments,

with least in first premolar region 8!.2mm in maxilla and !.Bmm in mandible9

At the mucogingival =unction 8$/%9 the effect of the instrument will be seen to

end abruptly, indicating the transition from lightly bound gingiva to more flexible

mucosa.

Perio&on&i*m

The periodontal probe is one of the most reliable and useful diagnostic

tools available for examining the periodontium. It provides a measurement 8in

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mm9 of the depth of periodontal pocet and healthy gingival sulcus around

each tooth.

In this examination the probe is inserted essentially parallel to the tooth

and @?aled@ circumferentially through the sulcus in firm but gentle steps,

always in contact with the base of the apical portion of the sulcus. Thus any

sudden change in attachment level can be detected.

ocet depths are recorded at 0 points per tooth usually with ?illiams

probe ,along with that we chec for

Tooth mobility&malposition

open&deficient contact

inconsistent marginal ridge height

missing&impacted teeth

areas of inadequate eratani;ed gingiva

/ingival recession, furcation involvement and malpositioned frenum

attachment.

+% Occl*sal e'amination

It should be checed for !9 Any large facets&wear whether locali;ed 8or9

widespread, #9 Any non-woring interferences, '9 The amount of slide between

the retruded position and the position of maximum intercuspation, (9 The

presence&absence of simultaneous, contacts on both sides of the mouth, 59

existence and amount of anterior guidance. 4estorations of anterior teeth must

duplicate existing guidance in-patients who replace that with which has been

lost through wear&trauma.

!. The teeth can be evaluated for crowding rotation, overeruption, spacing,

malocclusion and vertical and hori;ontal overlap.

#. The presence&absence of tooth contact with eccentric movements can be

verified with a thin mylar strip 8+him +toc9. Any posterior cusps that holds

the shim stoc will be evident.

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'. Tooth movement can be identified by *remitus Test.

A more detailed examination of the occlusion is possible with mounted

diagnostic casts.

I" A$TICLATED DIA(NO!TIC CA!T!

)iagnostic casts are an integral part of the diagnostic procedures.

Articulated diagnostic casts are essential in planning fixed prosthodontic

treatment as they provide critical information not directly available during the

clinical examination. The diagnostic casts must be an accurate reproduction of

maxillary and mandibular arches made from distortion free alginateimpressions.

nmounted casts can give information as to the alignment of the

individual arches but they do not permit analysis of functional relationships. *or

this, the diagnostic casts need to be attached to an articulator 8semiad=ustable9

when they have been 8positioned9 with a face bow and the articulator

ad=ustments have been set by the use of lateral interocclusal records or chec

bites a reasonably accurate simulation of =aw movements will be possible. The

articulator settings should be included in the patients permanent record to

facilitate resetting the instrument when restorations are fabricated. *inally the

mandibular cast should be set in a relationship determined by the patients

optimum condylar position.

Articulated diagnostic casts allow an unobstructed view of the

edentulous spaces and an accurate assessment of the span length, as well as

occluso gingival dimension. The curvature of the arch in the edentulous region

can be determined so that it will be possible to predict whether the pontics will

act as a lever arm on the abutment teeth. The length of abutment teeth can

be accurately gauged to determine which preparation designs will provides

adequate retention and resistance.

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The true inclination of the abutment teeth will also become evident, so

that problems in a common path of insertion can be anticipated. $esiodistal

drifting, rotation and faciolingual displacement of abutment teeth can also be

clearly seen.

:cclusal discrepancies can be evaluated and the presence of centric

prematurities&excursive interferences determined. )iscrepancies in the occlusal

plane become very apparent on the articulated casts. Teeth that have

supraerupted into the opposing edentulous spaces are easily spotted and the

amount of correction needed can be determined.

" #LL MOTH $ADIO($APH!

4adiographs provide essential information to supplement the clinical

examination. The radiographs should be examined carefully for signs of caries,

presence of periapical lesions as well as the existence and quality of previous

endodontic treatment.

/eneral alveolar bone levels, especially on the abutment teeth. The

crown root ratio of the abutment teeth can be calculated. The length

configuration and direction of those roots should also be examined. Any

widening of the periodontal ligament should be correlated with occlusal

prematurities or occlusal trauma.

An evaluation can be made of the thicness of the cortical plate of bone

around the teeth and of the trabaculation of the bone. The presence of retained

root tips or other pathosis in the dentulous areas should be recorded.

Thus a full mouth periapical series is normally required. atient

exposure can be minimi;ed by using a technique that gives maximum

information with the least need for repeat films and by using appropriate

protection.

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anaromic films provide useful information as to the presence&absence

of teeth. They are especially useful in !9 Assessing third molars, #9 3valuating

the bone prior to implant placement, and '9 *or screening edentulous mouths

for retained root tips.

"owever, they do not provide a sufficiently detailed view for assessing

bone support root morphology&caries. +pecial radiographs may be needed for

the assessment of T$% disorders. Transcranial exposure with the help of a

positioning device, will reveal the lateral third of the mandibular condyle and

can be used to detect structural and positional changes.

$ore information can be got from serial topography, arthrography,7T-+canning, $agnetic 4esonance Imaging of the =oints.

CONCL!ION

The history and examination must provide sufficient data to enable the

practitioner to give a successful treatment plan. If they are too hastily

accomplished, details may be missed that can cause significant problems

during treatment, at which time it may be difficult or impossible to mae

correction. Articulated diagnostic casts can provide a great deal of information

for diagnosing problems and arriving at the treatment plan.

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AT34I:474:?+s

ability to incise properly.

!ormal "ersus Pathologic cclusion

In only slightly more than !1K of the population is there complete harmony

between the teeth and the temporomandibular %oints. This finding is based

on a concept of centric relation in which the mandible is in the most retruded

position. ?ith the present concept of the condyles being in the most

superoanterior position with the disc interposed, the results could be different.

onetheless, in a ma=ority of the population, the position of maximum

intercuspation causes the mandible to be deflected away from its optimum

position. In the absence of symptoms, this can be considered physiologic, or

normal. Therefore, in the normal occlusion there will be a reflex function of the

neuromuscular system, producing mandibular movement that avoids

premature contacts. This guides the mandible into a position of maximum

intercuspation with the condyle in a less than optimal position. The result will

be either some hypertonicity of nearby muscles or trauma to the

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temporomandibular =oint, but it is usually well within most people>s physiologic

capacity to adapt and will not cause discomfort.

"owever, the patient>s ability to adapt may be influenced by the effects of

psychic stress and emotional tensions on the central nervous system. y

lowering the threshold, frequently parafunctional =aw activity such as

clenching or bruxing occurs, and a normal occlusion can become a pathologic

one. +imple muscle hypertonicity may give way to muscle fatigue and spasm,

with chronic headaches and locali;ed muscle tenderness, or

temporomandibular =oint dysfunction may occur. athologic occlusion can

also manifest itself in the physical signs of trauma and destruction. "eavyfacets of wear on occlusal surfaces fractured cusps, and tooth mobility often

are the result of occlusal disharmony. There is no evidence that occlusal

trauma will produce a primary periodontal lesion. "owever, when occlusal

trauma is present, there will be more severe periodontal breadown in

response to local factors than there would be if only the local factors were

present.

"abit patterns may develop in response to occlusal disharmony and

emotional stress. ruxism and clenching, the cyclic rubbing together of

opposing occlusal surfaces, will produce even greater tooth destruction and

muscle dysfunction.

?hen the acute discomfort of a patient with a pathologic occlusion has been

relieved, changes that will prevent the recurrence of symptoms must be

effected in the occlusal scheme. 7are must also be taen when providing

occlusal restorations for a patient without symptoms. The dentist must not

produce an iatrogenic pathologic occlusion,

In the placement of restorations, the dentist must strive to produce for the

patient an occlusion that is as nearly optimum as his or her sills and the

patient>s oral condition will permit. The optimum occlusion is one that requires

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a minimum of adaptation by the patient. :eson has described the cri teria for

such an occlusions occlusion9 has been consistently supported by scientific studies.

:cclusal devices are particularly helpful in determining whether a proposed

change in a patient>s occlusal scheme will be tolerated. The proposed

scheme is created in an acrylic resin overlay, which allows testing of the

scheme through reversible means, although at a slightly increased vertical

dimension. If a patient responds favorably to an occlusal device, the response

to restorative treatment should be positive as well. Thus, occlusal device

therapy can serve as an important diagnostic procedure before initiation of

fixed prosthodontic treatment. The device can be made for either maxillary or

mandibular teeth. +ome clinicians express a preference for one or the other

and cite advantagesE however, both maxillary and mandibular devices have

proved satisfactory.

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#A+$ICATION O# DE"ICE

There are several satisfactory methods for maing an occlusal device. :ne

made from heat-polymeri;ed acrylic resin will have the advantage of dura-

bility, but auto-polymeri;ing resin used alone or in con=unction with a vacuum-

formed matrix can serve equally well.

(irect Procedure

"ac**m-#orme& Matri'

!. Adapt a sheet of clear thermoplastic resin to a diagnostic cast using a

vacuum-forming machine. "ard resin 8! mm thic9 is suitable. e sure thatexcessive undercuts have been bloced out. Trim the excess resins so all the

facial soft tissues are exposed. :n the facial surfaces of the teeth, the device

must be ept well clear of the gingival margins. :n the lingual surface of

maxillary devices, the matrix should cover the anterior third of the hard palate

for rigidity.

#. Try in the matrix for fit and stability. Add a small amount of

autopolymeri;ing acrylic resin in the incisal region. /uide the mandible into

74 using the bimanual manipulation technique. "inge the mandible to mae

shallow indentations in the resin.

'. Add more resin to the incisor and canine regions and guide the patient to

retrusive, protrusive, and lateral closures in the soft resin. Allow the resin to

polymeri;e. :T3< The resin should be allowed to polymeri;e on the cast or

with the appliance in place in the mouth. :therwise, the heat generated by

polymeri;ation may distort the thermoplastic matrix.

(. ?ith the help of maring ribbon, ad=ust the resin to give smoothE even

contacts during protrusive and lateral excursions as well as adefinite occlusal

stop for each incisor in centric relation. 7onfine protrusive contacts to the

incisors and lateral contacts to the laterotrusive canines. All posterior contacts

should be relieved at this stage.

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5. "ave the patient wear the device for a few minutes in the office. 4epeated

protrusive and lateral movements will overcome most problems in =aw

manipulation. :ccasionally it will be necessary for the patient to wear the

device overnight before the acquired protective muscle patterns are

overcome. :T3< In such cases, if posterior tooth eruption is to be avoided,

the patient must be seen again within #( to (B hours.

0. Add autopolymeri;ing acrylic resin to the posterior region of the device and

guide the patient into centric relation. "old 74 until the acrylic resin has

polymeri;ed.

D. 4emove the device and examine the impressions of the opposing arch inthe resin. olymeri;ation can be accelerated by placing the device on the cast

in warm water in a pressure pot.

B. lace pencil mars in the depressions formed by the opposing centric

cusps. If a cusp registration is missing, new resin can be added and the

device reseated.

2. 4emove excess resin with a bur or wheel to leave only the pencil mars.

All other contacts must be eliminated if posterior disocclusion is to be

achieved,

!1. 7hec the device in the mouth for 74 contacts, maring them with a

ribbon. 4elieve heavy contacts by continued ad=ustment until each centric

cusp has an even mar.

!!. Identify protrusive and lateral excursions using different-colored tape.

Ad=ust excursive contacts as necessary, being careful no9 to remove the

centric cusp stops.

!#. +mooth and polish the device, again being careful not to alter the

functional surface.

!'. After a period of satisfactory use, the device can be duplicated in heat-

polymeri;ed rest using a standard denture reline technique

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In&irect Proce&*re sing A*topolymeri;ing Acrylic $esin

Accurately mounted diagnostic casts are essential for this procedure. A

relatively small mounting error can lead to considerable loss of time at try-in.

articular attention must be given to occlusal defects or interfering soft tissue

pro=ections on the casts, which could cause errors during mounting.

!. e sure that the device is made at the same vertical dimension of occlusion

as the 74 record. This will reduce mounting errors derived from using an

arbitrary facebow.

#. *it the articulator with a mechanical incisal guidance table initially set flat.

'. ower the incisal guide pin until there is approximately ! mm of clearancebetween the posterior teeth. This should be the same vertical dimension of

occlusion as the one at which the 74 record was made.

(. )epending on the type of articulator used, it may be necessary to

reposition the incisal guide table after step '.

5. 7hec the clearance between opposing casts during protrusive movement

of the articulator. ?here this is less than ! mm, increase it by tilting the incisal

guidance table.

0. 4aise the platform wings of the incisal guidance table so there is at least !

mm of clearance in all-lateral excursions.It may be necessary to raise the

incisal pin occasionally to ensure adequate clearance.

D.$ar the height of contour of each tooth on the cast and bloc out

undercuts with wax.

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$E!TO$ATION

O#

ENDODONTICALL copings

!.ost +election

4::T $:4"::/N

43$AI/ 7:4:A T::T" +T47T43

:77+A *:473+

#.4oot +election

'.ost 3mbedment )epth

(./utta ercha 4emoval

5.7hannel reparation

0.ost Installation

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An endodontically treated tooth can resume full function and serve

satisfactorily as an abutment for a fixed or removable partial denture.

"owever, special techniques are needed to restore such a tooth. sually a

considerable amount of tooth structure has been lost because of caries,

endodontic treatment, and the placement of previous restorations. The loss of

tooth structure maes retention of subsequent restorations more problematic

and increases the lielihood of fracture during functional loading.

Two factors influence the choice of techniqueE the type of teeth i.e. whether it

is an incisor, canine, premolar, or molar and the amount of remaining coronaltooth structure. The latter is probably the most important indicator when

determining the prognosis.

efore restoration, existing endodontically treated teeth needed to be

assessed carefully for the

evaluation of patient in fpd

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