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Abutment: tooth serving as attachment for FPD Retainer: extracoronal restoration cemented to abutment Pontic: artificial tooth suspended from abutments Connector: rigid or non-rigid metal connecting pontics / retainers
Occlusal interferences are produced when FPD is made to a supraerupted opposing dentition. Opposing tooth restored to correct occlusal plane May require RCT; periodontal surgery; orthodontics; extraction
Alveolar ridge resorption results vary due to individual patient factors length of time, existence of periodontal disease, trauma, arch, etc.
Replace function of missing teeth Stabilize occlusion (drifting, prematurities) Improve stress distribution Provide esthetics and phonetics Comfort
An FPD distributes forces favorably by directing forces in the long axis of the abutment teeth.
Abutment on each end Periodontally sound abutments, straight alignment No gross soft tissue defect Dry mouth increases risk of failure
Conservative, enamel preparation Single missing tooth; slight - moderate tissue resorption Good axial alignment and light occlusal stresses Especially indicated for younger patients
Occlusal rests; 180o encirclement of axial tooth structure. Single molar replacement requires minimum occlusal load.
Indications: insufficient abutments / no distal abutment Single tooth implant saves virgin adjacent teeth Span length limited by availability of bone / ridge configuration
Prosthesis is usually not attached to adjoining natural teeth. Implant-supported fixed prosthesis placed in a totally edentulous mandible
Amount of bone may severely limit potential for implant placement - maxillary sinus / mandibular canal Precise abutment alignment and positioning for occlusal forces
Insufficient number of abutment teeth Lack of distal abutment Connection of implants / natural teeth can be compromised
Periodontally involved teeth Tilted molar abutments Multiple edentulous spaces Edentulous space with no distal abutment
Soft tissue irritation of edentulous ridge Less comfortable than FPD Esthetics often inferior to FPD
Case Presentation
Present treatment options
Advantages / disadvantages Patient input esthetics, finances
Abutment Evaluation
Caries Existing restorations Endodontic assessment Periodontal health Orthodontic position Occlusion
Abutment Evaluation: Remove all caries, old restorations, base; then evaluate.
Pulp exposure? Symptomatic? PA pathology? Proximity of cavity depth to alveolar crest Biologic width
Pulpal Health: Vital or Endodontically Treated Asymptomatic with sound tooth structure remaining. Questionable / pulpal exposure RCT before FPD
Complicates the ability to prepare parallel paths of insertion. Facio-lingual and mesio-distal inclinations
Interocclusal space is necessary to re-establish a proper occlusal plane. The occlusion may be acceptable or changes may necessary.
No mobility / zone of attached tissue / good oral hygiene Additional abutment evaluation of the periodontium: Crown-root ratio Root configuration Periodontal ligament area
Crown - Root Ratio Length of tooth occlusal to the alveolar crest compared with the length of root embedded in bone Optimum C:R is 2:3 Minimum C:R is 1:1
Periodontal disease - Horizontal bone loss dramatically reduces supported root surface area
Artificial teeth
Periodontally compromised
Rosenstiel
Conical root shape diminishes actual area of support more than expected from the height of bone. The center of rotation (R) moves apically and the lever arm (L) increases, magnifying the forces on the supportive structure.
Root Morphology
2nd molar long, separated roots; 1st molar extensive caries and positioned against adjacent tooth.
Generally successful
Antes Law: The root surface area of the abutment teeth (embedded in bone) should equal or surpass that of the teeth being replaced with pontics.
Antes Law: The root surface area of the abutment teeth should equal or surpass that of the teeth being replaced with pontics.
Generally unacceptable
Any FPD replacing more than 2 posterior teeth - risky
Antes Law: The root surface area of the abutment teeth should equal or surpass that of the teeth being replaced with pontics.
Antes Law: The root surface area of the abutment teeth should equal or surpass that of the teeth being replaced with pontics.
Most common FPD to replace more than two teeth with success
Long span FPDs fail due to abnormal stress attributed to: Leverage and torque Material failure
Antes Law A guideline with validity (More than just overloading the PDL) Long span FPDs fail due to abnormal stress which is attributed to:
1) Leverage and torque 2) Material failure
Fracture of porcelain veneer Connector breakage Retainer loosening and caries Unfavorable tooth or tissue response.
Law of Beams
Bending also varies inversely with the cube of the occlusogingival thickness of the pontic / connector
Design pontic/connector with adequate O-G thickness Use alloy with high yield strength
BIOMECHANICAL CONSIDERATIONS
Double abutments (splinting) can help problems caused by poor crown-root ratio and long spans.
Grooves / boxes 8resistance to dislodgement. Place boxes / grooves in response to direction of anticipated torque. Use retainer with appropriate retention / resistance.
Double abutments help stabilize the prosthesis by distributing forces over more teeth.
Root surface area and C:R must = 1o abutments 2o retainers must have retention of 1o retainers Long crown length and adequate interproximal space for connectors
Bone loss and increased physiologic movement Deflection / torque microleakage / debonding Caries involvement of abutment teeth Fracture of RCT abutment with large amount of missing tooth structure
Pontics lying outside the inter-abutment axis act as a lever arm torquing movement. Additional resistance in opposite direction from lever arm; distance = to length of the lever arm
An edentulous space on both sides of a lone freestanding abutment Physiologic tooth movement
direction and amount varies from anterior to posterior
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Extensive caries through crown resulting from #6 retainer debonding from abutment.
Non-Rigid Connector
Location:
Where periodontal support is adequate, a simpler approach could be a mesial cantilever pontic.
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Discrepancy between long axis of molar and premolar abutments 25o - 30o - maximum angle of tilting
Mesial wall must be over-reduced ( resistance) Distal adjacent tooth may intrude on the path of insertion
Plan path of insertion / preparation design on diagnostic cast. Surveyor may help in determination
Occlusal reduction is not always the same as clearance needed. Remove only enough to provide necessary space for the restoration. Allows for longer axial wall length.
Molar uprighting
Places abutment in better position for preparation Distributes forces under loading through long axis of tooth (helps eliminate mesial bony defects) Enables replacement of optimum occlusion
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Proximal Half Crown does not involve distal wall A 3/4 crown rotated 90o Requirements: Caries-free distal surface Low incidence of caries Even marginal ridge height
Allows slight movement - short span Keyway in distal of premolar to avoid intrusion of molar (mesial seating action) Must prepare box in distal of premolar preparation
Pontic lies outside the inter-abutment axis Stress is greater on maxillary arch
Forces inside arch (weak - tension)
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Forces outside inter-abutment axis (esp. maxillary) Generally longer lever arm with more pronounced curve on maxillary Forces against maxillary are directed unfavorably (outward) Forces against mandibular are directed favorably (inward)
Pontic lies outside the inter-abutment axis Adjacent teeth are weakest possible abutments Should not replace more than one additional tooth Canine plus 2 contiguous teeth poor prognosis
restore with RPD or implants
Replace only 1 tooth, and have at least 2 abutments Criteria for abutment teeth:
Long root w/ good configuration Long clinical crown Favorable crown:root ratio and healthy periodontium Only the canine should be used as a solo abutment
Rest should be placed on mesial of pontic against a rest prep in a restoration in the distal of the central incisor
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Full crown retainer central incisor #9 Resin-bonded wing / mesial preparation #7 Favorable occlusion
Cantilever FPD:
Limit pontic occlusion to distal fossa. Use full veneer retainers on the 2nd premolar and 1st molar.
When using a rest on a cantilever pontic, always place a rest prep in a restoration on the abutment.
Caries
Change proximal contour / occlusion Button pontic Importance of resistance form: clinical crown length; facial lingual grooves; minimal taper
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Extreme forces generated by posterior position (Class 2 lever) Occlusal forces place tensile stress on 2o retainer
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