Pontic Abutment Preparation Connector

Retainer

FIXED PARTIAL DENTURES

Treatment Planning and Biomechanics
Donna N. Deines, DDS, MS
Resources: Shillingburg, et al. Fundamentals of Fixed Prosthodontics Rosenstiel, et al. Contemporary Fixed Prosthodontics Aquilino & Gratton, ACP Prosthopaedia Goodacre, Principles of Tooth Preparation DVD
Abutment Edentulous Ridge

Abutment Preparation

Abutment

Abutment: natural tooth/implant 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

Treatment of Tooth Loss

Consequences of tooth loss:

Caries Periodontitis Trauma, congenital

Decision to remove tooth Careful assessment Replacement decision

Supra-eruption Tilting Loss of proximal contact Disruption of occlusion

Restoration of the Occlusal Plane

Relation of Tooth Loss to the Edentulous Ridge

Shillingburg

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 Prevents occlusal interferences in restored dentition

Alveolar ridge resorption results vary due to individual patient factors length of time, existence of periodontal disease, trauma, arch, etc.

Relation of Tooth Loss to the Edentulous Ridge

Gross soft tissue defects

Knife-edge ridge Loss of interdental papillae

Traumatic injury Ablative surgery

Indications for a Fixed Partial Denture

Contraindications for Fixed Partial Dentures

Replace function of missing teeth Stabilize occlusion

drifting, prematurities

Properly distributed abutments

Both ends of edentulous space Reasonable span length

Provide esthetics and phonetics Comfort

Biomechanically solid abutments

Restorable Periodontally stable No apical pathosis (vital or RCT)

Long edentulous spans / no distal abutment / non-restorable abutment Poor 1o abutments: tipped teeth / divergent alignment / periodontally weakened / short clinical crowns / insufficient # abutments Unresolved periodontal disease / high caries index and risk Severe loss of tissue in edentulous ridge Minimally restored teeth where an implant retained restoration is preferable.

Selection of the Type of Prosthesis for the Partially Edentulous Patient

Removable Partial Denture Tooth-Supported Fixed Partial Denture (FPD)
Resin-Bonded Fixed Partial Denture C til Cantilever Fi d P ti l D t Fixed Partial Denture

Treatment Options for Tooth Loss

Removable Partial Denture (RPD)

Implant-Supported Fixed Partial Denture Factors to consider

Biomechanical, periodontal, esthetic, financial Treatment simplification

Long edentulous spans / no distal abutment / multiple edentulous spaces Tipped / widely divergent abutments / few abutments Periodontally weakened 1o abutments Severe loss of tissue in residual ridge

Disadvantages of Removable Prostheses

Conventional Fixed Partial Denture

Soft tissue irritation of edentulous ridge / dry mouth Less comfortable than FPD
Large tongue Unfavorable attitude toward RPD

Esthetics often inferior to FPD

Abutment on each end Periodontally sound abutments, straight alignment No gross soft tissue defect Dry mouth increases risk of failure

Resin-Bonded Fixed Partial Denture

Resin-Bonded Fixed Partial Denture

Conservative, enamel preparation Single missing tooth; slight - moderate tissue resorption Good axial alignment and light occlusal stresses Especially indicated for younger patients

Conservative, enamel preparation Single missing tooth; slight - moderate tissue resorption Good axial alignment and light occlusal stresses Especially indicated for younger patients

Aquilino & Gratton,

Posterior Resin-Bonded FPD

Implant-Supported Crown / Fixed Partial Denture

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 Limitations: availability of bone / ridge configuration

Implant-Supported Fixed Partial Dentures

Limitations of Implant Placement

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 favorable occlusal forces Vertical forces prevent unfavorable lateral loading of implants

Implant-Supported Fixed Partial Dentures

Case Presentation
Present treatment options
Advantages / disadvantages Patient input esthetics, finances

Agree on definitive treatment plan

Understand risks / responsibilities
Insufficient number of abutment teeth Lack of distal abutment Connection of implants / natural teeth can be compromised Biomechanical differences due to lack of PDL in implants Informed Consent

No prosthetic treatment
Unrealistic expectations Do no harm

Abutment Evaluation
Coronal Tooth Structure Pulp Status / Endodontic Assessment Periodontal Health / Support Abutment Inclination Ab t t I li ti Orthodontic position Occlusion

Coronal Tooth Structure

Clinical exam, radiographic exam, diagnostic casts (mounted) Adequate retention and resistance form?
Is the tooth restorable as is? If not, can it be gained with foundation or modification of preparation?

What is the apical extent of caries or restoration?

Abutment Evaluation: Remove all caries, old restorations, base; then evaluate.

Pulpal Health: Vital or Endodontically Treated

Pulp exposure? Symptomatic? PA pathology? Proximity of cavity depth to alveolar crest Biologic width Adequacy of retention / resistance form

Asymptomatic with sound tooth structure remaining Questionable / pulpal exposure RCT before FPD

Radiographic Evaluation for FPDs

Caries
Un-restored proximal surfaces Recurrent restorations

Evaluation of Diagnostic Casts:

Accurate
Mounted on semi-adjustable articulator w/ facebow / CR Edentulous spaces and span length Curvature of the arch I li ti of abutment teeth Inclination f b t t t th M-D drifting, rotation, F-L displacement of abutments Occlusocervical dimension Interocclusal relationships

Periapical lesions Existence / quality of previous RCT General alveolar bone levels C:R / length, configuration, direction of roots Widening of PDL (w/ occlusal prematurities) Thickness of cortical plate; trabeculation Presence of root tips / other pathology
Thickness of soft tissue edentulous ridge Maxillary sinus; TMJ; third molars

Abutment Inclination / Alignment: Path of Insertion

Discrepancies in the long axes of abutment teeth

Axial walls of abutment teeth must be aligned w/o any undercuts.

Complicates the ability to prepare axial walls with a common path of insertion. Mesio-distal and Facio-lingual inclinations

Abutment Abutment InclinationInclination

Path of Insertion: Diagnostic Cast / Surveyor

Adjacent tipped tooth can prevent FPD from seating in the common path of insertion.

Useful for: Pre-preparation planning During preparation phase

Evaluation

Evaluation of Interocclusal Relations

Diagnostic waxing: visualize problems and results

Interocclusal space is necessary to re-establish a proper occlusal plane.

Thickness of pontics/ connectors for strength Room for artificial teeth / framework (FPD, implants, RPD)

The occlusion may be acceptable or changes may necessary.

Diagnostic Waxing and Case Planning

OR

Healthy periodontium: a prerequisite for all fixed prosthodontic restorations

No mobility / zone of attached tissue / good oral hygiene Additional abutment evaluation of the periodontium: Crown-root ratio Root configuration Periodontal ligament area

Abutment Evaluation: Crown-Root Ratio

Periodontal Disease - Horizontal bone loss dramatically reduces supported root surface area

2 3

1 1
Rosenstiel

Ratio of the portion of tooth occlusal to the alveolar crest (CROWN) VS. the portion of tooth embedded in bone (ROOT) Optimum C:R is 2:3 Minimum C:R is 1:1

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 Configuration Abutment Evaluation: Root Configuration

A crown-root ratio 1:1 may be adequate if:

Opposing occlusal force is diminished

Artificial teeth
Dentures, RPD

Broader facial-lingual than mesio-distal preferred to round Multi-rooted better than single, conical root Widely separated better than fused roots Long roots Single-rooted teeth with irregular configuration or curvature preferable to perfect taper

P i d t ll compromised Periodontally i d opposing dentition

Root Morphology

Abutment Evaluation: Root Surface (Periodontal Ligament) Area

2nd molar long, separated roots; 1st molar extensive caries and positioned against adjacent tooth.

Rosenstiel

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.

Generally successful

Probably, but limit is being approached

Shillingburg

Shillingburg

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.

Generally unacceptable
Any FPD replacing more than 2 posterior teeth - risky

Anterior FPD replacing incisors

Shillingburg

Maxillary arch more often possible than mandibular (when all conditions ideal) - longer clinical crowns / less abutment inclination

Most common FPD to replace more than two teeth with success

Antes Law A guideline with validity (More than just overloading the PDL)

Bio-mechanical Considerations
Simple:
1 or 2 teeth missing 2 abutments

Complex:
1 3 or greater th 3 abutments 1, 3, t than b t t
splinted or pier abutments

Long span FPDs fail due to abnormal stress attributed to:

1) Leverage and torque 2) Material failure

more than 3 missing teeth non-parallel abutments combined anterior and posterior FPDs

Biomechanical Problems: Bending or Deflection of the FPD

Deflection of the FPD relates to span length

The deflection is proportional to the cube of the length of its span (varies directly).
Deflection = Load (Length)3 4e Width (Height)3

Fracture of porcelain veneer Connector breakage Retainer loosening and caries Unfavorable tooth or tissue response

FPD flexure varies directly by x3 where x is the inter-abutment distance, therefore:

2p = 8 times increase in flexure 3p = 27 times increase in flexure
Rosenstiel

Deflection and FPD Span Length

Deflection of the FPD relates to OG Dimension (Pontic / Connector Thickness)

Deflection = Load (Length)3 4e Width (Height)3

FPD flexure varies inversely by t3 where t is the height (or thickness) of the connector, therefore:
1/2t = 8 times increase in flexure 1/3t = 27 times increase in flexure
S.A.A. U of I

Deflection and Height of Connector / Pontic Thickness

BIOMECHANICAL CONSIDERATIONS

Deflection of the FPD

Abutments and retainers receive greater dislodging forces than a single crown
Magnitude and direction

Modify preparations to increase retention and resistance form / structural durability

Design pontic/connector with adequate O-C thickness
(Plan ahead with diagnostic waxing abutment evaluation)

Place boxes / grooves in response to direction of anticipated torque

Use alloy with high yield strength

Dislodging forces on an FPD

FPD and Dislodging Forces

Shillingburg

Occlusal force on pontics can cause M-D torque. Forces at an oblique angle or outside the center of the restoration cause F-L torque (around M-D axis of rotation) .

Grooves / boxes 8resistance to dislodgement. Place boxes / grooves in response to direction of anticipated torque. Use retainer with appropriate retention / resistance Wall length / occlusal convergence / geometric resistance form

Effect of Arch Curvature on FPD Deflection

Double abutments (splinting) can help problems caused by poor crown-root ratio and long spans.

Shillingburg

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 (2o abutments)

Double abutments help stabilize the prosthesis by distributing forces over more teeth.
Periodontally weakened teeth

Criteria for (splinted) secondary abutments:

Long-term periodontal splint

Shillingburg

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

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SPECIAL PROBLEMS: Pier Abutments

SPECIAL PROBLEMS: Pier Abutments Cause of failure - loosened retainer

Prosthesis flexure / movement of teeth Tensile stresses between terminal retainers and abutments; intrusion of abutments under loading Differences in retentive capacities between abutments (relative to size)

An edentulous space on both sides of a lone freestanding abutment Physiologic tooth movement
direction and amount varies from anterior to posterior

Non-Rigid Connector

Extensive caries through crown resulting from #6 retainer debonding from abutment.

Rosenstiel

Non-Rigid Connector / Pier Abutment

Special Problem: Pier Abutment

Criteria for use: Location: Short span length Within distal surface of pier retainer Non-mobile abutments (mesial seating action of posteriors) Equal distribution of occlusal force
No edentulous space / RPD

Rosenstiel

Where periodontal support is adequate, a simpler approach could be a mesial cantilever pontic.

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Implant-supported Cantilever FPD #5-#6-#7

SPECIAL PROBLEMS: Tilted Molar Abutment

Discrepancy between long axis of molar and premolar abutments 25o - 30o - maximum angle of tilting

Stress Distribution in Fixed Partial Dentures

SPECIAL PROBLEMS: Tilted Molar Abutment

An FPD distributes forces favorably by directing forces in the long axis of the abutment teeth. Well-aligned abutment teeth provide better support than tipped abutment teeth. Non-axial loading proximal crestal bone loss

Rosenstiel Generally poor abutments Mesial wall must be over-reduced ( resistance) Distal adjacent tooth may intrude on the path of insertion

Mesial surface may need re-contouring or restoration

SPECIAL PROBLEMS: Tilted Molar Abutment

SPECIAL PROBLEMS: Tilted Molar Abutment

Rudd & Morrow

Rosenstiel

Shillingburg

Plan path of insertion / preparation design on diagnostic cast. Surveyor may help in determination of preparation design for common path of insertion.

Occlusal reduction is not always the same as clearance needed. Remove only enough tooth structure to provide necessary space for the restoration. Allows for longer axial wall length.

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SPECIAL PROBLEMS: Tilted Molar Abutment

Tilted Molar Abutments: Proximal Half Crown

Molar uprighting optimum

Rosenstiel Shillingburg Rosenstiel

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

Proximal Half Crown does not involve distal wall 3/4 crown rotated 90o Requirements: Caries-free distal surface Low incidence of caries Even marginal ridge height Short span length

Tilted Molar Abutments:

Tilted Molar Abutments: Non-Rigid Connector

Telescopic Coping and Crown

Full crown preparation and coping with path of insertion in long axis of tooth Full coverage crown compensates for discrepancy in paths of insertion Must over-reduce molar to accommodate the thickness of coping and crown
Shillingburg

Shillingburg

Too much inclination

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
(To accommodate the female / keyway)

Canine Replacement FPD (Complex)

Canine Replacement FPD

Shillingburg Pontic lies outside the inter-abutment axis Stress is greater / less favorable on maxillary arch

Forces inside arch (weak - tension)

Stress more favorable in mandibular arch

Forces outside arch (strong compression)

Pontic lies outside the inter-abutment axis Shillingburg Adjacent teeth are weakest possible abutments Should not replace more than one additional tooth Canine plus 2 contiguous teeth poor prognosis
restore with implants if possible (Splint central incisors and premolar / molar)

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SPECIAL PROBLEMS: Cantilever FPD

(Potentially destructive lever arm)

Conventional FPD (replacing lateral incisor)

Conventional FPD

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

Shillingburg Shillingburg

Cantilever FPD (replacing lateral incisor)

Cantilever FPD

Cantilever FPD: Replacement of maxillary lateral incisor

Shillingburg

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
Good clinical crown length / orthodontic position

Unfavorable Occlusion: deep vertical overlap

(Cantilever FPD or Resin-Bonded FPD)

Unfavorable Central Incisor Cantilever Pontic FPD

Unfavorable Cantilever: Lateral incisor abutment Severe vertical overlap

Maximum Intercuspation Solution: 1) Conventional FPD #8-#10 2) Single implant-retained crown

Lateral Excursive Canine Guidance

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Cantilever FPD:

Replacement of First Premolar

Cantilever FPD: First Premolar

Metal-ceramic crown retainer 2nd Premolar Mesial rest on pontic Resin-bonded rest seat on canine

Shillingburg

Rosenstiel

Use full veneer retainers on the 2nd premolar and 1st molar. Limit pontic occlusion to distal fossa.

When using a rest on a cantilever pontic, always place a rest seat in a restoration on the abutment. Caries can develop due to inadequate cleansability. Caries

Cantilever FPD: Molar Replacement

Very Unfavorable

Shillingburg

Extreme leverage forces generated by posterior position Occlusal forces place tensile stress on 2o retainer

Cantilever FPD: Replacement of First Molar

(Unfavorable)
Pontic size small (premolar) Light occlusal contact; no excursive contact Pontic and connector Maximum O-G height for rigidity Good crown:root ratio of abutments Clinical crowns - maximum preparation length and resistance form

Shillingburg

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