Assessment of dentition and treatment options of replacing missing teeth - PowerPoint Presentation

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Assessment of dentition and treatment options of replacing missing teeth

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The dentist has a wide range for replacing missing teeth . And these can due to dental disease, trauma, developmental anomalies.

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All these have an impact on the

condition and prognosis of the remaining teeth

which will therefore require very assessment careful to determine whether they require remedial

treatment and furthermore whether they

would provide suitable abutments for fixed or

removable prostheses.

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Initial examination and considerations

The minimal clinical examination should assess

the restorative status of the teeth, a periodontal

screening, mucous membranes, TMJs, jaw and occlusion

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. Vitality testing should also be carried out where appropriate and complete periodontal examination for all those whose screening indicates significant periodontitis.

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Dental panoramic tomogram is the most convenient overall radiographs.

It may needs to be supplemented

with intra-oral radiographic examination.

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Bitewing radiographs are adequate for dentitions minimally affected by caries or early periodontitis

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Periapical

radiographs

using a paralleling technique should be advisable for all potential abutment teeth,

heavily restored teeth, teeth with known or suspected endodontic problems and teeth with moderate to advanced periodontitis.

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Following a full clinical and radiographic

examination, it may be helpful to assign a prognosis to individual teeth , taking into account all factors restorative, endodontic, periodontal.

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The prognosis may be simply

categorised

e.g.

excellent/good, fair, questionable/poor, hopeless.

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Important factors which adversely affect individual tooth prognosis

Restorations and caries Extensions

subgingivally

or onto root surfaces

Extension within the pulp chamber or root canal

Minimal remaining coronal tooth substance

Inadequate or overextended posts in root filled teeth

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Endodontic factors

Periapical

symptoms/signs

Inability to control the coronal seal

Inadequate previous RCT including broken instruments in root canal

Sclerosed

canals

Fractures/splits

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Periodontal factors Probing depths over 6 mm

Attachment loss over 6 mm

Bone loss, more than 50%

Poor root morphology — especially short roots

Involvement of

furcations

— especially grade II/III

Mobility — especially grade III

Occlusal

factors

Signs of

parafunction

or severe attrition

History of repeated tooth restoration/fractures

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Potential abutment teeth

The size and shape of the natural crown and

root form are important considerations.

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Healthy

unrestored

teeth make the best abutment for fixed bridges. But teeth with short and conical crown offer poor retention and support .And this can be

overcome by surgical crown lengthening.

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The edentulous area

The requirements for restoring an edentulous

area depend upon its location and size. In cases of missing molars

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patients will accept or prefer non-replacement

of missing molars. The concept of the shortened

arch is well established and most patients

will accept a dentition extending from first

molar to first molar or from second premolar to

second premolar.

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But replacing of missing molars is important to

prevnt

the

overeruptioon

of the opposing ones

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Single missing teeth

The size of the edentulous space of

singl

missing units varies enormously. Orthodontic

realigment

may need to be considered to either eliminate the space or provide enough .space to accommodate the missing unit

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In spaced dentitions the prosthetic

options for replacement of the single missing

tooth are more limited

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Multiple missing teeth

In these cases we have to consider the

aethetic

requirement including the number and size of teeth , the shape and the height of the ridge, and the

the

alveolar

resorption

either vertical or horizontal.

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These information can be collected from existing prosthesis, or carry out a diagnostic wax

up,or

temporary denture.

Loss of ridge height and width may

necessitate prosthetic replacement of the missing

soft and hard tissues to provide adequate

aesthetics at the gingival margin and lip support.

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In cases of removable prostheses this can be

achieved with a labial flange but if a fixed

restoration is to be chosen, then some form of

ridge augmentation may be necessary.

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Occlusal

relationships

Examination of the occlusion should encompass

basic jaw relationships and determination

of the

intercuspal

position.

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For individuals with

edentulous spans greater than one unit it is

advisable to take accurate study casts and

mount these in a semi-adjustable articulator

using a

facebow

. This will allow a clear assessment

of the

occlusal

scheme and implications

of the treatment alternatives to be more accurately

assessed.

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Tilted and

overerupted

teeth , patient with

parafunctional

activitis

or sever

occlusalwear

may need to be

corrected before a satisfactory restoration can

be provided.

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Treatment options

Removeable

prostheses

These are a commonly prescribed treatment

option and may be used as a long term or provisional restoration prior to a fixed prosthesis.

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Advantages

• Replace multiple teeth in multiple sites

• Support obtained from mucosa and/or teeth

• Generally do not require extensive preparation

of abutment teeth

• May be designed to accommodate future

tooth loss

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Can be used to replace missing soft tissue

• Can provide good lip support by incorporating

labial flanges

• Aesthetics may be very good

• The least expensive of restorations

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Disadvantages

•

Removeable

prostheses may not be liked by

patient and may reduce self-confidence

• Connectors cover soft tissue such as the

palate and

gingiva

• In subjects with less than ideal oral hygiene

they may compromise the health of the periodontal

tissues and promote caries around

abutment teeth.

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Retentive elements such as clasps may spoil

aesthetics

• Moderate maintenance requirements and

durability

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Fixed prostheses

Fixed prostheses fall into two main categories

1.Resin bonded bridgework .

2.Conventional partial or full coverage bridgework

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Resin bonded bridgework

Advantages

• Minimal or no preparation required

• Fixed restoration

• Good aesthetics if ideal spacing exists and

abutment teeth are satisfactory

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• Less expensive than conventional bridges

• Consequences of failure are relatively small -

caries is readily diagnosed in most instances.

Cantilever designs for single tooth replacements

minimise

potential problems

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Disadvantages

• Lack of predictability:

decementation

leading

to loss of retention or caries under one of the

retainers — average life span 5 to 7 years.

• Dependent upon meticulous technique and

available enamel surface area for bonding

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Change in

colour

/translucency of abutment

teeth due to presence of retainer

• May interfere with occlusion, particularly

incisal

guidance

• Patients may feel sense of insecurity with

restoration, especially if their bridge has

debonded

previously

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Conventional partial or full coverage

bridgework

Advantages

• Fixed

• Good appearance, including that of abutment

teeth if they need to be improved/

harmonised

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• Medium term predictability is good for short

span bridges

• Good control of occlusion possible

• Minimally compromise oral hygiene

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Disadvantages

• Involve considerable tooth preparation

which sometimes result in

pulpal

sequelae

• Failure due to

decementation

and caries of

abutment teeth may lead to further tooth

loss

• Moderately expensive

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• Highly operator dependent requiring exacting

techniques both clinically and technically

• Requires lengthy clinical time and temporary

restorations

• Irreversible

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Implant retained prostheses

Advantages:

• Fixed or

removeable

• Independent of natural teeth — can provide

fixed restoration where no abutment

teeth exist

• Immune to dental caries

• High level of predictability

• Good maintenance of supporting bone

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Disadvantages

• Dependent upon presence of adequate bone

quantity and quality

• Involves surgical procedure(s)

• Highly operator/ technique dependent

• High initial expense and lengthy treatment

time

• Moderate maintenance requirements especially

for

removeable

or extensive fixed prostheses

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Treatment choices:

dependent upon the patient

expectations/desires, financial budget and willingness to undergo treatment

the patient’s expectations are realistic

and achievable.

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Conclusion

The patient should be presented with the

treatment alternatives and an indication of

their respective advantages and disadvantages

in their particular case.

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important to ensure that the

patient understands the treatment plan and a written consent to the agreed treatment

plan is advisable.

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Thank You

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