Esthetic Considerations in Fixed Replacement of Missing Teeth

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    Presented by

    MOHAMED ABD EL AZIZ MOHAMED

    Assistant Lecturer of Fixed ProsthodonticsMust University

    2007

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    ESTHETIC CONSIDERATIONS IN FIXEDREPLACEMENT OF MISSING TEETH

    Introduction:

    - Once the patient decides to have a lost tooth replaced with afixed partial denture, especially in the anterior region, the patientwill judge his result primarily on the basis of esthetics.

    - Esthetic is the study of beauty. Knowledge of esthetics helps thedentist achieve a pleasing appearance. Esthetic dentistry aims toachieve an attractive smile.

    - Todays patient is more aware of the interrelationship betweenteeth and facial appearance and is entitled to the dentists bestartistic efforts.

    - !rior to choosing a fixed partial denture as the restoration ofchoice for a given edentulous situation, a logical se"uence ofdiagnosis and treatment planning must be followed to achieve asuccessful outcome. # thorough diagnostic wor$-up should beperformed, which will provide the restoring dentist with all of theinformation needed to determine the best treatment plan for thepatient.

    DIAGNOSIS

    %- Medical and Dental History:

    - &nformation gathered on the written history sheet can provide therestoring dentist with data important for successful prosthodontictreatment.

    - 'ental history is important in developing information about thepatients dental experiences and attitude toward treatment.

    - The patient should be given an opportunity to describe the natureof his chief complaint that has brought him to the dental office fortreatment. &f it is esthetic in nature, specific esthetic desires andneeds should be assessed, as well as any esthetic shortcomingswith previous prostheses.

    2- Intraoral Examination:

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    - # comprehensive intraoral examination should be performed. #lldiagnoses should be documented, such as missing teeth,periodontal status, pulpal pathosis, caries, fractures, wear,

    unesthetic restorations, muscle and temporomandibular jointpathosis.

    - #ll data should be recorded, and the patient should be treatmentplanned as a total entity, rather than only addressing the specificedentulous area and adjacent tooth structure.

    - The intraoral examination can be enhanced by using an intra oralcamera or surgical microscope. The surgical microscope, due to

    the extremely bright field and high magnification, it provides theultimate in intraoral diagnosis.

    - #ny defects such as( hidden micro-crac$s, defective restorationmargins, and other tooth and tissue defects should be recorded inthe chart and)or electronically in the computer.

    An intra-oral a!"ra #it$ a o!%&t"r !onitor

    A surgical microscoe

    !- Extraoral Examination:

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    - The extra oral examination should include assessment ofsymmetry, muscle hypertrophy, possible loss of vertical dimensionof occlusion, and a smile analysis that determines the amount of

    each tooth that will be seen while smiling, spea$ing, etc.

    *- "adiogra#s(

    - # full-mouth series of radiographs or a panoramic radiograph withselected periapical radiographs of the proposed abutment teeth isnecessary in the evaluation for treatment with a fixed partialdenture.

    - The purpose of radiographs is to evaluate the root morphology,pulpal outline, periodontal ligament space, and the extent of caries.#lso, the radiographs can provide information about pulpalpathosis, crown-to-root ratio, and "uality of remaining bone and aidin determining the tilt of teeth.

    +- Diagnostic $asts:

    - !roperly mounted, accurate diagnostic casts on a suitablearticulator are a very important element of the diagnosis andtreatment planning of a fixed partial denture.

    T$" 'ia(no)ti a)t) !o&nt"' in "ntriol&)ion on a )"!i-a'*&)ta+l" arti&lator

    - 'iagnostic casts will enable the restoring dentist to evaluate the

    condition of the patients mouth.

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    - linical crown length, tipped or rotated teeth, ridge form, and thespan of the edentulous area can all be evaluated.

    - The inter arch space and the occlusal plane can be evaluated on

    the diagnostic casts, which may lead to the diagnosis of lostinterocclusal space or super-eruption of a segment of the dentition.The treatment, therefore, may involve crown lengthening, ridgereduction, endodontic therapy, repositioning of teeth, segmentalosteotomy, or extraction.

    - Diagnostic Waxing(

    - # diagnostic waxing of the proposed fixed partial denture can beinvaluable in determining the esthetic criteria for a treatment plan(

    a- &t allows for the observation of the abutment tooth-ponticrelationship and the pontic-ridge relationship.

    b- &t allows the dentist to evaluate the edentulous area. Theedentulous area may be badly resorbed and re"uire surgicalcorrection with grafting of bone, soft tissue, or both.

    c- &t may indicate orthodontic treatment for limited spaces androtated, tipped, or malposed teeth. This may be done inplace of or prior to fabrication of a fixed partial denture.

    d- &t may indicate the need for endodontic treatment whentooth preparation will involve the pulp of slightly malposed ortipped teeth.

    T$" 'ia(no)ti #a,-&% )$o#) t$" %lann"' r")toration

    Est#etic $onsiderations

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    - ommunication with the patient provides a general sense of whatthe patient expects esthetically before treatment begins to avoidesthetic disasters.

    - !atients prefer their dental restorations to loo$ as natural aspossible. owever, care must be ta$en that esthetic considerationsare not pursued at the expense of a patients long-term oral healthor functional efficiency.

    The elements of an esthetic fixed partial denture include(

    %- Retainer: its type, material, amount of coverage of the teeth,

    margin location and ceramic-metal junction location on metal-ceramic crowns.

    /- Pontic design.

    - 0hen designing these elements, the following should beconsidered(

    a- The arch in which the prosthesis is to be placed.b- The restorations position in that arch.

    c- The amount of display of the prosthesis.d- The patients esthetic awareness.

    - These esthetic considerations must be coupled with biologic andfunctional considerations such as:

    a- 1pan length.b- The need for splinting.c- !eriodontal support.

    d- 1oft tissue management.e- The use of provisionals.f- The need for adjunctive care such as orthodontics,

    endodontics, periodontics, and oral and maxillofacial surgery.

    - The anterior fixed prosthesis often presents the most difficultesthetic problem. The choice of tooth form, shade, andarrangement used for complete dentures is not usually availablefor the fabrication of a fixed prosthesis.

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    - !leasing esthetics can best be achieved when restorations blendwith the patients remaining natural dentition. #n exception to thisrule is when the entire dentition is changed.

    - Computer-generated analyses and imagingcan also be used asan adjunct when considering esthetic re"uirements. One of thegreatest advantages of this techni"ue is the ability to evaluateproposed tooth si2es and shapes before the final restoration isconstructed.

    $omuter image maniulation %as used to determine t#e attracti&eness o' &arioussmiles( )ig#t colours and o&al-s#aed teet# in %omen and rectangular teet# in men%ere considered t#e most attracti&e(

    * +unctional $onsiderations

    - 3unctional considerations should meet together with the estheticconsiderations.

    - The type and number of abutments re"uired for functionalconsiderations can affect the esthetic result.

    - The use of intracoronal or extra coronal retainers depends on thelength of the space to be restored and the functional stresses thatwill be placed on the prosthesis.

    - &f extra coronal retainers are chosen, the same considerations

    apply to the choice of either complete- or partial-coverage crowns.

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    ,reatment otions

    - 4ultiple treatment modalities and all treatment options for the

    patient should be investigated and presented during the treatmentplanning phase.Once the diagnostic process has been completed,treatment options may be selected from the following choices(

    I( "etainers

    A. Partial coverage: %. emented /. 5esin bonded

    6. !orcelain veneers

    B. Complete coverage: %. #ll metal /. #ll ceramic 6. eramo-metal

    a. 4argins 7 8ocation 7 4aterial

    7 4etal collar margin 7 'isappearing metal margin 7 !orcelain margin

    b. !orcelain-metal junction

    C. Other considerations: %. antilever fixed partial denture

    /. &mplants 6. 1plinting *. 9se of telescoping crowns as abutments

    II( ontics

    #. 'esign :. Edentulous ridge form

    . 4aterial

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    * Est#etic $onsiderations o' t#e treatment otions

    I- "E,AINE"S

    - 0hen selecting appropriate retainers for a fixed partial denture,esthetics is only one of three important factors to be considered.The other two are biologic considerations and functional ormechanical considerations.

    ; 9nfortunately, some of the most esthetically advantageousretainers can be the poorest from a mechanical standpoint, and

    other very esthetic retainers can be the most biologically invasive.

    - 3ixed partial denture retainers can be separated broadly into twocategories, partial- and complete-coverage retainers.

    A- artial-$o&erage "etainers:

    - 9sually, the most esthetic material that matches the patientsexisting dentition is natural tooth structure. This display of naturaltooth structure in the esthetic 2one is accomplished by usingpartial-veneer restorations.

    %- The cemented partial-coverage retainers are the metal inlay,onlay, or three-"uarter crown. These are usually made of goldalloy.

    'ue to retention, and resistance form necessary to ma$e theseretainers functionally successful, it is impossible to avoid someshow of metal at the proximal and incisal or occlusal line angles.

    - :ecause of this show of metal, this retainer is unacceptable in theanterior region. &t can be used very acceptably, however, in lessesthetically critical areas of the mouth. &ts best application is foruse on large, relatively unrestored second premolars and firstmolars in the maxillary arch.

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    a< bssmile did not gi&e a #int o' missing teet#(

    5. rearation o' ,issue:

    - # diagnostic waxing of the fixed partial denture will aid inassessing the pontic-ridge relationship to determine if the threedesign re"uirements will be met.

    - &f the relationship reveals that an esthetic result would beenhanced through modification of the edentulous ridge area, thenfurther adjunctive therapy should be considered to correct thepontic-tissue site.

    - The edentulous ridge with ideal dimensions both buccolinguallyand occlusogingivally can be treated with a modified ridge lappontic design, meeting all three esthetic design re"uirements.

    - 5idge contour for the modified ridge-lap pontic should be slightlyconvex in a labiolingual direction and gently concave mesiodistally.

    Modi'ied ridge la ontic( A +D artially seated( 5 +D seated

    - 3or the edentulous ridge that has excessive hard or soft tissue,surgical reduction can be performed.

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    ,o ma4e a roer ontic site tissue surgery %as done( A natural-aearing toot#

    relacement due to a 'a&oura1ly s#aed tissue site(

    - &f the soft tissue is thic$, scalloping of the tissue may create afavourable pontic site. &f the hard tissue is excessive with aminimal soft- tissue covering, osseous resection may benecessary.

    - Ovate pontic designs are generally used in two types of clinicalsituations( the healed edentulous ridge and new extraction sites.

    O&ate ontic( A +D artially seated( 5 +D seated(

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    - #t the time of extraction, the abutment teeth can be prepared andthe fixed partial denture provisional fabricatedA then, the ovatepontic provisional can be placed so that it emerges from theextraction site. This type of procedure "uite often leads to a highly

    acceptable esthetic effect.

    # :A Atraumatic toot# extraction( 5 $ross section &ie% o' t#e immediate ro&isional+D demonstrating o&ate ontic 'orm(

    $ '$ ro&isional restoration( Note t#e 2(?-mm aical extension o' t#e o&ate ontic( D ,#e

    seated ro&isional to reser&e t#e interdental ailla(

    Ad3uncti&e ,issue ,reatment

    - #djunctive treatment involves a deficient edentulous ridge.'eficient pontic areas may occur as a result of trauma,developmental defects, or disease.

    - The edentulous area may be deficient in height, width, or both,depending on the individual situation.

    - 'ei"ert classi#ied the de#icient ridgebased on the dimensionof the defect as follows(

    - $lass I de'ect( # buccolingual loss of tissue with normalridge height.

    - $lass II de'ect( #n apicocoronal loss of tissue withnormal ridge width.

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    - $lass III de'ect:# combined loss of ridge contour inboth the buccolingual and apicocoronal dimensions.

    - 3or the deficient ridge, adjunctive treatment involves surgical site

    augmentation, which can be accomplished using an autogenous orallogenic graft of hard or soft tissues, an alloplastic graft, or acombination of these grafts depending on the amount ofaugmentation needed.

    - The goal of the pontic site tissue preparation procedure is toprovide a ridge in which the pontic loo$s natural in its emergence.

    - &f attempts at surgery are unsuccessful resulting in small blac$

    triangles, then esthetic mas$ing must ta$e place in the fabricationof the prosthesis. This can ta$e the form of either fixed orremovable tissue inserts.

    - The fixed tissue insert can be fabricated from tissue- coloredceramic material. Dreater longevity if ceramics are used to replacethe interdental tissue should be expected.

    aSmall 1lac4 triangles &isi1le in anterior 'ixed artial denture

    b

    ,#e old 'ixed artial denture %as remo&ed and t#e a1utments rereared(

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    c,#e ne% 'i&e-unit 'ixed artial denture included 'ixed in4 orcelain to resem1le

    gingi&al ailla to mas4 t#e interdental sace(

    dA maximum smile re&eals an est#etic result(

    ,#is eig#t-unit 'ixed artial denture 'eatured 'our anterior ontics %it# a in4 orcelain

    'ixed-tissue insert %as constructed to 1lend in %it# t#is atient@s tissue(

    - #s an alternative, some patients use a removable tissue insertfabricated from acrylic resin.

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    $. ontic Materials:

    - The type of material used to fabricate the pontic also depends onthe esthetic result re"uired.

    - !ontic material types can be( all metal, metal ceramic, allceramic, or metal with acrylic resin.

    - !orcelain covering all visible areas is the selection of choice foran esthetic situation.# well fabricated metal-ceramic pontic isstrong, easy to $eep clean, and loo$s natural. owever,mechanical failure can occur.

    - #crylic resin veneered pontics have had limited acceptancebecause of their reduced durability =wear and discoloration

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    - (osenstiel '.). et al ( ontemporary fixed prosthodontics =*th

    edition>B.

    - 'hillin"erg *.. et al ( 3undamentals of fixed prosthodontics,%F.

    - +oldstein (. E. et al: Esthetics in dentistry, vol=/< - /ndEd.,/>>/.

    - +oldstein (.E.( hange your smile. =6rd ed