Y O U N G . . . V O L U M E 41.

SEPTEMBER 1950 • 289

preparation of the above crown was only strongest abutment known at present.
for the full cast crown. Sometimes it is With recent developments it is now more
advantageous to construct a banded adaptable and, if necessary, can be used
crown and this preparation is also ideal on any tooth in the mouth. Certainly,
for this technic. A band is fitted onto much criticism of crown and bridge
the die, slit and adapted closely to the service can be avoided if an abutment
prepared stump. A cap may or may not is chosen which is sure to serve without
be used. The crown is waxed up on this loosening, and if it is made to measure
band and cast. up to the standards of a health service.
It is my belief that the full crown is the 1546 Medical Arts Building

Indications and the diagnosis for

fixed partial denture prosthesis

Alfred C. Young, D.D.S., Pittsburgh

As the title indicates, this discussion will thinking. Regardless of whether it is a

consider the factors in the diagnosis fa­ new patient or one returning at stated or
vorable to fixed partial dentures. It may occasional intervals, as complete as neces­
be necessary to make certain comparisons sary a study should be made by means of
with removable appliances or with no clinical observation, discussion with the
treatment at all to clarify thinking. The patient, and, where it can help, by means
discussion will not be concerned with the of the aids formed in study models, roent­
methods of constructing fixed appliances genographs and vitality tests. In short,
by the present day accepted methods, but every patient, whether he has 32 teeth or
will be confined to the title subject, diag­ 1 is a possible partial denture patient.
nosis and general indications. Diagnostic methods should end with a
Close observation of beautifully ex­ plan of treatment which will give the
ecuted work, with finest technics evident, patient the best in function, comfort,
often shows an incomplete attempt to appearance, where necessary, and longest
correct occlusal discrepancies, and even life for such teeth as will remain in po­
closer inspection will disclose soft tissue sition, if there are any. The plan of treat­
disease and lack of alveolar support. The ment following the diagnosis will not
fixed appliance must be built upon a necessarily be that of some other dentist;
sound biological foundation. each patient presents individual prob­
It should not be necessary, but I believe lems. So long as the plan o f treatment
it is essential, to start out with a plea for achieves the proper mechanical and bio­
complete diagnosis in every case apply­ logical aims of service, the prosthetist
ing to the dentist for care and treatment. has accomplished his goal.
The dental office is so completely a place
for doing something, that there are too Presented before the Section on Partial Denture Pros­
thesis, ninetieth annual ^session of the American Dental
many times when the doing precedes the Association, San Francisco, O ctober 19, 1949.
290 • T H E J O U R N A L O F T H E A M E R IC A N D E N T A L A S S O C IA T IO N

What are those aims of service? Tyl- not arrest the changes, but by proper
man1 in his textbook says: awareness, diagnosis and treatment plan­
T h e aims of prosthetic treatment are sev­ ning, the prosthetist can avoid hastening
eral : ( 1 ) the correction o f abnorm al oral con ­ the changes, and by frequent inspection
ditions; (2 ) the restoration o f part or all o f and necessary adjustments keep pace with
the masticating organs and their related parts; them.
(3 ) the maintenance o f these organs in a
normal healthy condition for as long a time as A long involved routine of diagnosis is
possible; (4 ) the prevention o f further injury not necessary in every case. Certain cases
to them. need great consideration given every
Later, Tylman1 continues: angle involved. In others, given experi­
W e know that the potential capacity o f ence or background understanding, or
resistance o f the dental tissues is quite sub­ both, decisions can be made at once, or
stantial; yet there are so many vital variables relatively quickly.
and unknown quantities that it is rather dif­
ficult to predict w ith any degree o f certainty
the probable outcom e o f tissue reactions to PLAN OF DIAGNOSIS
changed environmental conditions other than
by clinical study and by an analysis o f care­ A plan o f diagnosis, always modified as
fully kept data. W e frequently find teeth conditions warrant, is described here.
w hich, from the standpoint o f structural form
The first appointment is given over to
and position, are definitely handicapped, yet
functionally they prove satisfactory. Although as complete a clinical examination as can
the science o f mechanics is com putable with a be made without roentgenographic in­
fair degree o f accuracy, biology is not. W e formation and study models. Some may
can determine the arc described and the dis­ prefer to make no records until these have
tance traveled by a football when it is kicked
with a given force, yet it is difficult to predict
been secured. This is a matter of prefer­
with any degree o f accuracy the biological ence as to detail of procedure.
reaction likely to result if the same blow is I find that it serves my purpose best to
given an animal. Biology and mechanics, tissues make two clinical examinations, first with­
and prostheses, are the two extremes between
out roentgenograms and study models, a
w hich a most favorable mean must be estab­
lished. second with them. This simply gives more
time and opportunity for comparisons. It
Considering these views, a partial den­ is not essential to follow this routine. As
ture, fixed or removable, should, in the the mouth itself is first studied in a general
normal occlusal plane, be esthetic where way, information is charted as to age, sex,
necessary. Not only should it be in har­ general health o f patient and, by obser­
mony with the biology of supporting vation, reactions of the patient to dental
teeth, soft tissues and alveolar supporting operating. With reference to age and sex,
bone, but it should, where possible, stimu­ Tylman1 says:
late those tissues so as to promote their
health and the health of the patient. O f Although a fixed bridge may be considered
in most o f the partially edentulous arches and
course this is not always possible. There
for patients o f every age, w e find1 that this
are cases which, after the loss of certain type o f service is indicated primarily for the
key teeth, run a gamut of experience with adult patient. A fixed bridge is ordinarily con ­
a series of gradually more inclusive partial traindicated in children and young adolescents,
because the teeth very often are not fully
appliances until full dentures eventually
erupted, and the pulp is unusually large and
result. All body tissues grow older as the hence may be easily exposed or damaged
individual becomes older: not only is during the preparation o f the abutment. W hen
there an aging, but physiological changes placed in children’ s mouths, a fixed appliance
are going on in the body.
The tissues of the mouth take part in I. Tylman, Stanley D., Theory and Practice of Crown
and Bridge Prosthesis, ed. 2. St. Louis: C. V. Mosby
this process. Prosthetic appliances can­ Company, 1947.
 Y O U N G . . . V O L U M E 41, SEPTEM BER 1950 • 291

is primarily em ployed as a space maintainer, erance to be expected of supporting bone,

follow ing the loss o f a tooth at an early age. teeth and tissues. The matter of resistance
W hen employed, these space maintainers are
o f a type serving a temporary function. They
is important locally as well as generally.
should be replaced by a permanent structure Fortunately, general debility usually
when the patient reaches a more mature age. means local troubles. A local examination
often reveals lesions or lack of develop­
Age in years does not mean dental age ment in the dental structures, which not
any more than it does mental age or phys­ only affect dental planning in itself, but
ical age in any other part of the human call attention to general disease.
body. It is not necessary to expand this
matter of premature senility. It affects the
teeth themselves, the soft tissues, and the ACCURATE RECORD OF ALL TEETH
supporting bony structures, particularly.
O n the other hand many old people have At the first examination a record of
remarkably sound dental structures. every tooth should be made, with as com ­
I recently constructed a fixed appliance plete a description as possible of former
for a man 77 years of age whose general dental work, cavities, suspected cavities,
physique seemed that of a man in young erosion and abrasion. Note also the proxi­
or middle adult life. A clinical examina­ mal relation of teeth to each other, proper
tion revealed good teeth, good contacts or improper contacts and resulting nor­
and firm normal appearing gingiva. The mal or abnormal condition o f the gingival
roentgenographic examination confirmed tissues which are visible in a clinical ex­
the first appearance, showing fine inter- amination. In cases already having eden­
proximal alveolar bony structure. The tulous areas record the number of teeth
only aspect o f advanced age was normal missing, approximate time since their loss,
abraded incisal and occlusal surfaces. I the length of the span (which is not nec­
cite this case in contrast to so many essarily the expected length if the teeth
familiar ones showing early loss of tooth have been missing for some time) and the
structure, resorption of alveolus, destruc­ changes in remaining teeth which have
tion of periodontal membrane, with the resulted from their loss. Note also abnor­
resulting infection which makes an effec­ mal positions which are the result of lack
tive plan of treatment difficult and some­ of needed orthodontic treatment. Most
times impossible. of these cases should not have appliances
Notations are made regarding the of any kind until some other condition
patient’ s apprehensive attitude (or the develops.
opposite) toward cooperation in the The anatomic form of the coronal por­
work and nervous habits that will possi­ tion of the teeth often becomes a factor
bly interfere with detail operating. There in treatment planning. Study by palpa­
are cases in every practice in which the tion the apparent thickness of the labial
local mouth factors indicate a fixed ap­ alveolar plate, especially over all the re­
pliance, but for which a removable one maining upper teeth, and sometimes over
is constructed because of nervous afflic­ lower anteriors and bicuspids.
tions or lack of cooperation by the patient. Time should be spent observing the
When appearance of the patient, or mouth in closed centric position and then
information secured from the patient or in mandibular movement. A study of
his family, points to any systemic trouble models is valuable in observing actual
which in itself becomes a factor in partial mandibular movements.
denture planning, necessary information This does not exhaust the conditions to
should be obtained from the physician. be observed at the first examination. The
This will help in the consideration of tol­ dentist “ sees” many conditions and vari­
292 • T H E J O U R N A L O F THE A M E R IC A N D EN T A L A S S O C IA T IO N

ables that are guiding factors in his anal­ study of the health of periodontal tissues
ysis o f a case and in his planning. and bone; to allow a study of the size and
After this thorough examination, study shape of the roots of the teeth; to allow
model impressions are made, and com ­ comparison of coronal stresses with this
plete roentgenograms are taken. A pulp supporting root strength or lack of
test of all remaining teeth should also strength.
be made, and the information recorded.
The resulting models and mounted roent­ TREATM ENT PLANN IN G
genograms, together with the chart of the
clinical examination, give the dentist all Now that all the information is as­
the available information he can obtain sembled a plan of treatment must be
for his second examination. A thorough formulated. In many cases one factor
prophylaxis should be made as a part of stands out so definitely as the controlling
the first examination. This combination one that the decision is easy. At other
with the examination allows the dentist times conflicting factors must be analyzed,
to observe details of mouth conditions and the best possible decision made. Hav­
which might be missed otherwise, and ing checked the general factors, age, sex,
through this routine he becomes better personal hygiene, health and type of pa­
acquainted with the individual as a pa­ tient, and finding one or more of these is
tient, and can make better decisions in a controlling factor, a fixed or a remov­
borderline cases with conflicting data. able appliance is decided upon accord­
Also discussion with the patient becomes ingly. However, the local symptoms are
easier and much information is uncovered still to be considered.
which leads to a more complete knowl­ First there is the question of health
edge of the patient’s history, family char­ of mouth tissues. It is often necessary to
acteristics and general health. defer complete planning at this point
This may open up many avenues for until necessary treatment is undertaken
investigation, dental or general or both. and at times completed. This may mean
Congenital defects, supernumerary teeth, extraction of certain teeth, periodontal
history of extreme caries, past dental or treatment, replacement of defective res­
facial injuries are examples o f local torations and removal of all carious areas.
troubles. Known heart or blood stream In treatment of any of these, conditions
disease, diabetes, arthritis, tuberculosis or may be developed which will change a
syphilis are typical family or personal plan of treatment, so it is necessary to ex­
diseases which need investigation. Many plore every local health condition to be
cases call for consultation with the phy­ sure of the prognosis as it affects the
sician before dental operating. M ore than partial denture planning. Thus by re­
dental service alone may be indicated. moval o f all foci of infection, and by
Tim e should be set aside to study the treatment of every doubtful health factor
case before the second appointment, and partial dentures can be planned more
some method of marking utilized to in­ confidently.
dicate the controlling factors. When the The double question of tooth position
patient is again in the chair, the study and of occlusion must be considered. The
models are used to compare the relation­ mouth must be studied as a whole from
ship o f the maxillary and mandibular this angle, and plans made to place the
teeth and how this relationship will affect occlusion of all remaining teeth in the
the plan of treatment. The roentgeno­ best possible relationships. This may
grams are used for several purposes: to mean spot grinding, dental operating on
locate pathologic conditions that must be elongated or subocclusal teeth, or extrac­
treated or removed; to make a further tion. The mouth cannot always be re­
 Y O U N G . . . V O L U M E 41, SEPTEM BER 1950 • 293

stored to an absolute normal occlusion in FIXED OR REMOVABLE APPLIANCE

partial work. But physiologic function is
necessary and further pathologic changes When, with these facts in mind, are
must be prevented. fixed appliances indicated and preferred?
Teeth tipped out of position are always In cases with loss of teeth in the upper
a problem and must be studied. Tylman1 anterior region, and upper posterior teeth
says, “ Those teeth tipped out of position in place, fixed bridges are usually pre­
beyond 24 degrees as a rule should not ferred. First be satisfied with the vitality
be used for bridge abutments. If they are, of supporting teeth, second the health of
it will be found that the vertical stresses supporting bone structure and enveloping
on the bridge will not be transmitted in soft tissues, third be sure that root sup­
the direction of the long axis of the tooth. port is sufficient, fourth that the coronal
The result will be a periodontal mem­ part o f the teeth will allow proper prepa­
brane that is crushed and a breaking rations with retention and no probability
down of the tissues on the mesial aspect of fracture. (Teeth which have the lin­
of the tooth.” If a key tooth is tipped so, gual contour worn by attrition do not
it may be the controlling factor. answer this test in most cases.) Fixed
Rotated teeth are only a problem when appliances are not a good risk in V
they are turned so far that proper stresses shaped arches or in cases which will put
become improper ones. a lateral anterior stress upon supporting
The size and shape of the teeth them­ teeth. A majority of cases with from one
selves are very important. Coronal size to four incisors missing should be restored
is important for proper preparation and with fixed appliances. I do not believe in
retention and, in certain cases, is the con­ double abutments to resist lateral stresses.
trolling factor. Abnormalities such as It is my experience that any such stress
short or extremely conical roots rule out which will adversely affect a single abut­
tooth borne stresses unless distributed ment will also affect two. Such a plan
over many teeth. Mobility, normality of also emphasizes a problem of stagnation
bony support and roentgenographic study of interseptal tissues, and of questionable
of the periodontal membrane are neces­ fixation of adjacent teeth.
sary parts of diagnosis. A fixed appliance may be contraindi­
The number and location of remain­ cated in the case with such an irregular
ing teeth and the length of span or spans or destroyed ridge that a saddle is neces­
must also be observed. It has been stated sary to replace this lost tissue. If possible
by many for years that only in the short this tissue should be restored by baking
span should fixed bridges be used. This of porcelain to the gingival of facings,
is generally true, but if all of the factors the preferred fixed appliance still being
are studied, and if the buccolingual width used.
is related to the length of the bridge, In upper posterior unilateral cases with
many successful longer fixed bridges can the mechanical and biological factors
be made. answered positively, fixed bridges are
The vertical height is important too. again preferred in all cases where one or
Many fixed bridges should not be made, two teeth are to be replaced, except in
and fail if tried, in cases with a short such cases as cannot be made self-cleans­
vertical height. Areas surrounding fixed ing. When the vertical dimension is so
bridges should be cleansable. In short short that space is insufficient for this
bite cases, or in very short spans, self- purpose, or in cases where the healed
cleansing cannot be achieved. When ridge is positioned so far to the lingual of
hygiene cannot be planned, removable the buccal alignment that an extreme
appliances or none are indicated. buccal ridge lap is required in the ap­
294 • T H E J O U R N A L O F T H E A M E R IC A N D E N T A L A S S O C IA T IO N

pliance, the precision bridge makes a ridge. This has brought about the use of
more satisfactory appliance. Even when the so-called “ hygienic bridge” and its
three upper posterior teeth are missing principle of convex pontic surface, and
in one segment, if all support and space op>en embrasures. The problem of “ food
factors are favorable, there are times locks” gives less trouble in the lower jaw.
when fixed appliances can be made. A second factor more favorable in lower
These must be studied carefully however, jaw is the matter of vertical stress. The
and only planned in cases where there lower arch being the smaller of the two,
are not only favorable conditions for stresses are usually in the direction of the
fixed work, but unfavorable conditions for long axis of the tooth, whereas they are
removable appliances. toward the buccal in the upper arch, the
If the patient has teeth missing in two direction least able to absorb lateral
or all three of the three upper segments, stresses. This fact also allows a greater
and if each can be considered independ­ number of lower appliances to be fixed,
ently, two or three fixed bridges can be which would be removable with corre­
made. At times a removable appliance is sponding teeth missing in the upper arch.
made because of the economic factor, Fixed bridges should be used to replace
but this should be the exception if the lower anterior teeth whether they supply
conditions are favorable for fixed appli­ one lost tooth or four. Simple lower pos­
ances. terior losses, always assuming the biolog­
In all cases isolated teeth require special ical factors before discussed are favor­
study as to bony support, root size and able, indicate a need for fixed appliances.
shape and detail treatment planning. A warning again to study the drifted or
Complex cases which necessitate unit­ tipped abutment should be repeated. An
ing an appliance so that it includes re­ isolated posterior abutment tooth particu­
placed teeth in two or even three o f these larly should be studied for root support.
segments in one arch are borderline cases Complex lower cases, and those having
which can be supplied by either fixed or a loss of teeth in two or more areas, are
removable appliances. A complete analy­ usually better supplied by removable
sis of all background factors, with empha­ work. While it is possible to construct
sis on vertical rather than lateral stresses upper fixed bridges in favorable cases
and upon the amount of vertical space, supplying a cuspid this is seldom true in
is necessary. The most common cases that the lower arch.
utilize fixed bridges are: the unilateral Fixed appliances are not preferred in
case which needs replacement of the two cases which call for changing the vertical
bicuspids and a lateral incisor; the uni­ dimension or “ raising the bite.” Such a
lateral case which calls for replacement plan may occasionally be used by building
of a lateral incisor and cuspid, even oc­ up lower posterior teeth, but never the
casionally including one bicuspid. The upper posterior teeth. In cases where this
latter instance needs exceptional strength is necessary, it is better to distribute the
in root size and support in the central stresses over all remaining teeth with re­
and bicuspid abutment. Most of the other movable appliances constructed.
compound and complex cases which in There are many patients who should
the day of the common use of the hollow have fixed partial dentures rather than
metal crown were supplied by fixed work removable. At times a patient with a
should today be removable appliances. mouth susceptible to caries is better
In planning and constructing fixed served with a fixed partial denture. It is
appliances for lost teeth in the lower jaw, often easier to control future caries by
less difficulty is encountered with space operating for fixed appliances than by
problems and with relationship to the placing certain types of removable ap­
 SELTZER— BEN DER . . . V O L U M E 41, SEPTEM BER 1950 • 295

pliances. Many sound teeth never before facts uncovered by that investigation.
touched by dental bur and stone should Construct a fixed appliance wherever
be prepared for fixed partial denture sup­ possible, but never in cases where there
ports. Not to do so when indicated shows is question of mechanical strength or
lack of conviction. M y plea is for com ­ healthy biological support.
plete diagnosis, then action based on the 121 University Place

Antibiotics in the treatment of yeastlike

infections o f the root canal

Samuel Seltzer, D.D.S., and I. B. Bender, D.D.S., Philadelphia

With the advent of the use of antibiotics culture, for identification. Dr. Lynferd
in root canal therapy, the simple report­ J. Wickerham, zymologist, subsequently
ing of the presence or absence of growth identified the organism as Candida
in the test culture is no longer adequate. (M onilia) -albicans.s This species belongs
A positive culture may indicate not only to a subclass of the true fungi known as
the presence of bacteria, but also that Hyphomycetes or fungi imperfecti, which
the microorganism or organisms present includes practically all the fungi patho­
are insensitive to the action of the anti­ genic to human beings.4
biotic employed. This fact has become Candida (M onilia) albicans is seldom,
increasingly evident ever since a com ­ if ever, found on the skin. It is a common
bination of penicillin and streptomycin, inhabitant of the gastrointestinal tract,
as advocated by Pear1 and more recently where it may produce no symptoms. It
by Grossman,2 has been employed in is also frequently found in the vagina
endodontia. With this combination, rapid where it commonly causes vaginitis. It
sterilization of infected root canals was also causes thrush in newborn babies.
accomplished. However, in a small per­ According to Fisher and Arnold5 the
centage of cases it was observed that distribution of Candida (M onilia) albi­
cultures remained positive despite treat­ cans on the human body is as shown in
ment. U pon microscopic examination, Table 1.
some of these organisms were identified
as yeasts. At first it was believed that
these were contaminants. However, when- 1. Pear, J. R., Preliminary case reports and tech­
nic on the treatment of apical infections with peni­
five or six consecutive cultures were taken cillin and streptomycin. J. Endodontia 1:32 (Sept.)
1946.
and the same organism persisted, the
2. Grossman, L. I., Preliminary report on the use
question arose whether this organism it­ of a penicillin-streptomycin suspension in endodontia.
J. Endodontia 3:39 (July) 1948.
self was the pathogenic agent. 3. Wickerham, L. J., Identification of the test or­
Accordingly, the yeastlike organism ganism. Personal communication.
4. Zinsser, H., A Textbook of Bacteriology, ed. 8,
was isolated in pure culture on Sabou- New York: D. Appleton-Century Co., Inc., 1939.
raud’s agar and sent to the Fermentation 5. Fisher, C . V., and Arnold, L. A., Classification
of Yeasts and Yeast-Like Fungi. University of Illinois
Division, Northern Regional Research Bulletin, Vol. 33, no. 51. Ill, M ed. & Dent. Monographs,
Vol. I, nos. I and 3, 1936. C hicago: University of Illi­
Laboratory, U. S. Department of Agri­ nois Press, 1936.