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If life on Earth is Temporary…
… What makes you think that your
problems are permanent?
GOOD MORNING
Presented by – Dr. Dwij Kothari
2nd year PG student
Darshan Dental College & Hospital
Introduction
Examination & evaluation of diagnostic data at the first diagnosis appointment Organizing the examination
Health questionnaire
Patient interview
Infection control in clinical prosthodontics
Evaluating the effect of physical problems on treatment
Evaluating the effect of drugs on treatment
Initial examination
Diagnostic impressions & casts
Examination and evaluation of diagnostic data at the second diagnostic appointment Face - bow transfer
The mounted diagnostic casts
Centric jaw relation record
Vertical dimension of occlusion
Definitive oral examination
Evaluation of diagnostic data
Consultation requests
Development of treatment plan
PDI
Review of literature
Conclusion
References
For any disease or condition to be treated, it is very
important to know the background and forms of the
disease itself, so that it can be identified in the
various patterns that it presents and the necessary
treatment be instituted. So, an accurate diagnosis
is important.
Many failure in removable partial denture
treatment can be traced to inadequate diagnosis
and incomplete treatment planning.
Therefore, a thorough, properly sequenced
treatment plan is essential to successful
removable partial denture therapy.
The restoration of partially edentulous mouth
presents the challenge to re-establish
masticatory efficiency, esthetics and comfort.
As the remaining teeth and edentulous ridges
have to sustain greater stress than that intended
by nature, the preservation of these tissues is
one of the primary objectives.
Before any rehabilitation procedures are
attempted, patient information must be
gathered to provide the evidence necessary to
arrive at an accurate diagnosis and develop a
treatment plan.
The examination can be completed mosteffectively and expeditiously if twoappointments are used.
In the first appointment the patient fills out ahealth questionnaire and is interviewed.
A cursory examination of the oral cavity is made toidentify any condition that requires immediateattention.
Oral prophylaxis is accomplished; a radiographicsurvey is completed.
Accurate diagnostic impressions and casts are made.
The second appointment includes
Mounting of The diagnostic casts ,
A definitive examination of the oral cavity,
Interpretation of radiographs & correlated with the clinical findings,
Arrangements are made for any needed consultation with a medical or dental specialist,
The diagnostic data are analyzed and a definitive treatment plan is formulated.
Objective: To assess the patients general
health.
It should be inclusive enough to provide
information concerning any systemic
condition that may affect the prognosis of
the treatment.
Objectives:
1. To Establish Rapport with the patient
In 1961, Dr M. M. Devan stated, “ We should
meet the mind of the patient before we meet
the mouth of the patient.”
2. To Gain Insight Into The Psychologic Makeup of
the patient (Philosophical, Exacting, Hysterical,
Indifferent)
New M.M. HOUSE Classification
MM HOUSE MENTAL CLASSIFICATION REVISITED : INTERSECTION OF PARTICULAR PATIENT
TYPES & PARTICULAR DENTIST’S NEEDS(J Prosthet Dent 2003;89:297-302.) SIMON
GAMER,TUCH,GARCIA 13
3. To Ascertain The Patients Expectations of treatment.
4. Explore Any Physical Problems that may affect the treatment .
Any positive responses in the healthquestionnaire must be explored in detail andevaluated.
When any doubt exists, the most prudent actionis to seek a medical consultation before initiationof the dental treatment.
The fourth objective of the interview -
determine whether they are realistic in the light
of oral and physical conditions.
Any partial denture will complicate oral hygiene
procedures, occupy space in the oral cavity,
necessitate a learning and adaptation period.
If these inconveniences are not acceptable,
chances for successful treatment are limited.
Valuable information may be gained from
many patients by simply allowing them to talk.
The patients opinion of the dentists, past dental
treatment, their fears, their health,
expectations of treatment may be learned by
asking few general questions.
Phrasing of questions
Open-ended questions
Dentist's attitude and behavior:
The patient who perceives the dentist as caring,
understanding, and respectful is more likely to
be honest and co-operative.
The dentist should make eye contact with the
patient, looking directly at the patient and
displaying complete attention rather than
studying radiographs or writing.
The dentist should maintain a relaxed and
attentive physical posture.
The dentist should employ head nodding,
verbal following, and verbal reflection.
Personnel protection:
Disposable gloves, face masks, protective eye
wear, immunization
Environmental surface and equipment
cleaning and disinfection
Shield surface from direct or indirect exposure –
plastic wrap
Instrument sterilization
Heat sterilization – if possible,
Clean with hot water and soap or by an ultra sonic
cleaner dry, wrap, package and heat
sterilization
Reusable item that can not be sterilized – use
ethylene oxide
Prosthodontic clinical protocol
Impression trays
Clean (detergent – alcohol) Sterilize
Store
Instruments, articulators, custom trays
2 min application of Sodium hypochlorite
Disinfecting impressions
Spray with sodium hypochlorite solution
loosely wrap in plastic for minimum 2 min.
Pour within 12 min
Denture asepsis
Concentrated Sodium hypochlorite solution
Medical History
DIABETES :
Uncontrolled diabetes - accompanied by multiple smalloral abscesses and poor tissue tone.
The disease should be brought under control beforeProsthodontic treatment is accomplished.
The decreased resistance to infection - special careduring treatment and follow-up.
Reduced salivary output – significantly reduces theability of a patient to wear the prosthesis with comfortand increases the possibility for occurrence of caries.
HYPERPARATHYRODISM
The patient is likely to suffer rapid destruction of the
alveolar bone as well as generalized osteoporosis.
The dental radiographs typically show a complete or
partial loss of lamina dura.
Such a patient is poor risk for partial denture therapy.
HYPERTHYROIDISM
Individual may show no oral symptoms other than
early loss of the deciduous teeth followed by an
accelerated eruption of the permanent teeth.
Mainly poor risks for prosthodontic therapy.
ARTHRITIS
If arthritic changes occur in the temporomandibular
joint, the making of jaw relation records can be
difficult, and changes in the occlusion may occur.
PAGET'S DISEASE:
Patients with Paget's disease may have enlargement of
the maxillary tuberosities, which can cause changes in
the fit and occlusion of the prosthesis
Frequent recall program should be instituted for such
patients.
ACROMEGALY :
Enlargement of the mandible
They should be observed frequently to evaluate the fit and
occlusion of the prosthesis.
PEMPHIGUS VULGARIS
Formation of bullae in the oral cavity with gradual
spreading to the skin.
Care must be taken to establish smooth and well polished
contours and borders of the prosthesis .
Greater than normal post- insertion care can be
anticipated.
PARKINSON'S DISEASE :
Rhythmic contractions of the musculature, including
muscles of mastication.
If the symptoms are severe it is difficult to insert and
remove the partial denture.
Impression procedures are also compromised by the
presence of an excessive quantity of saliva.
EPILEPSY
A grand mal seizure may result in fracture and
aspiration of the prosthesis , and possibly the
loss of additional teeth.
Consultation with the patients physician is
essential before treatment is initiated.
Construction of removable partial denture is
usually contraindicated if the patient has
frequent , severe seizures with little or no
warning.
All the materials used must be radio opaque
If the patients medication includes Dilantin ,one
must take care to ensure that the removable
prosthesis does not irritate the gingival tissues,
(hypertrophy of these tissues may result.)
CARDIOVASCULAR DISEASES
Patients with the following require medicalconsultation before any dental procedures
Acute or recent myocardial infarction
Unstable or recent onset of angina pectoris
Congestive heart failure
Uncontrolled arrhythmia
Uncontrolled hypertension
The patients physician should be consulted and writtenapproval should be obtained before any dentaltreatment is initiated.
Prophylactic antibiotic coverage is always
recommended if surgical procedures are to be
accomplished for patients with a history of
Congenital or rheumatic heart disease
Cardiac murmurs or repeated contraction of
aorta
When lesser degree of tissue trauma are anticipated,
such as placement of restorations, making
impressions – many physicians do not recommend
antibiotic prophylaxis
CANCER
Oral complications are also common side effect ofradiation and chemotherapy for malignancies in areasother than the head and neck.
Mucosal irritations
Xerostomia
Bacterial and fungal infections
These symptoms will complicate the construction andwear of the removable partial denture.
Sonis and others, 1978 indicated that 40% of allpatients treated with chemotherapy and radiotherapyfor malignancies remote from the oral cavitydeveloped some form of oral complication.
Transmissible diseases
Hepatitis, Influenza, Tuberculosis, HIV
May be transmitted by contact with patient blood,
saliva, contaminated dental instruments, and aerosol
from the hand piece.
Make sure impressions are disinfected
Some of the frequently prescribed drugs that can
affect Prosthodontic treatment are
Antihypertensive drugs:
Most common side effect is orthostatic, or postural
hypotension which may result in syncope when the
patient suddenly assumes upright position.
Therefore care must be taken when the patient gets
up from the dental chair.
Diuretic agents prescribed for hypertension patients
leads to decrease in saliva, and dry mouth
Anti coagulants:
Post surgical bleeding could be a problem
These patients should be referred to an oral
surgeon for management of the surgical phase of
the treatment.
Endocrine therapy:
May develop an extremely sore mouth
Saliva inhibiting drugs
Banthine, atropine which are used to control
excessive salivary secretion are contraindicated in
patients with cardiac disease because of their
vagolitic effect.
Other contraindications are prostatic hypertrophy,
and glaucoma.
Saliva should be controlled by mechanical means in
these patients.
Dental History
• How did he/she lose his/her teeth? Caries? Periodontal?
Gather information about existing dentures. (reason for
dissatisfaction)
Presence of large number of restored teeth,signs of recurrent caries, the evidence ofdecalcification – susceptible to caries
Unless an exceptional level of plaque control canbe achieved, the prognosis for the treatment ispoor.
The placement of crowns on the abutment teethmay be indicated if the patient is highlysusceptible to caries.
Palate and posterior ridge are dried with
air, any dimples or craters should be
carefully inspected.
Paper or gutta-percha points can be used
to probe the area.
Before diagnostic impressions are made,
any communication should be closed with
gauge tied to dental floss.
Oral prophylaxis
Supra gingival calculus should be removed and
oral prophylaxis should be performed if these
procedures have not been performed recently.
The diagnostic casts and the definitive intra oral
examination will be more accurate if the teeth
are clean.
Radiographs
A complete series of periapical and bitewing
radiographs is essential for complete examination.
Panoramic radiographs are ideal for screening for
pathologic conditions.
Excellent periapical radiographs are essential for
determining the crown/ root ratio of the remaining
teeth, the status of periodontal ligament space, and
lamina dura, quality of ridge in the edentulous areas.
Frequent usage of mints, soft drinks, sugar-containing
products, a change must be affected.
The problems caused by sugar are compounded by the
wear of removable partial denture because the
denture shields the micro organisms from the
cleansing and buffering action of patient’s saliva.
Evaluated to determine their effect on prognosis
Bruxism and clenching:
Bruxism is often initiated by interceptive occlusal
contacts
The occlusion should be analyzed to determine any
correction is indicated, if the efforts are
unsuccessful the patient should wear occlusal
splint to protect the remaining teeth.
Tongue thrusting:
Could cause extensive stress on the teeth
retaining and supporting the partial denture.
Eliminate the habit before fabrication of the
prosthesis, if it persists the partial denture
should be designed to distribute the forces to
as many teeth and supporting structures as
possible.
Asking whether the patient has any questions is a
good way to terminate the interview, and it
allows the patient to open any new subject or to
add to any previous areas that have been
discussed.
Problems requiring immediate attention: Large carious lesions: excavation, temporary
restorations
Ill-fitting dentures: adjustment or temporaryrelining to eliminate discomfort & allow recoveryof the damaged tissues.
Evaluation of oral hygiene: Inadequate oral hygiene must be recognized
Preventive dentistry programs are initiated
The ultimate success of the treatment depends onhome care of the patient, technical proceduresprovided by the dentist.
It is the dentists responsibility to explain to
the patient
The signs and symptoms of dental disease,
The equipment and techniques for proper home
care,
The patients responsibilities in preventing further
dental disease, and their importance for the
long-term success of the treatment.
Cummer’s system – 1921
The Kennedy System – 1923
The Applegate – Kennedy system
Fiset-Applegate-Kennedy classification
Bailyn’s system – 1928
Neurohr’s System – 1939
Mauk’s system – 1941
Godfrey’s system – 1951
Beckett’s system – 1953
Friedman’s system – 1953
Craddock’s system- 1954
Watt’s system - 1958
The Austin Ledge – 1956
The Skinner’s system – 1957
Wild’s system
Swenson’s System – 1960
Avant’s System – 1966
Osborne and Lammie’s system
McDermott’s system
American college of prosthodontics system
Costa’s system
Classification for implant dentistry
Proposed by Dr.Edward Kennedy in 1925.
Class-I : Bilateral edentulous area located posterior
to the remaining natural teeth.
Class II : Unilateral edentulous area located
posterior to the remaining natural teeth.
Class III : A unilateral edentulous area with natural
teeth both anterior and posterior to it.
Class IV : Single but bilateral edentulous area
located anterior to the remaining natural teeth.
CLASS I CLASS II
CLASS III CLASS IV
Class V : An edentulous situation in which
teeth bound, anterior and posterior but the
anterior boundary tooth not suitable for
abutment.
Class VI: Edentulous situation in which
boundary teeth are capable of total support
of required prosthesis.
Rule I : Classification should follow rather than
precede, any extraction of the teeth that might alter
the original classification.
Rule II : If 3rd molar is missing, it is not considered in
classification.
Rule III : If 3rd molar is present, and is used as
abutment, it is considered in classification.
Rule IV : If 2nd molar missing, not replaced not
considered in classification.
Rule V : The most posterior edentulous area always
determine classification.
Rule VI : Edentulous area other than those
determining the classification are referred to
modifications.
Rule VII : Extent of modification is not considered;
only the number of additional edentulous areas.
Rule VIII : There is no modification for Class IV.
Indications for fixed restorations
Tooth bounded edentulous regions:
Any edentulous space (short span) bounded by teeth
suitable for use as abutments should be restored with
a fixed partial denture.
Additional modification spaces in Class III
modification 1 situation:
Class III arch is better supported and stabilized when a
modification area on the opposite side of the arch is
present.
Indications for removable partial dentures
Although a removable partial denture should be
considered only when a fixed restoration is
contraindicated, there are several specific
indications for the use of a removable
restoration.
Long span:
A long edentulous span would have abutment
teeth which cannot bear the trauma of
horizontal and diagonal occlusal forces.
Also because of ridge resorption, the pontics
may have to be placed in extreme labial
inclination for lip support.
In such cases a removable partial denture which
provides favorable esthetics and cross arch
stabilization is indicated.
Need for effect of bilateral stabilization:
In a mouth weakened by periodontal disease, a
fixed restoration may jeopardize the future of
involved abutment teeth.
The removable partial denture on the other hand
may act as a periodontal splint through its
effective cross-arch stabilization of teeth
weakened by periodontal disease.
Excessive loss of bone in posterior area.
Where a future change in denture design is
anticipated
Distal extension cases.
Economic considerations
The choice of alloy should be based on
following factors:
1. Weighed advantages or disadvantages of the
physical properties of alloy
2. Dimensional accuracy with which the alloy can
be cast and finished
3. Availability of the alloy
4. Versatility of the alloy
5. The individual clinical observation and
experiences with alloys in respect to quality
control and service to the patient
Chromium – cobalt alloy :
Low density (weight)
High modulus of elasticity (stiffness)
Low material cost
Resistance to tarnish
Comparable characteristics of gold alloys and
chromium – cobalt alloys
1. Each is well tolerated by oral tissues
2. Esthetically - equally acceptable
3. Enamel abrasion - insignificant on vertical
tooth surfaces
4. A cast to wrought wire or its components may
be soldered
5. Accuracy in casting - clinically acceptable
6. Soldering procedures for the repair of
frameworks can be performed on each alloy
Comparative physical properties
Yield strength is the greatest amount of stress an alloy
will withstand and still return to its original shape in an
unweakened condition.
Thus dentist must design chromium – cobalt framework
so that the degree of deformation expected in a direct
retainer is less than comparable degree of deformation
for gold component.
Density Modulus
of
elasticity
Yield
strength
Tarnish
resistance
Cost Hardness
Chromium
-Cobalt
Low High Low Good Low High
Gold High Low High Good High Mod
Titanium Low Low Low Good Mod-high High
Wrought wire : selection and quality control
Wrought wire direct retainer arms may be
attached to the restoration by:
Embedding a portion of it in resin denture base,
By soldering to fabricated framework or
by casting the framework to a wire embedded in the
wax pattern.
The physical properties like –
Yield strength or proportional limit
Percentage elongation
Tensile strength
Fusion temperature - are important considerations
Craig has suggested – the tensile strength of
wrought structure is aprox 25% greater than cast
alloy from which it was made.
Means wrought structure having a smaller cross –
section than a cast structure which is used as a
retainer arm (retentive) to perform the same
function
Minimum yield strength of 60,000 psi required for
retentive element of a direct retainer
Percentage elongation of less than 6% is
indicative which can be generated best by
tapering wrought wire 0.8 mm which won’t
change undesirable changes in microstructure.
Craig RG: Restorative dental materials, ed 11, 2002
Position of the patient
The occlusal plane of the arch should be parallel
to the floor when the patient opens his mouth.
The patients mouth should be at the same level
as the dentists elbow.
Selection of the trays for alginate impression
Rim lock trays
Perforated metal trays
Plastic disposable trays
Ask the patient to rinse the mouth with a
mouth wash
Mixing alginate impression material
22°C 45 sec. / 20 lbs of vaccum for 15 seconds
Making impressions
Removal of impression from the mouth
2-3 min. after initial set
Cleaning the impression
Disinfecting the impression
Pouring of the cast
Dental stone
Trimming of the cast
A diagnostic procedure is incomplete unless it
includes the evaluation of accurate diagnostic
casts.
Permits analysis of contour of both hard and soft
tissues of the mouth
Determines the type of restorations to be placed on the
abutment teeth
Determines the need for the correction of exostoses,
frena, tuberosities, and undercuts
The casts are surveyed, the proposed design is drawn
on the casts.
The designed casts serve as a blue print for the
placement of restorations, the re contouring of
teeth, and preparation of rest seats.
Aid in the presentation of proposed treatment
plan to the patient.
The mounted diagnostic casts permit analysis of
the patients occlusion, adequacy of inter arch
space, and of the presence of over erupted or
malposed teeth and tuberosity interferences.
Objective:
To position the casts of dental arches on an
articulator so that the casts have the same
relationship as do the mandible to maxilla in
the patient skull.
Three distinct phases of the procedure are
Orientation of the maxillary cast to the
condylar elements of articulator by means
of a face- bow transfer.
Orientation of the mandibular cast at the
patients centric jaw relation by means of an
accurate centric jaw relation record
Verification of these relationships by means
of additional centric jaw relation records
and comparison of occlusal contacts on the
articulator with those in mouth.
Face – Bow Transfer
1. Softened modeling plastic is adapted to the
bite fork
2. Bite fork is positioned with bite fork arm on
patients left side
3. Modelling plastic is trimmed , leaving only
indentations of cusp tips
4. Check the stability of bite fork in mouth
5. Check the stability of bite fork on cast
6. Face- bow centered on face and attached to
bite fork.
7. Anterior reference point marked at the level
of infra orbital notch
8. Face-bow is adjusted according to the third
point of reference
9. The nuts are tightened
10. Transfer of face bow to the articulator and
mounting of maxillary cast
Centric jaw relation record
• It is the most posterior relation of the mandible
to the maxilla at the established vertical
relation.
• It is a bone to bone relation of the mandible to
the maxilla in terminal hinge closure.
Why to mount the diagnostic casts
in centric relation
• It can be recorded repeatedly and can be
verified in the articulator.
• It is the best reference position for studying the
other relationships of jaws.
Media for recording centric jaw relation
Wax: modelling, alu wax
Zinc oxide eugenol paste
Plaster of paris
Dental stone
Acrylic resin
Modelling plastic
Poly ether bite registration paste
Centric jaw relation records using
base - plates with occlusion rims
• If patient does not have enough teeth to mount
lower cast to upper (i.e. no posterior teeth),
fabricate record bases.
• Wax-up, record centric relation.
It should include
A thorough examination made of a dry field in
good light
Carious lesions and defective restorations are
correlated with radiographic and other diagnostic
findings
All teeth that appear questionable clinically or
radiographically are tested for pulp vitality.
The teeth are tested for sensitivity to percussion
and mobility
Periodontal examination that includes
Determination of pocket depth, examination for
evidence of infection or inflammation, the amount of
attached gingiva of the prospective abutment teeth is
made
The oral mucosa is examined visually and with
palpation for evidence of pathologic change
The examination is made for the presence of
tori, exostoses, sharp or prominent bony areas ,
soft or hard tissue undercuts, enlarged
tuberosities.
Other diagnostic steps
Radiographic examination with special attention
focused on the abutment teeth and residual ridge
areas.
The mounted casts are examined for the
presence of extruded teeth, malposed teeth,
reduced inter arch space, unfavorable occlusal
plane and other potential problems.
The occlusion is examined and evaluated.
Periodontal probe is used to determine the
distance from the active floor of the mouth to
the gingival margins of the mandibular teeth.
The diagnostic casts are analyzed on a dental
surveyor , and design of the removable partial
denture is drawn on the cast.
Evaluation of caries and existing
restorations
A simple two surface intra coronal restoration may
be adequate for restoring a carious tooth.
If the tooth is extruded above the occlusal plane
because of lack of an antagonist – extra coronal
restoration to improve the occlusal plane .
If a tooth is not possessing adequate contours for
clasping – full coverage restoration
The selection of teeth to rest seats must be made
before restorative procedures begun.
Evaluation of pulp
Electric pulp tester in conjunction with thermal
tests should be used to detect pulpitis or necrosis.
The success of endodontic treatment must be
assured before an affected tooth is selected as an
abutment.
Full crown restorations are indicated for
endodontically treated abutment teeth.
Evaluation of sensitivity to percussion
Positive in case of
Tooth movement caused by a prosthesis or the occlusion
A tooth or restoration in traumatic occlusion
Periapical or pulpal abscess
Acute pulpitis
Gingivitis or periodontitis
Cracked tooth syndrome
A removable partial denture should not be
constructed until the cause discovered and the
sensitivity is eliminated.
The use of a percussion sensitive tooth as an
abutment would result in early failure of the
treatment.
Evaluation of mobile teeth
Mobile tooth as an abutment tooth – poor
prognosis
The causes for mobility
Trauma from occlusion- reversible
Inflammatory changes in the periodontal
ligament- may be reversed if the inflammation is
eliminated
Loss of alveolar bone support – not reversible
A tooth with less than a 1:1 crown/root ratio is
not suitable as an abutment tooth, indicated for
extraction or can be used as an over denture
abutment.
Indications for splinting of abutment
teeth
Indicated when all remaining teeth have reduced
support because of
Periodontal disease
Teeth with short ,tapered roots
Evaluation of periodontium
Periodontal disease is one of the main etiologic
factors in the loss of the teeth
A removable partial denture placed in the presence
of active periodontal disease will contribute
significantly to the rapid progression of the disease
and the loss of the remaining teeth.
The causative factors must be eliminated, the
disease process must be controlled before the
fabrication of the prosthesis.
o Examination findings that indicate possible need
for periodontal treatment include
Pocket depth in excess of 3 mm
Furcation involvement
Deviations from normal color and contour in
gingiva, indicating gingivitis
Marginal exudate
Potential abutment teeth with less than 2 mm of
attached gingiva
Pulling of muscle or frena on attached gingiva
o Several types of periodontal treatment are
effective in restoring the abutment teeth, the
other remaining teeth, to optimum health.
Root scaling and planing
Gingivectomy:
Allow the use of a tooth undercut that was hidden by the
gingival tissue.
Create a longer clinical crown when retention becomes a
problem in crown preparation.
Periodontal flap procedures
Used to correct pocket depth that extends beyond the
mucogingival junction
To correct the muscle or frena pull on the attached
gingiva.
Free gingival grafts
Evaluation of oral mucosa
Pathologic changes:
Any ulceration, swelling , or color change that might
indicate malignant or pre malignant changes should be
recognized and evaluated through biopsy or referral.
Tissue reactions to the wearing of a prosthesis
o Palatal papillary hyperplasia:
Caused by inflammatory response in the sub mucosa,
consists of numerous papillary growths.
Food debris, fungi, bacteria collect in the crevices
and may give rise to secondary infection.
If the patient will not be able to keep the lesion
adequately clean, it should be removed.
o Epulis fissuratum:
It is a tumor like hyperplasic growth caused by an
ill- fitting or overextended border of removable
prosthesis
It may occur in double fold of tissue with one fold
on the tissue side and one on the polished side of
the denture border
Surgical removal – formation of scar tissue - not
good for proper border seal
If the irritation is removed – resolves on its own
o Denture stomatitis
Characterized by generalized erythema, usually
including all the tissues covered by the prosthesis.
Occurs under metal as well as acrylic resin denture
bases, usually under maxillary prosthesis.
Frequently the mucosa is swollen and smooth – patient
complaints of burning or itching.
Contributing factors: TFO, poor fit of the prosthesis,
poor oral hygiene, continuous wearing of prosthesis
Candida albicans has been shown to be present in
much higher percentages of denture stomatitis patients
than normal patients.
Teeatment : nystatin, good oral hygiene
Evaluation of hard tissue abnormalities
o Torus palatinus:
Removal is not necessary unless it is so large
that interferes with the design and
construction of the prosthesis.
If removal is deemed necessary, acrylic resin
surgical splint should be constructed pre
operatively.
Splint is used to adapt and support the
mucosal flaps in contact with the bone.
o Torus mandibularis:
Usually occurs bilaterally, on the lingual surface
of body of the mandible.
Tori should be removed if the patient is to wear
the removable partial denture with any degree
of comfort.
o Exostoses and undercuts:
That are present in residual ridge areas that
prevent the proper extension of the denture
borders should be evaluated and , if necessary,
surgically corrected.
o Mandibular / Maxillary tuberosity:
A bony protuberance at the distal end of the third
molar area
The soft tissue covering is thin, traumatized by the
insertion and removal of removable partial
denture.
Surgical reduction is indicated
Evaluation of soft tissue abnormalities
Various tissue conditions can present problems in
the design and construction of removable partial
denture.
Labial and lingual frena as well as un supported
and hyper mobile gingiva should be evaluated to
determine whether surgical correction will
improve the prognosis of the treatment
Evaluation of quantity and quality of saliva
If the mouth is dry, the patient will probably be
uncomfortable wearing a removable partial
denture.
The denture bases will drag across the tissues
during placement and removal if the lubricating
effect of the saliva is not present.
A lubricating saliva substitute can help make the
prosthesis more tolerable for the treatment.
Evaluation of space for major connector
The width of lingual bar – 5 mm
The superior border – should be located 3 mm
below the free gingival margins of the
mandibular teeth to avoid damage to the gingival
tissues.
When the space is less than 8 mm- lingual plate
is indicated.
Evaluation of radiographic survey
All prospective abutment teeth must be critically
evaluated
o Root size, length and form
Teeth with large or long roots - Greater
periodontal support
Tapered or conical roots- un favorable
Multi rooted teeth with divergent roots are
stronger abutment teeth than single rooted,
multi rooted teeth with fused roots.
o Crown / root ratio:
o Lamina dura:
loss of lamina dura- hyperparathyroidism, Paget's
disease
Thickening of lamina dura- mobile teeth,
occlusal trauma,
Evidence of changes in lamina dura should be
correlated with findings of the clinical
examination and evaluation of the occlusion.
o Periodontal ligament space:
Widening with thickening of lamina dura
indicates – mobility, occlusal trauma, and heavy
function.
o Bone index areas:
These are the areas of alveolar bone that support
the teeth known to have been subjected to a
larger than normal work load.
If there is a positive response of alveolar bone
and the periodontal ligament to the increased
forces, the patient has a positive bone factor.
• Signs of positive bone factor
A supportive trabecular pattern
Heavy cortical layer
Dense lamina dura
Normal bone height
Normal periodontal ligament space.
If retograde bone changes occur, the patient has a
negative bone factor ; prognosis is poor.
Evaluation of mounted diagnostic casts
Potential problems such as insufficient inter arch
distance, irregularity or mal position of the
occlusal plane, extruded or malposed teeth, and
unfavorable maxillomandibular relationships are
more apparent in accurately mounted casts
because the lips, cheeks, and skull block out
good visual access to the teeth in the mouth.
o Interarch space
Lack of sufficient inter-arch distance- difficult
for placing the teeth
Frequently it is caused by maxillary tuberosity
that is too large in vertical height- surgical
reduction vertical height is necessary for
satisfactory replacement of the missing teeth.
o Occlusal plane
Occlusion plane may be irregular because of
extrusion
One or more unopposed teeth.
Such conditions require corrective procedures if
an acceptable occlusion is to be developed.
• Irregular occlusal plane
Treatment
Moderately extrude tooth – aprox 2mm -
enameloplasty.
If the extrusion is greater than 2 mm or if the tooth
does not lend itself to enameloplasty, the placement
of a crown is indicated.
If size of pulp prevent the required tooth reduction
endodontic therapy
If clinical crown length is inadequate crown
lengthning
Severely extruded teeth – contacting the opposing
ridge & if alveolar bone followed eruption remove
the tooth and recontour the bone is necessary
Traumatic vertical overlap
Akerly classification
Type 1:
The mandibular incisors extrude and impinge into the
palate.
Type 2:
The mandibular incisors impinge into sulci of the
maxillary incisors
Type 3:
Both maxillary and mandibular incisors incline lingually
with impingement of the gingival tissues of each arch
Type 4:
The mandibular incisors move or extrude into the
abraded lingual surfaces the maxillary anterior teeth
o Clinical symptoms of traumatic vertical overlap
Abrasion
Mobility
Migration of the teeth
Inflammation , ulceration of the gingiva and
palatal mucosa
Early recognition of problems and treatment with
orthodontic or combined orthodontic and
orthognathic surgical procedures are the treatment
of choice
Malrelation of jaws
Severe malrelation of the jaws can preclude the
restoration of adequate function and esthetics
Several maxillary and mandibular osteotomy
procedures are useful in correcting these
problems.
o Tipped or malposed teeth
Limited orthodontic procedures for minor tooth
movement can be used to upright the tipped
tooth to allow the placement of an artificial
tooth of more normal size.
Orthodontic appliances, rubber ligature used to
correct the position
o Occlusion
The information obtained from the analysis of
occlusion should be correlated with other clinical
findings.
The common finding is the presence of occlusal
interferences.
Partially edentulous patients have greater
probability of having premature contacts because
of drifting and migration.
The most common causes of Bruxism
Occlusal interferences between centric jaw relation
and centric occlusion,
Balancing side contacts.
• Clinical symptoms of traumatic occlusion
Excessive wear of teeth
Mobility, tooth migration,
Pain during and after occlusal contact.
Muscle spasm,& joint symptoms.
• Radiographic findings
Widening of periodontal space with either thickening
or loss of lamina dura
Periapical or Furcation radiolucency
Resorption of alveolar bone
Root resorption
The decision must be made in the diagnostic
phase of the treatment.
The clinical situations that indicate construction
of prosthesis at centric jaw relation
Coincidence of centric relation and centric
occlusion
Absence of posterior tooth contacts (opposing
missing teeth)
Situation in which all posterior contacts are to be
restored with cast restorations.
Only few remaining posterior contacts
Symptoms of traumatic occlusion of the anterior
teeth
Clinical symptoms of occlusal trauma
In the absence of these conditions the removable
partial denture should be constructed at centric
occlusion
Provides a guide for tooth preparation and
problems that may be encountered in
positioning cusps and in establishing acceptable
occlusal contacts.
The treatment of partially edentulous
patient can be divided in to five phases.
Phase 1 :
Collection and evaluation of the diagnostic data,
including a diagnostic mounting and analysis of
diagnostic casts
Immediate treatment to control pain or infection
Biopsy or referral of the patient
Development of treatment plan
Initiation of education and motivation of patient.
Phase 2:
Removal of deep caries and placement of
temporary restorations
Extirpation of inflamed or necrotic pulp tissues
Removal of non retainable teeth
Periodontal treatment
Construction of interim prosthesis for function or
esthetics
Occlusal equilibration
Reinforcement of education and motivation of
patient
Phase 3 :
Preprosthetic surgical procedures
Definitive endodontic procedures
Definitive restoration of teeth, including
placement of cast metallic restorations
Fixed partial denture construction
Reinforcement of education and motivation of
patient
Phase 4 :
Construction of removable partial denture
Reinforcement of education and motivation of
patient
Phase 5 :
Post insertion care
Periodic recall
Reinforcement of education and motivation of
patient
Following a complete and thorough diagnosis of
dental and oral conditions, it may be helpful to
classify the patient.
A classification system provide a framework for
orgainizing clinical diagnostic findings,
categorizing potential treatment approaches,
and indicating when specialty referal is most
appropriate.
This PDI , offer the following benefits:
A tool for improved diagnostic consistency
Standardized criteria for substantial
interoperator consistency in patient classification
Improved professional communication
An objective method for patient screening
A standardized and documented aid for decision
making related to referral for specialty care
A basis for insurance reimbursement
commensurate with complexity of care
Standardized criteria for outcomes assessment in
private, institutional, and research settings
Criteria 1 : Location and extent of the
edentulous area(s)
Class I
Ideal or minimally compromised edentulous area
– single arch and one of the following:
Any anterior maxillary edentulous area – not exceed 2
incisors
Any anterior mandibular edentulous area – not exceed
4 incisors
Any posterior maxillary or mandibular edentulous area
– not exceed 2 PM or 1 PM and 1 molar
Class II
Moderately compromised edentulous area –
edentulous areas in both arches and one of the
following:
Any anterior maxillary edentulous area – not exceed 2
incisors
Any anterior mandibular edentulous area – not exceed 4
incisors
Any posterior maxillary or mandibular edentulous area –
not exceed 2 PM or 1 PM and 1 molar
A missing maxillary or mandibular canine
Class III
Substantially compromised edentulous area
Any posterior maxillary or mandibular edentulous area
greater than 3 teeth or 2 molars
Any edentulous areas including anterior and posterior
areas of 3 or more teeth
Class IV
Severely compromised edentulous area
Any edentulous area or combination of edentulous
areas requiring a high level of patient compliance
Congenital or acquired maxillofacial defects
Criteria 2 : Abutment conditions
Class I
Ideal or minimally compromised abutment
conditions
No preprosthetic therapy indicated
Class II
Moderately compromised abutment condition
Abutments in 1 or 2 sextants have insufficient tooth
structure to retain or support intracoronal restorations
Abutments in 1 or 2 sextants require localized
adjunctive therapy (periodontal, endodontic, or
orthodontic procedures)
Class III
Substantially compromised abutment condition
Abutments in 3 sextants – insufficient tooth structure to
retain or support intracoronal or extracoronal restorations
Abutments in 3 sextants – require more substantial
localized adjunctive therapy
Class IV
Severely compromised abutment condition
Abutments in 4 or more sextants – insufficient tooth
structure to retain or support intracoronal or extracoronal
restorations
Abutments in 4 or more sextants – require extensive
adjunctive therapy
Criteria 3 : Occlusion
Class I
Ideal or minimally compromised occlusal
characteristics
No preprosthetic therapy required
Class 1 molar and jaw relationships are seen
Class II
Moderately compromised occlusal characteristics
Occlusion requires localized adjunctive therapy
(enameloplasty or premature occlusal contacts)
Class 1 molar and jaw relationships are seen
Class III
Substantially compromised occlusal
characteristics
Entire occlusion must be reestablished, but without
any change in the occlusal vertical dimension
Class II molar and jaw relationships are seen
Class IV
Severely compromised occlusal characteristics
Entire occlusion must be reestablished, including
changes in the occlusal vertical dimension
Class II, division 2 and Class III molar and jaw
relationships are seen
Criteria 4 : Residual ridge characteristics
Radiographic height of the residual mandibular
alveolar bone –
Class I – bone height ≥ 21 mm – measured at the most
reduced vertical dimension of the mandible on
panoramic radiograph
Class II 16-20 mm bone height
Class III 11-15 mm bone height
Class IV ≤ 10 mm of mandibular radiographic bone height
Partial Edentulism Checklist
Location & extent of edentulous area
Ideal or minimally compromised – single arch
Moderately compromised – both arches
Substantially compromised 3 teeth
Severely compromised – guarded prognosis
Congenital or acquired maxillofacial defect
Abutment tooth condition
Ideal or minimally compromised
Moderately compromised – 1-2 sextants
Substantially compromised – 3 sextants
Severely compromised – 4 or more sextants
Occlusal scheme
Ideal or minimally compromised
Moderately compromised – local adjunctive
treatment
Substantially compromised – occlusal scheme
Severely compromised – change in VDO
Class I Class II Class III Class IV
Residual ridge
Class I edentulous
Class II edentulous
Class III edentulous
Class IV edentulous
Conditions creating a guarded prognosis
Severe oral manifestations of systemic
disease
Maxillomandibular dyskinesia and/or ataxia
Refractory patient
Guidelines for use of the worksheet:1. Any single criterion of a more complex class, places the patient into more complex class.
2. Consideration of future treatment procedures must not influence the diagnostic level.
3. Initial preprosthetic treatment and/or adjunctive therapy can change the initial
classification level.
4. If there is an esthetic concern/challenge, the classification is increased in complexity by
one level.
5. In the presence of TMD symptoms, the classification is increased in complexity by one or
more levels.
6. In the situation where the patient presents with an edentulous maxilla opposing a partially
edentulous mandible, each arch is diagnosed with the appropriate classification system.
Kelly studied that almost inevitable degenerative changes
develop in the edentulous regions of wearers of complete
upper and partial lower dentures.
This problem might be solved with treatment planning to
avoid the combination of complete upper dentures against
distal-extension partial lower dentures. The alternative of
complete maxillary and mandibular dentures is not
attractive to patients. Preserving posterior teeth to serve
as abutments to support lower partial dentures and to
provide a more stable occlusion is a better alternative.
Ellsworth kelly: Changes caused by a mandibular removable partial denture opposing a maxillary
complete denture. J Prosthet Dent 1972;27:140-150.
Ill fitting denture have been blamed for all of the lesions
of the edentulous tissues, yet the most perfect denture
will be ill-fitting after bone is lost from the anterior part
of the ridge.
Ellsworth kelly: Changes caused by a mandibular removable partial denture opposing a maxillary
complete denture. J Prosthet Dent 1972;27:140-150.
The treatment of partially edentulous patientrequires the knowledge and the skill of thedentist in every phase of dental practice.
Many failures in removable partial denturetreatment can be traced to an inadequatediagnosis and inappropriate treatment plan.
The formulation of an appropriate treatmentplan requires the careful examination,evaluation of all patient diagnostic data, andcorrelation of the clinical findings with theradiographic and other investigatory findings.
A successful partial denture cannot be produced
by the skillful application of technique alone. It
must be conceived and constructed upon the
knowledge of oral and dental anatomy, biology,
histology, pathology, physics and their allied
sciences if the oral tissues are to be preserved.
Rodney D. Phoenix, David R. Cagna, Charles
F. DeFreest; Stewart’s Clinical removable
partial prosthodontics - 4th edition
Ernest L. Miller, Joseph E. Grasso; Removable
partial prosthodontics - 3rd edition
Renner& Boucher; Removable partial
prosthodontics
Alan B. Carr, Glen P. McGivney, David T.
Brown; MaCracken’s Removable partial
prosthodontics -11th edition
Ellsworth kelly: Changes caused by a
mandibular removable partial denture
opposing a maxillary complete denture. J
Prosthet Dent 1972;27:140-150.
Craig RG, Power JM : Restorative dental
materials, 11th edition, 2002
Dawson PE : Evaluation, diagnosis, and
treatment of occlusal problems, 2nd edition,
1989
Laney WR, Gibilisco JA: Diagnosis and
treatment in prosthodontics, 1983
Applegate OC: Essentials of removable
partial denture prosthesis, 1965
Kennedy E : Partial denture construction,
dental items of interest, 1928
Dunn BW: Treatment planning for removable
partial dentures, JPD 11 : 247-255,1961
