Diagnosis And

Treatment Planning for

Partially Edentulous
Patients

Duggal
Kanika Jaitly
second year

Guided by:
Dr.Nidhi
Presented By:P.G.

Content:
General

information (name, age, sex,

occupation)
Chief complaint
Recording the relevant medical history.
Recording the relevant dental history.
Performing a thorough visual and manual
extra-oral and intra-oral examination.
Radiographic examination.
Treatment planning

Who is a partially edentulous or

potentially edentulous patient?

A partially edentulous
patient is one who has
suffered a partial loss
of the natural dentition,
with some healthy teeth
remaining in one or
both the arches.
e.g. A patient with

Restored teeth
Adequate
interridge
distance.
Uniform occlusal plane.
Discrepancies correctable by
mouth preparation.
3

A potentially edentulous
patient
is
one
whose
conditions of remaining all
or few teeth & their
supporting periodontium is
such that it warrants a
total balance situation .
e.g. A patient with
Grossly carious remaining
teeth with multiple root
stumps.
Chronic periodontitis with
multiple mobile teeth &
generalized bone loss.
Gross occlusal disharmony

A patient is often rendered

partially edentulous due to loss of one or more
teeth due to:

Failure to maintain oral hygiene & plaque-control measures

Trauma
Parafunctional habits
Congenitally missing teeth

Effects of partial edentulism

Esthetic alteration

Tipping & migration of remaining teeth

Extrusion of opposing teeth in the edentulous space.

Mandibular deviation

Loss of facial support

Shortening of face height & overclosure
Loss of alveolar bone

Reduced masticatory efficiency

Decreased self esteem
Altered speech

Loss of maxillary anterior teeth may prevent the clear

reproduction of certain sounds, particularly the F and V. The
replacement of missing maxillary anterior teeth will make a
significant contribution to the quality of speech.
8

Aims of Diagnosis & treatment

planning

To assess the disease status of the patient

General/medical status
Dental status
To evaluate the effect of systemic conditions on the
success of treatment/prosthesis.
To anticipate potential difficulties which may be
encountered during treatment.
To anticipate the prognosis of the treatment or
prosthesis.
To explain the possible treatment strategies, the
limitations and result to the patient to gain his
cooperation and confidence
Need for alteration of treatment plan to serve the
9
patient better.

OBJECTIVES OF PROSTHODONTIC
TREATMENT FOR A PARTIALLY
EDENTULOUS PATIENT

Muller De Van stated The perpetual preservation of what

remains is more important than the meticulous replacement of
what is lost.
To eliminate the disease.
To preserve the remaining teeth and oral tissues in
a healthy state.
Satisfactory replacement of missing natural teeth &
tissues to improve masticatory function, esthetics,
phonetics and comfort besides overall health, general
and psychological well being of the patient.

10

Successful Prosthodontic Treatment for a

Patient depends upon :
An

accurate diagnosis or analysis made after a

number of examination procedures as:
Medical

history
Dental history
Extra oral & intra oral examination
Radiographic examination
Study of mounted diagnostic casts
An inspection of any existing dental prosthesis

Treatment
Should

plan :

be highly individualized for each patient,

depending upon his problems & needs.
11

Recording
general
information:

ACQUAINTED INTERVIEW
NAME
AGE
SEX
OCCUPATION
CHIEF COMPLAINT

Chief complaint:
Chief

complaint and duration should

be recorded as far as possible in the
patients own words and in
chronological order.
Patients must tell what problems they
had with their old dentures.
These complaint will act as a guidance
for the dentist in the area of greatest
concern to the patient.

HEALTH HISTORY
There

are 3 basic technique for

obtaining the information:

1. Direct

interrogation by the dentist

2. Comprehensive questionnaire
3. Combination of both

1)

Direct interrogation technique:

This type of technique is guided by the

tone of the patient answers and can be
very revealing.
Disadvantage:
-time consuming
-relies heavily on the skill and
experience of
the dentist
-easy to forget

2) Questionnaire approach:
Quick method
It can be filled by patient in waiting room
Disadvantage:
-sometimes patient do not read them
carefully
-important information is often
skipped out
or left out
-some patient may not be able to
read the
small print common to
these forms
-may not understand by some
patients

3) Combination
It

of both:

is the best system

Form is filled by the patients and then
verbally reviewed by the dentist.

Health history
includes :
1.
2.

Medical history
Dental history

Medical History:
Basic

aim is to determine any condition

that might affect the procedure and
out come of the treatment.
By being aware of medical condition.
Dentist can be ready in case of any
medical emergencies arising during
the course of treatment.
In case patient having a transmissible,
suitable procedure precaution can be
made to decontaminate the operatory
as well as prevent its transfer.

Diabetes mellitus :Short appointments

Patient must be instructed to have a
normal diet before dental appointment.

If patient will be empty

stomach

sudden decrease in normal

glucose level

Hypoglycemia
Due to excessive fluid loss, dryness of
mouth occurs.

 Dryness

of mouth will cause :

- Difficulty in chewing
- Ulceration/mucosal soreness
patients physician should be consulted
for the alternate drugs.
Salivary substitute should be given.
e.g. milk
Agents can be use to stimulate salivary
flow for e.g. sugar free candies etc.
Beverages that may produce more
saliva such as water with lemon,
lemonade etc. can be used.

 Rapid

rate of bone resorption can

occur therefore tissue rest should be
maximized.
Dentist should recall patient
frequently to correct occlusion and
monitor bone stability.
It can effect the wound healing
capability and therefore must be
taken into consideration if
preprosthetic surgery is planned.

Anaemia:
Due to nutritional deficiency dryness of
mouth and disturbance of taste
sensation is present.
Mucosal tissue become susceptible to
denture trauma.
Ridge may be lose and flabby.
Mucostatic impression technique is
used.
Prosthodontic considerations :- Constant monitoring of denture
stability
and occlusion is required to
minimize pressure areas.

- Poor denture retention results from

lack
of saliva.
Hypertension:
Clinical

signs and symptoms:- Breathlessness on exertion

- Angina on effort
- Palpitation
- Epistaxis
- Headache
- Dizziness

 Prosthodontic

considerations:- Avoidance of hypertension

episodes is
important.
- Pre-medication should be used
when necessary.
- Appointment should be short and
stress less.
- Dentist should have a reassuring
and
considerate attitude.

Salivary gland disorders:

Clinical signs and symptoms:- Xerostomia
- Painful and burning mucosa
- Mucosal sensitivity
Prosthodontic consideration:- Wearing of RPD becomes
intolerable because of pain, burning
and frictional abrasion of the OMM
from tissue-fitting surface.

Bells palsy:
Clinical signs and symptoms:- Facial paralysis with mouth drawn over to
opposite side.
- Saliva runs out from the angle of mouth.
- In oral cavity, numbness in affected side.
- Inability to feel collected food in buccal
sulcus.
Prosthodontic considerations:
- Dentist should not over stretched the angle
of mouth.
- Should add sufficient bulk to buccal surface
contour of maxillary RPD to support flaccid
muscle.

Parkinsonism:
Clinical

sign and symptom:- Impaired movement

- Muscular rigidity
- Tremor
- Slowness
- Limited range of movement.
- Speech difficulty
- Increased salivation
- Difficulty in mastication

 Prosthodontic

considerations:- Dentist should teach careful oral

hygiene,
use tissue conditioner,
balance
occlusion, and use nonanatomic teeth.
- Retention is impaired from increased
salivation.
- Maximum peripheral extension
decreases denture retention.
- Patients lacks muscular coordination to
control RPDs.
- Judgment of vertical dimension of
occlusion is difficult because of tremors
and hypertonicity of muscles.

Dental history:
Period of partial edentulism:
Edentulous ridges resorb with time.
After extraction, ridge remodeling occurs which
converts the freshly extracted alveolar bone into
the characteristic shape such as high well
rounded ridge, knife edge etc.
In above given characteristic shapes high well
rounded ridge is the most favorable for denture.
Rapid rate of ridge remodelling occurs in the 1 st
few month of extraction, therefore, rapid
loosening can be expected if the dentures are
constructed soon after total extraction.

History of tooth loss:

Poor

ridges can be expected if teeth

were lost due to periodontal disease.
If there is early loss of lower posterior
teeth due to which supraeruption of
the opposite arch posterior teeth can
occur.
This will result in a overhanging
tuberosity in later stage.
A history of severe dental caries raises
suspicions of current as well as past
neglect or nutritional problems.

 Reason

Previous denture:

should be asked for the failure of

the previous denture.
This will guide the dentist to avoid similar
problem in the construction of new denture.
Therefore, existing denture should be
examined thoroughly. By the examination
we come to know about:
-Denture experience
-Denture care
-Para functional habits of the patients.
Patients

who keep changing dentures in a

shot period of time are difficult to satisfy
and risky to deal with.

Psychological
Evaluation

Determining the level of

motivation:
Self

motivated patient have better chance

of success than a patient who has been
motivated.

Mental Attitude:
Following equation depicts the
prosthodontic therapy for edentulous
patients.
Clinical skill + Knowledge = Successful care

 But

the modern equation for

prosthodontic treatment now
includes both technical and patient
management skill, with the later
being based on a keen understanding
of the patients mental attitude.

 Dr.

milus house proposed a general

classification of patients mental attitudes.
This classification is based on extensive
clinical experience and personality:
Classification:

Philosophic:
Best mental attitude
Well motivated
Cooperates with the dentist and learns to
adjust
Rational, sensible, calm and are composed
even in difficult situation.

Indifferent:
Have little concern for their teeth or oral
health.
Have little appreciation for the efforts of
their dentist.
Patients require more time for their
instruction on the value and use of
denture.
Their attitude can be very discouraging
to dentist.

Critical:
Finds

faults with every thing that is done for

them.
Never happy with their previous dentist
because the previous dentist did not follow
their instruction.
Firm control of these patients is essential.
These patients can be traumatic in a dental
practice if they are not properly controlled.
Medical consultation is always advisable for
critical patients before treatment is started.

Skeptical:
These patient had bad results with previous
treatment and are therefore doubtful that
any one can help them.
Often they will have a recent series of
personal tragedies such as loss of a spouse,
business problems, or other things not
directly related to their denture problems.
They think the world is against them and
doubt the ability of any one helping them.
They need kind and sympathetic help as
much as they need new dentures.

 Dentist

should take more time then

usual, in making examination of
these patients, since care and
attention will help the patient begin
to develop confidence in the new
dentist.

Application Of The House

Classification:
Dentist

should learn to detect patient

attitudes and reactions during
diagnostic appointments. So, that
dentist should modify their own
attitude and reactions by which
mutual confidence can be established.
Dentist must have a sense of real
concern for the health, comfort and
welfare of their patients to establish
the mutual confidence.

 International

prosthodontic work
shop identifies following factors
which produce an adaptive or
maladaptive response:

Factors for a favorable adaptive response to

removable partial denture:
Trust and confidence in the dentist
Previous favorable experience with a
dentist.
Positive attitude and ability to cope with
change
Realistic expectation of the patient
Good general health
Willingness to please the doctor.
Good learning capacity

Factors producing a maladaptive response to

removable partial denture:
Lack of trust in the dentist
Poor communication between dentist and
patient
Previous negative experience
Unrealistic expectation
Anxiety and low tolerance to pain
Poor health and senility
Poor muscle coordination
Poor learning ability
Psychological disorder.

Clinical examination
of the patients:
1)
2)

Extra oral
Intra oral

EXTRA ORAL:
Facial examination:
It includes the evaluation of facial form and
facial profile.

a)

Facial form:
House and loop, Frush and Fisher, and
Williams classified facial form based on
the out line of the face.
- Square

- Square tapering
- Tapering
- Ovoid

b)

Facial profile:

Angle

classified facial
profile as:
-class I normal or
straight
profile
-class II retrognathic
profile
-class III prognathic
profile

Temporomandibular joint
(TMJ) :

TMJ should be evaluated

for the following:
- Pain and tenderness
in the muscles of
mastication and TMJ.
- sounds during
condyler movements
- limited of
mandibular
movement

 Patient

suffering from one or more above

symptoms are considered to be suffering from
a TMJ disorder.
TMJ is often associated with MPDS.
4

cardinal symptoms are:

Subjective symptoms
symptoms
Pain
muscle tenderness
movement
TMJ

Objective
clicking
limited jaw

is innervated by the masseteric

nerve and the auriculotemporal nerve.

 The

auriculotemporal
nerve sends sensory
fibers to the facial
nerve, which makes
Auriculotemporal nerve (A)
it difficult to determine
the source of pain in
this region.

The internal
pterygoid and
masseter muscles
form a sling for the
mandible and
external pterygoid
muscle hold the
mandibular condyle
and disk in a
position of
equilibrium on the
articular eminence. A internal pterygoid muscle
B masseter muscle

 All

3 muscles and the temporal

muscle may become rigid because of
occlusal disharmonies.
It is a physiological protective
reaction of the body to protect the
masticatory system.
This can be easily ascertained by
palpating the rigidity of the muscles
and comparing them to the ones of
the contralateral side of the jaw.

 For

anterior fibers of
the temporal
muscle, the
forefinger is placed
on the cheek
opposite the
insertions of the
muscle on the
coronoid process.
The other forefinger
is placed inside the
cheek opposite the
contralateral finger.

 The

masseter and
internal pterygoid
muscles are
palpated with
forefingers of
each hand, one
on the cheek and
one opposing it in
the mouth.

 External

pterygoid
muscle cannot be
palpated.
Patients with
occlusal
disharmonies
exhibit tenderness
in the region of the
hamular notch.

 Mode

of treating the TMJ include

occlusal equilibrium, intraoral
prostheses, exercise, drug therapy,
surgery, Etc.
In case of any disorder, treatment
with an R.P.D should not be initiated
until a state of equilibrium exists.

INTRA ORAL EXAMINATION:

Good lighting, a clean mouth mirror, a
sharp explorer, and a calibrated
periodontal probe are required for the
examination.

Oral hygiene status

The

dentist observes
whether the patient
follows excellent,
fair, or poor oral
hygiene practices,
as evidenced by the
presence of food,
bacterial plaque or
calculus.

 All

the remaining teeth and tissues

receive consistent and meticulous
cleaning.
If there is lack of oral hygiene, then
the treatment plan must include oral
health care instruction.
Location of unusual accumulation of
plaque, calculus or food debris
should be recorded so that these
areas may be rechecked at
subsequent examination.

Interproximal food
impaction:
There

are two type of interproximal food

impaction:-

Vertical food impaction:

- Due to forceful
wedging of food against
the gingival tissues and
into the interproximal
spaces through occlusal
pressure.

 Horizontal

food impaction:
- Due to forceful wedging of
food between the teeth by the
tongue, lips, and cheek.
Dentist should note whether food
impaction between 2 particular teeth
is the result of faulty marginal ridge
relations, faulty contact areas, or a
plunger cusp in the opposing
dentition.

Carious lesions and missing

teeth:
All

the carious lesions, defective

restorations, areas of erosion or unusual
abrasion should be recorded.
All the carious teeth must be restored
before prosthodontic treatment is
started.
In caries prone patients, carious control
program should be the part of treatment
plan including plaque control instruction
and dietary counseling.

 After

elimination of all active carious

lesions, trial period is
recommended, during this period,
patients oral hygiene practices and
susceptibility to disease are
reevaluated before prosthodontic
treatment is begin.
Unless an exceptional level of plaque
control can be achieved, the
prognosis for treatment will be poor.

Periodontal health:
Oral

mucosa consist of 3 zones:

Masticatory mucosa:
(gingiva and covering of the hard
palate)
Specialized mucosa:
(dorsum of tongue)
Lining mucosa:
(lining the remainder of oral cavity)

 Gingiva:

oral
mucosa that covers
the alveolar
processes of the
jaws and surrounds
the neck of the
teeth.
Healthy gingiva are
coral pink in color,
stippled, and
presence of varying
degrees of melanin
pigmentation may
be seen.

 Red,

smooth,
shiny gingiva
may indicate the
presence of
gingivitis.

Marginal gingiva:
It turns red, due to any infection.
Blunting and thickening may be
observed.
Pronounced festooning will create
problems if clasps or other
component of an R.P.D frame work
must pass over them.
Festooning also tend to trap debris
and hinder the cleaning of tooth
surfaces in the gingival area.

Attached gingiva:
It is normally stippled.
The bands of attached gingiva should
be several millimeters wide.
It is essentially important that the
patient have an adequate zone of
this tissue around the teeth that are
potential abutments of an R.P.D.
Gingival recession are occasionally
associated with the loss of attached
gingiva.

 This

may indicate the presence of

periodontal pockets that require
therapy before prosthodontic
treatment.
Areas of gingival recession that extend
apically farther than the
cementoenamel junction of any tooth,
should be noted in the records.
Depths of the periodontal pockets
around all the remaining teeth
should be measured
and recorded.

 Base

of the gingival sulcus and

periodontal pockets is probed at 3
points on the buccal surface and 3
points on the lingual surface.
Periodontal health can also be
determined radiographically.
The amount of horizontal or vertical
bone loss is measured on a
radiograph.
This record is essential in determining
the type of periodontal therapy, that
may be required.

 Degree

of mobility of all mobile

teeth should be recorded.
A scale commonly used for classifying
mobility is given below:
Class I tooth demonstrate greater
than normal movement, but less than
1 mm of movement in any direction.
Class II tooth moves 1 mm from
normal position in any direction.
Class III tooth moves more than
2mm in any direction, including the
rotation or depression.

 Teeth

exhibiting class III mobility

have an extremely poor prognosis
and usually will require extraction.

Oral mucosa:
Mucosa

of the palate, edentulous

ridges, tongue, cheeks, floor of the
mouth and vestibules should be
examined.
Location and appearance of any
ulceration, area of inflammation or
suspicious lesions are recorded.
Irritation due to rough teeth or by an
existing prosthesis should be noted.

 White

or red lesions, any where in the

oral cavity must be diagnosed and
appropriate treatment must be planned.
Candidiasis is a fungal infection
frequently seen on the mucosa
underneath existing complete and
removable partial dentures, especially in
maxilla.
Antimycotic antibiotic therapy ( nystatin)
is required to control the infection
before prosthodontic treatment is
begun.

 Candida

albicans infection is
frequently associated with the
presence of papillary hyperplasia of
the palate.
Inflammed tissues provide a wrong
recording while making an
impression.

Residual ridge (R.R) :

Ridges

are visually inspected and

palpated.
Size and shape of the ridges and height
and location of the adjacent muscle
and soft tissue attachments are noted.
Ridges are described as: high, flat,
narrow or wide.

According to Branemark et al in 1985,

ridges were classified on the basis of bone
quantity and bone quality by radiographic
means

BONE QUANTITY:
Class A : most of the alveolar bone is present.
Class B: moderate residual ridge resorption
occurs.
Class C: advanced residual ridge resorption
occurs.
Class D: moderate resorption of the basal bone
is
present.
Class E: extreme resorption of the basal bone.

BONE QUALITY
Class 1: Almost the entire jaw is composed of
homogenous compact bone.
Class 2: A thick layer of compact bone
surrounds a
core of dense trabecular
bone.
Class 3: A thin layer of cortical bone surrounds
a
core of dense trabecular bone.
Class 4: A thin layer of cortical bone surrounds
a
core of low density trabecular bone.

ATWOODS CLASSIFICATION:

Order I:
Order II:
Order III:
Order IV:
Order V:
Order VI:

pre-extraction.
post extraction.
high, well rounded.
knife edge.
low, well rounded.
depressed.

 Firmness

of the overlying mucosa is

determined by palpation.
Crest and sides of the ridges should
be palpated to detect the presence
of sharp spines or ledges of bone.
Ridges those are flat, narrow, sharp,
sensitive or covered with flabby
tissue will not function well, as areas
of support.

 These

conditions will compromises in

denture comfort and function.
Mandibular R.R tend to exhibit these
undesirable characteristics more
frequently than maxillary R.R.
Enlarged, hyperplastic tuberosities
frequently found in the maxillary arch,
which can be flabby or spongy or if
they intrude into the inter ridge space,
are planned for surgical removal.

 Atrophic

mucous membrane commonly

found on R.R of elderly or malnourished
patients.
This type of mucosa appears to be thin,
smooth and transparent, somewhat
resembling layer of plastic food wrap.
Atrophic mucous membrane sometimes
burns or hurts spontaneously and
usually sensitive to pressure, intolerant
of pressure from denture, easily
bruised and slow to heal after injury.
These conditions can be cured by
medical and nutritional therapy.

Tori:

Dentist should note,

if there is any
presence of palatal
or lingual tori.

Generally,

small tori
do not have to be
removed when a
patient is treated
with R.P.D.

Maxillary tori

 The

major connectors of
R.P.D are modified
according to these
anatomical anomalies.

If

the tori is very large or

mushroom shaped, or if
they will otherwise
interfere with comfort,
function or speech, they
should be surgically
removed before
prosthodontic treatment
is started.

Mandibular tori

Evaluation of space for mandibular major connector

To determine if at least 8mm of space between

the gingival margins of teeth and elevated floor
of mouth is present.

Height of floor of mouth (tongue elevated) in

relation to lingual gingival sulci measured
with a periodontal probe.

Recorded measurements are transferred to diagnostic cast

and then to master cast after mouth preparations are
completed. Line connecting marks indicates location of
87
inferior border of major connector .

Lingual bar major connector is indicated if at least 8mm of

space is available.
Linguoplate major connector if there is less than 8mm of
space.

Lingual bar
Linguoplate
88

Occlusion:
The

existing teeth
should be examined for
occlusion.
Teeth should have a
good cusp to fossa
relationship.
Premature contacts in
normal closure and
deflective occlusal
contacts that cause the
mandible to slide
protusively or laterally
must be corrected.

 The

presence of
supraerupted teeth into
opposing edentulous
spaces that disrupt the
continuity or the orientation
of the occlusal plane of the dental
arches and interridge space between
maxillary tuberosity and the retromolar
area should be reevaluated.

Reestablishment

of a relatively regular,
straight plane of occlusion is important.

 Correction

of this problem eventually

requires one of the following treatment
alternatives:
a) Selective grinding of the cusps.
b) Restoration with a crown at the proper
height.
c) Gross reduction and restoration, often
involving endodontic treatment.
d) Extraction of the offending tooth.

Deep or excessive anterior vertical

overlap (overbite more than 3mm) of
anterior teeth often results in problems
in the design and fitting of R.P.Ds and
may also be a sign of posterior occlusal
collapse, with its accompanying loss of
interarch space.
Abnormal horizontal overlap (overjet)
may be diagnostic of abnormal
swallowing or tongue thrust habits
which can lead to difficulties in wearing
R.P.Ds.

 Due

to the loss of some of the teeth,

drifting of the remaining teeth
occurs, results in malposed teeth and
traumatic occlusion, with mandibular
guidance being forced upon weak
teeth.
Common signs of traumatic occlusion
are mobile teeth or excessive
attrision of the occlusal surfaces.
Teeth that exhibit abnormal mobility
during lateral jaw movements often
have an unfavorable prognosis.

 Dentist

should also at this time look

for any parafunctional habit like
bruxism or clenching of teeth.
If a parafunctional habit is verified or
even strongly suspected, the patient
must be counseled regarding the
effects of the habit and if necessary,
treatment for the adverse habit
should be instituted.

Tongue:
- Tongue should be examined for:
a) SIZE:
- Large tongue decreases the stability of denture
and makes impression making difficult. Tongue
biting is common after insertion of the denture.
- Small tongue does not provide adequate lingual
peripheral seal.
b) MOVEMENT AND COODINATION:
- It is important to register a good peripheral
tracing.
- Helps in maintaining the denture in the mouth
during the function activities like speech,
deglutition and mastication.

Diagnostic cast:
Diagnostic

cast should be accurate

reproduction of the teeth and adjacent
tissue.
Purpose of the diagnostic cast:-

It

should permit dentist to plan ahead

to avoid undesirable compromises in
the treatment being given to a patient.

Cast should be surveyed with a cast surveyor to

determine the parallelism or lack of parallelism
of tooth surfaces involved and to establish their
influence on the design of partial denture and to
determine the need for mouth preparation:-

Proximal tooth surfaces, which can be made

parallel to serve as guiding plane.
Retentive and non retentive areas of the
abutment teeth.
Areas of interference to placement and
removal.
Esthetics effects of the selected path of
insertion.

It should use to permit a logical and

comprehensive presentation to the patient of
present and future restorative needs, as well
as of the hazards of future neglect.
It should point out:Evidence of tooth migration and the existing
results of such migration.
Effects of further tooth migration.
Loss of occlusal support and its consequences.
Hazard of traumatic occlusal contacts.
Cariogenic and periodontal implications of
further neglect.

Individual impression trays may be

fabricated on the diagnostic casts,
or the diagnostic cast may be used
in selecting and fitting a stock
impression tray for the final
impression.
Diagnostic cast may be used as a
constant reference as
the work progresses.

To determine the most suitable path of insertion that

will permit locating retainers and artificial teeth to
best esthetic advantage.

To record the cast position in relation to the selected

path of insertion for future references.

100

 Diagnostic

wax-up:

Indicates problems which may be encountered during treatment.

Provides a guide for tooth
preparation.

Definite examination is carried out at second

appointment when patient, radiographs & articulated
study casts can be brought together for final study &
decision making.
A treatment plan is formulated & presented to the patient
with the help of study casts.

101

Roentgenographic
interpretation:
Alveolar

bone is evaluated for the

quality and quantity (height) .
Roentgenographic changes are not
observed until approximately 25% of
the mineral content has been depleted.
An increased thickness of the
periodontal space around the tooth,
suggests varying degrees of mobility,
which can be evaluated clinically.

Index areas:
Reaction of bone adjacent to teeth that
have been subjected to abnormal stress
serves as indication of probable
reactions of that bone when such teeth
are used as abutments for fixed or
removable restorations. Such areas are
called index
areas.

 Teeth

that have been subjected to

abnormal loading because of the loss
of adjacent teeth or that have
withstood tipping forces in addition to
occlusal
loading may be better risks as
abutment teeth than those that have
not been called on to carry an extra
occlusal load.

 With

the former the patient is said to

have a positive bone factor, which
means the ability to build additional
support whenever needed.
And with the latter the patient is said
to have a negative bone factor,
which means the inability to respond
favorably to stress.

Alveolar lamina dura:

It

is the thin layer of

hard cortical bone that
normally lines the
sockets of all teeth.
It affords attachment for
the fibers of the
periodontal membrane.
Its function is to
withstand mechanical
strain.

 It

is a radiopaque white line around

the radiolucent dark line that
represents the
periodontal membrane.
When a tooth is in the process of
being tipped, resorption of the bone
occurs on the pressure side and
apposition occurs on the tension side.
Therefore lamina dura on the side to
which the tooth is sloping becomes
uniformly heavier.

Root morphology:
It determines the ability of abutment
teeth to resist additional rotational
forces that may be placed on them.
Teeth with multiple and divergent
roots will resist stresses better than
teeth with fused and conical roots

<

Third molars:
Unerupted 3rd molars should be
considered as prospective future
abutments to eliminate the need of a
distal extension removable partial
denture.
It will help in increasing the stability
of the denture.

Carious lesions:
Initial

carious lesion and recurrent

caries adjacent to existing
restorations should be noted.
Deep lesions or extensive
restorations in teeth that are
potential abutments for prostheses
should receive special scrutiny.

111

Phase II
Removal

of deep caries and placement of

temporary restoration.
Extirpation of inflamed pulp.
Removal of non-retainable teeth.
Periodontal treatment.
Construction of interim prosthesis for function
or esthetics.
Occlusal equilibration.
Reinforcement of education and motivation of
patient.

112

Phase III
Pre-prosthetic

surgical procedures.
Definitive endodontic procedures.
Definitive restoration of teeth.
Fixed partial denture construction.
Reinforcement of education and motivation of the
patient.

Phase IV
Construction

of prosthesis.

Reinforcement

of education and motivation of patient .

Phase V
Post-insertion

care.

Periodic

recall
Reinforcement of education and motivation of patient.

113

Preprosthetic surgery:
When

establishing a treatment plan it

often is useful to compare the patients
presenting condition with the ideal
shape and form of the edentulous jaw,
which provides for maximum support
and stability and minimum interference
with function. This ideal edentulous
ridge should.
Provide adequate bony support
Have bone covered by normal attached
soft tissue

 Have

no bony or soft tissue

protuberances or undercuts.
Have no sharp ridges.
Provide adequate buccal and lingual
sulci
Have no peripheral scar bends that
prevent seating of a denture prosthesis.
Have no muscle fibres or frena that
mobilize the prosthesis.
Contain no soft tissue folds,
redundancies or hypertrophies on the
ridges or in the sulci, and
Posses no neoplastic lesions

NON-SURGICAL METHODS
Rest for denture supporting
tissues: Removal

of denture from the mouth for an

extended period of time (48 72 hours).
Use of temporary soft reliners/tissue
conditioners.
Regular home care program:
Rinsing of mouth
Managing the residual ridge areas, palate
and tongue with a soft tooth brush.

Occlusal correction of old

prosthesis: An

attempt should be made to restore

an optimal vertical dimension of
occlusion to the denture presently worn
by the patient by using an interim
resilient lining material.

Conditioning of patients
musculature: Use

of jaw exercises can permit

relaxation of the muscles of mastication
and strengthen their coordination.
This facilitates the registration of jaw
relation.

SURGICAL METHODS
Certain

conditions of denture bearing

tissues requires to be surgically
treated.
There should be adequate healing
time before the fabrication of the
prosthesis.
Common conditions where surgical
intervention is indicated are:

Hyperplastic
tissue:-

- It is seen in the

form of fibrous
tuberosities, soft
flabby ridges, folds
of redundant
tissue in the
vestibule, on the
floor of the mouth
and palatal
papillomatosis.

- All these excess tissues should

removed to provide a firm base and a
more stable denture and reduced
stress and strain on the supporting
teeth and tissues.

 Pendulous

fibrous maxillary
tuberosities:- It occurs unilaterally or bilaterally and
interfere with denture construction.
Enlargement

of denture
bearing areas:-

- Vestibuloplasty and ridge

augmentation varied out to improve
denture retention function.

 Frenular

and muscle
attachment:-

- Due to loss of alveolar bone height,

muscle attachment may insert on or
near the alveolar crest.
- Maxillary labial and mandibular
lingual frenulas are frequent sources
of interferences with denture design.

Pressure on
mental foramen:

- Pressure from the

denture against the
mental nerves and
over the sharp bony
edge will cause pain.
- This can be dealt in 2
ways
i.
Alter the dental
design.
ii. Trim the bone and
relieve mental nerve
from pressure.

 Discrepancies

in jaw size:-

- Mandibular osteotomy is done to

create optimal jaw relations for
prosthetic patients who have
discrepancies in jaw size.

Mouth preparation

1.
2.
3.
4.

The preparation of the mouth is

fundamental to a successful
removable partial denture service.
In general mouth preparation includes
procedures in the categories:
Oral surgical preparation
Periodontal preparation
Orthodontic preparation
Preparation of abutment teeth

Oral surgical
preparation:
Extraction of teeth:
-

Each tooth must be evaluated concerning

its strategic importance and its potential
contribution to the success of RPD.
Extraction of non-strategic teeth that
would present complication or those
whose presence may be detrimental to
the design of the partial denture, is a
necessary part of the overall treatment.

Teeth which are hopelessly

diseased or badly destroyed
as to be unsalvable should
be removed.

All impacted teeth should be

considered for removal. As they may
contribute to the formation of the
periodontal pocket and compromise
the periodontal condition.

 Removal

of residual roots:

- Residual roots adjacent to abutment

teeth may contribute to the
prognosis of periodontal pockets and
compromise the results from
subsequent periodontal therapy.

Periodontal
preparation:

Objectives

of periodontal therapy:
Removal of all etiologic factors
contributing to periodontal disease.
Elimination of all pocket.
Creation of physiologic gingival and
osseous architecture.
Development of personalized plaque
control program and definitive
maintenance schedule.

 Periodontal

treatment planning can

be divided in 3 phases:

Phase I/ Initial disease control therapy

Phase II/ Definitive periodontal surgery
Phase III/ Recall maintenance

Phase I:
This

phase include:
Oral hygiene instruction:- Motivate the use of disclosing agents,
soft nylon tooth brush and unwaxed
dental floss.
Scaling and root planning:- Elimination of all the calculus, plaque
and necrotic cementum.
- Without there removal periodontal
therapy can not be successful.

 Elimination

of local irritating factors other

than calculus:
- Overhanging margins of restorations,
overhanging crown margins and open
contacts leading to food impaction should
be corrected.
Elimination of gross occlusal
interferences:
- Poor occlusal relationships contribute to
more rapid loss of periodontal
attachment.
- Traumatic cuspal interferences are
removed by grinding procedures.

Phase II:
If

pocket with inflammation and

osseous defects are still present, a
variety of periodontal surgical
techniques should be considered to
restore periodontal health.
Procedures like gingivectomy,
periodontal flap surgery and other
reconstructive surgical procedures,
etc. is carried out in this phase.

Phase III:
The

frequency of recall appointments

should be customized for the
patients depending on the
susceptibility and severity of
periodontal disease.

Orthodontic
preparation:

Minor tooth movement: Anomalies

in tooth position, which

can interfere with the ideal design of
a prosthesis.

The mesially inclined molar:

The

mandibular molar that has tipped

mesially can be return to a more nearly
upright position, so that functional
stresses will be transmitted to the
periodontal apparatus in a direction
more in line with the long axis.
Additional benefit is that clasping will
be facilitated as a result of the partial
elimination of the overly severe
undercut.

Teeth in lingual or buccal

version:

Bicuspid which
have moved
out of
alignment with
the neighboring
teeth.
It may be
difficult to
clasp.

Migrated anterior
teeth:

Anterior

teeth which adjoin edentulous

spaces frequently migrate into the
space, often creating diastemas and
making the arrangement of the
replacement teeth into a pleasing
alignment more difficult.

Preparation of abutment
teeth:
Abutment teeth are prepared to provide

Abutment teeth are prepared to provide

support, stabilization, reciprocation and
retention of partial denture.
Teeth selected for abutment should have
following characteristics:
- Adequate support for roots
- Healthy periodontal tissues
- Healthy coronal structure
- Favorable coronal morphologic features
for clasping and preparation of rest seat.
- Proper axial alignment

Removable partial denture:

Any

prosthesis that replaces some teeth

in a partially dentate arch. It can be
removed from the mouth and replaced
at will.
(GPT-8)
An RPD is the restoration of choice
under the following conditions:
When there are no posterior terminal
abutment teeth present.

When the edentulous spaces are too

extensive or too curved to be
successfully restored with an FPD.
When there is a need to provide
replacement for missing hard or soft
tissues with an acrylic resin denture
base in order to restore normal tissue
contours and lip support.
When potential abutment teeth have
not fully erupted, so that treatment with
an FPD is not feasible. (common in
young patients)

When only periodontally

weakened anterior teeth
remain to provide
anchorage for a prosthesis.
E.g. swing lock partial denture.
When it is anticipated that additional
teeth will be lost sometimes after the
fabrication of the prosthesis.

When the difference in cost between

RPD treatment and extensive FPD
treatment may be sufficiently
deciding factor for a patient with
limited finance.

Treatment modalities for partially edentulous

patients

Dental implants or implant supported dentures

Fixed dental prosthesis

Removable partial denture

Resin bonded fixed dental prosthesis

Conventional fixed dental prosthesis
Cast partial denture.
Acrylic partial denture/interim partial denture.
Transitional partial denture.

Immediate dentures
Overdentures
Shortened dental arch
Single complete denture opposing some or remaining natural teeth
Upper and lower complete dentures
In the future, use of tooth germ or tooth bud cells may be used to
replace lost teeth.
145

Implant supported prosthesis

Short edentulous span

Maladaptive patients
Morphologically compromised denture
bearing area
Poor oral muscular co-ordination
Hyperactive gag reflex

146

Fixed dental prosthesis

Short tooth bounded edentulous span.

Anterior modification spaces.

Strong, well supported abutment teeth

on each side of edentulous space.

For handicapped patients and patients

with nervous disorders.

147

Removable partial prosthesis: Distal extension situations.

Need for effect of cross arch

stabilization.

Long edentulous span.

148

Excessive loss of residual

ridge.

To obturate a palatal cleft.

149

As a transitional denture.

Unusually sound abutment teeth.

Young patients

Alteration of vertical dimension

Economic considerations

When only periodontallyweakened anterior teeth remain

150

Shortened dental arch

By Arnd Kayser.
A treatment option to describe the
concept of acceptable oral function with
partial dentition.
Based on notion that patient have an
adaptive capacity to function with
missing teeth.
In addition to anterior teeth, most of the
people require at least 4 occlusal units of
posterior teeth.
A large proportion of middle aged &
elderly patients are satisfied with their
oral function even after molar loss.
Retention of solely anterior & premolar
teeth may be sufficient to satisfy
esthetics & functional needs of elderly
patients.
151

Immediate dentures
A patient who is A public figure.
Highly esthetic conscious.
Wants to avoid trauma of
being without teeth.
Wants exact replication of
teeth placement.
Upper complete denture and lower
immediate removable partial denture

152

Overdentures

Patient
with
some
congenitally missing teeth,
multiple
malposed
or
morphologically
compromised teeth.
Mutilated
or
severely
compromised dentition but
a few remaining teeth can
be altered to be used as
overdenture abutments.

153

Complete Dentures

Advanced periodontal disease of remaining teeth.

Chronically poor oral hygiene & with no tendency to improve.
Too few salvageable teeth capable of serving as abutments for
partial prosthesis or overdenture.
Gross occlusal disharmony.
Unsightly natural teeth constituting a personality hazard.
Extreme restorations needed with limited finances available.
Patients preference.
Refusal of mouth preparation.
Lack of patients cooperation for caries control.
Radiation therapy.

154

Single complete denture

Maxillary complete denture opposed by

Natural or restored mandibular dentition.

Mandibular removable partial denture.

Retained mandibular teeth enhance retention and stability

of prosthesis in preference to complete mandibular denture.
155

Combination of fixed and removable

prosthesis

Missing anterior teeth with

minimal alveolar bone loss
replaced
with
a
fixed
prosthesis
even
when
posterior teeth are to be
replaced by a removable
prosthesis:

A fixed prosthesis eliminates

the unfavorable leverages.
Patients are more apt to remove
the removable prosthesis at
night to rest the tissues if
anterior
esthetics
is
not
compromised in doing so.
Esthetics will not be affected if
posterior removable prosthesis
is to be repaired or replaced.
156

Lone standing mandibular

second premolar by being
splinted to adjacent canine
by a fixed abutment for a
distal extension removable
prosthesis.

157

No prosthetic treatment
This would be the best choice
when the harmful consequences
of providing a prosthesis could
outweigh the possible benefits.

Shortened dental arch

e.g. only 3rd molar or 3rd and 2nd molars
missing from both arches on the same side.

Very elderly patients

with adequate number of
occluding units.
Poor plaque control.

In this mouth the reasons for providing dentures are not overwhelming.
There are sufficient teeth at the front of the mouth to satisfy the demands of
appearance and speech. There are certainly enough teeth to allow a valid
diet to be eaten. Most of the teeth have antagonists in the opposing arch.

158

CONCLUSION

Complete oral rehabilitation is the objective in treating the

partially edentulous patient.
It has been seen that after receiving the treatment for tooth
loss, people experience increased self esteem & improved
function.
Whenever possible, a partially edentulous situations should
be best restored with fixed dental prosthesis or dental
implants.
Fixed dental prosthesis are better tolerated by patients &
provide better health, function & comfort.
There are situations which are non-restorable with fixed
dental prosthesis & are best served with removable partial
denture.
However, the most important thing is that each patient has a
unique situation and needs to be treated uniquely.
159

References:
Renner

RP, Boucher LJ Removable

partial dentures.
Miller EL, Grasso JE Removable
partial denture. 2nd edition
McGivney GP, Carr AB Removable
partial denture. 10th edition
Steward Removable partial denture.