diagnosis and treatment planning in rpd

1. Diagnosis and treatment
planning in removable
partial denture
BY
Dr.chakradhar
I st year post graduate student
Dept. of prosthodontics 1

2. • Introduction
• Definitions
• Patient interview and history taking
• Initial examination
• Diagnostic impressions and casts
• Development of treatment plan
• PDI
• Review of literature
• Conclusion
• References
contents
2

3.  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.
3

4.  Many failure in removable partial denture
treatment can be traced to inadequate diagnosis
and incomplete treatment planning.
sequenced
successful
 Therefore, a thorough, properly
treatment plan is essential to
removable partial denture therapy.
4

5. Diagnosis: The determination of the nature of a disease.
(GPT-9)
Treatment planning: The sequence of procedures planned
for the treatment of a patient after diagnosis. (GPT-9)
Removable partial denture prosthesis
Removable denture that replaces some teeth in
a partially edentulous arch,the removable
partial denture can be readily inserted and
removed from the mouth by the patient.– GPT9
DEFINITIONS
5

6.  Before any
attempted, patient information must
rehabilitation procedures are
be
gathered to provide the evidence necessary to
arrive at an accurate diagnosis and develop a
treatment plan.
6

7.  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)
7
Phoenix DR Cagna DR , DeFreest CF; Stewart’s Clinical removable partial
prosthodontics - 4th edition 119-204.

8. 8

9. 3.ToAscertain The Patients Expectations of
treatment.
4. Explore Any Physical Problems that may affect
the treatment .
 Any positive responses in the health
questionnaire must be explored in detail and
evaluated.
 When any doubt exists, the most prudent action
is to seek a medical consultation before initiation
of the dental treatment.
9

10.  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.
10

11.  The dentist should maintain a relaxed and
attentive physical posture.
 The dentist should employ head nodding,
verbal following, and verbal reflection.
11

12. Medical History
12

13.  DIABETES :
 Uncontrolled diabetes - accompanied by multiple small
oral abscesses and poor tissue tone.
 The disease should be brought under control before
Prosthodontic treatment is accomplished.
 The decreased resistance to infection - special care
during treatment and follow-up.
 Reduced salivary output – significantly reduces the
ability of a patient to wear the prosthesis with comfort
and increases the possibility for occurrence of caries.
13

14.  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.
14

15.  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. 15

16.  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.
16

17.  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.
17

18.  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
nofrequent , severe seizures with little or
warning.
18

19.  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.)
19

20.  CARDIOVASCULAR DISEASES
 Patients with the following require medical
consultation 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 written
approval should be obtained before any dental
treatment is initiated.
20

21.  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
21

22.  CANCER
 Oral complications are also common side effect of
radiation and chemotherapy for malignancies in areas
other than the head and neck.
 Mucosal irritations
 Xerostomia
 Bacterial and fungal infections
 These symptoms will complicate the construction and
wear of the removable partial denture.
 Sonis and others, 2017 indicated that 40% of all
patients treated with chemotherapy and radiotherapy
for malignancies remote from the oral cavity
developed some form of oral complication. 22
Sonis. ST Anna Yuan. A Oral complications of cancer and their treatment
Holland-Frei Cancer Medicine, Ninth Edition 1-13.

23.  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
23

24.  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
24

25.  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
25

26.  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.
26

27. Dental History
27

28. • How did he/she lose his/her teeth? Caries? Periodontal?
Gather information about existing dentures. (reason for
dissatisfaction)
28

29.  Presence of large number of restored teeth,
signs of recurrent caries, the evidence of
decalcification – susceptible to caries
 Unless an exceptional level of plaque control can
be achieved, the prognosis for the treatment is
poor.
 The placement of crowns on the abutment teeth
may be indicated if the patient is highly
susceptible to caries.
29

30.  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.
30

31.  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.
31

32.  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.
32

33.  Frequent usage of mints, soft drinks, sugar-containing
products, a change must be affected.
 The problems caused by sugar are compounded by the
denture shields the micro organisms from
wear of removable partial denture because the
the
cleansing and buffering action of patient’s saliva.
33

34.  Evaluated to determine their effect on prognosis
 Bruxism and clenching:
 Bruxism is often initiated by interceptive occlusal
contacts(occlusal prematurities).
 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. 34

35.  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.
35

36.  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.
36

37.  Problems requiring immediate attention:
 Large carious lesions: excavation, temporary
restorations
 Ill-fitting dentures: adjustment or temporary
relining to eliminate discomfort & allow recovery
of 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 on
home care of the patient, technical procedures
provided by the dentist.
37

38.  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. 38

39.  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
39

40.  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
40

41. 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 withnatural
teeth both anterior and posterior to it.
 Class IV : Single but bilateral edentulous area
located anterior to the remaining natural teeth.
41

42. CLASS I CLASS II
CLASS III CLASS IV
42

43.  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.
43

44.  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.
44

45.  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.
45

46.  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.
46

47.  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.
47

48.  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.
48

49. • Where a future change in denture
design is anticipated
• Distal extension case
• Economic
considerations
49

50.  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 50

51.  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
51

52.  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.
52

53.  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.
53

54.  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.
54

55.  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.
55

56.  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.
56

57. 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.
57

58.  Media for recording centric jaw relation
 Wax: modeling, alu wax
 Zinc oxide eugenol paste
 Plaster of paris
 Dental stone
 Acrylic resin
 Modelling plastic
 Poly ether bite registration paste
58

59. 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.
59

60.  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
60

61.  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.
61

62.  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.
62

63.  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.
63

64.  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.
64

65.  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.
65

66.  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
constructed until the cause discovered
not be
and the
sensitivity is eliminated.
 The use of a percussion sensitive
abutment would result in early failure
tooth as an
of the
treatment. 66

67.  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.
67

68.  Indications for splinting of abutment
teeth
 Indicated when all remaining teeth have reduced
support because of
 Periodontal disease
 Teeth with short ,tapered roots
68

69.  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
disease process
factors must
must be controlled before
be eliminated, the
the
fabrication of the prosthesis.
69

70.  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.
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.
70

71. 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 71

72. 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.
72

73.  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
73

74.  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. 74

75. 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.
75

76. o 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
76

77.  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
77

78.  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.
78

79.  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.
79

80.  Evaluation of radiographic survey
 All prospective abutment teeth must be critically
evaluated
80

81. roots - Greater
o Root size, length and form
 Teeth with large or long
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.
81

82. 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.
82

83. 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.
83

84. • 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.
84

85.  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.
85

86. 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.
86

87. may be irregular because of
o Occlusal plane
 Occlusion plane
extrusion
 One or more unopposed teeth.
 Such conditions require corrective procedures if
an acceptable occlusion is to be developed.
87

88. tooth – aprox 2mm -
• Irregular occlusal plane
 Treatment
 Moderately extrude
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
88

89.  Traumatic vertical overlap
Akerly classification
 Type 1:
 The mandibular incisors extrude and impinge into the
palate.
incisors impinge into sulci of the
 Type 2:
 The mandibular
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
89

90. 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
90

91.  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.
91

92. 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
92

93. 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.
93

94. • 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
94

95.  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) 95

96.  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
96

97.  Provides a guide for tooth preparation and
problems that may be encountered in
positioning cusps and in establishing acceptable
occlusal contacts.
97

98. 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.
Development of treatment plan
98

99. 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
• Reinforcement of education and
motivation of patient
99

100. 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
100

101. Phase 4 :
• Construction of removable
partial denture
• Reinforcement of education
and motivation of patient
101

102. Phase 5 :
• Post insertion care
• Periodic recall
• Reinforcement of education
and motivation of patient
102

103. 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.
Prosthodontic diagnostic index (PDI)
103

104. 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
DIAGNOSTIC CRITERIA FOR PDI
104
Phoenix DR Cagna DR DeFreest CF; Stewart’s Clinical removable partial
prosthodontics - 4th edition

105. 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
105

106. 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
106

107. 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) 107

108. 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
108

109. 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
109

110. 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 and Class III molar and jaw
relationships are seen 110

111. 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
111

112.  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.
112

113.  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.
113

114.  The formulation of an appropriate treatment
plan requires the careful examination,
evaluation of all patient diagnostic data, and
correlation of the clinical findings with the
radiographic 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.
conclusion
114

115. References
1. Phoenix DR . David R. Cagna , DeFreest CF;
Stewart’s Clinical removable partial prosthodontics
- 4th edition 119-204.
2. Alan B. Carr, Glen P . McGivney, David T. Brown;
MaCracken’s Removable partial prosthodontics -
11th edition
3. Dawson PE : Evaluation, diagnosis, and treatment
of occlusal problems, 2nd edition, 1989
4. Dunn BW: Treatment planning for removable
partial dentures, J prosthet dent 1961 11 : 247-255.
5. Classification System for Partial Edentulism,
Journal of Prosthodontics 2002 11 ( 3) : 181 – 193.
115

116. 116
6. Ellsworth kelly: Changes caused by a
mandibular removable partial denture opposing a
maxillary complete denture. J Prosthet Dent
1972;27:140-150
7. House MM. Mental classification revisited :
intersection of particular patient types & particular
dentist’s needs .J prosthet dent 2003;89:297-302
8. Sonis. ST Anna Yuan. A Oral complications of
cancer and their treatment Holland-Frei Cancer
Medicine, Ninth Edition 1-13.