diagnosis and treatment plane for RPD-part 2

Diagnosis and Treatment Planning - Removable Partial DenturePart-II

Assis.Prof.Radhwan Himmadi Hasan
B.D.S. , M.Sc. , Ph.D.
2018
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Dr.Radhwan Himmadi Hasan
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LEC 2
صناعة نظري \ رابع اسنان كركوك
د. رضوان
2\4\2018

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Diagnostic impressions and casts

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.

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Diagnostic casts are valuable for research purposes and forensic information as they provide observable, precise geometry of the teeth and jaws

Occlusion constantly changes, and comparison of the changes on stone casts provide valuable information to the practitioner and can be used to educate the patient.





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.
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Mounting of diagnostic casts

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.
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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.

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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.

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Definitive oral examination

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

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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.

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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.

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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.

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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.

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Indications for splinting of abutment

teeth

Indicated when all remaining teeth have reduced support because of

Periodontal disease
Teeth with short ,tapered roots

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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.
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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

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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.

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.

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• Tissue reactions to the wearing of a prosthesis

Epulis fissuratum: denture granuloma

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

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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.

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Contributing factors:, 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.

Treatment :

Remove causative factor
nystatin, good oral hygiene
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Evaluation of hard tissue abnormalities

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.

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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.

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.
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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.
1-relieve
2-path of insertion
3-One side surgical correction

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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
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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.
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Evaluation of radiographic survey

All prospective abutment teeth must be critically evaluated

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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.

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Signs of positive bone factor

A supportive trabecular pattern
Heavy cortical layer
Dense lamina dura
Normal bone height
Normal periodontal ligament space.


If retrograde bone changes occur, the patient has a negative bone factor ; prognosis is poor.
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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.

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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.

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• Treatment over erupted teeth

• If the tooth is extruded above the occlusal plane because of lack of an antagonist –
• 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
• Orthodontic treatment
• Severely extruded teeth – contacting the opposing ridge & if alveolar bone followed eruption  remove the tooth and recontour the bone is necessary
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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.


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Traumatic vertical overlap

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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
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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

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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.
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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
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Development of treatment plan

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.
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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
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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
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Phase 4 :

Construction of removable partial denture

Reinforcement of education and motivation of patient

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Phase 5 :

Post insertion care

Periodic recall

Reinforcement of education and motivation of patient

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