Diagnosis

Diagnosis and treatment planning of partially edentulous patient

Introduction:
Diagnosis and treatment planning for oral rehabilitation of partially edentulous mouths is an important step and must take the following into considerations (objectives) : –
control of caries and periodontal disease.
restoration of individual teeth.
provision of harmonious occlusal relationships.
replacement of missing teeth by fixed (natural teeth/implants) or removable prosthesis in a manner that ensures optimum stability and comfort in an esthetically pleasing manner.
Patient interview and diagnostic clinical examination includes four distinct goals:
(i)understanding the patient’s chief complaints/concerns. (ii(ascertaining the patients’ dental needs through a diagnostic clinical examination. (iii) developing a treatment plan that reflects the best management of the desires and needs. (iv) execution of the treatment plan with follow-up.

Patient interview:
A fundamental objective of the patient interview, is to gain a clear understanding of why the patient is coming for.
The interview involves understanding the patient's chief complaint or concern about their oral health. This can include clinical symptom of pain ,difficulty with function, concern about their appearance, problems with an existing prosthesis, or any symptoms related to their teeth, periodontium, jaws, or previous dental treatment. the patient interview follow a sequence explained in the diagram:

Oral examination:

-Preliminary oral examination:
This is performed in the first appointment. It helps determine the need for the management of acute conditions and whether a prophylaxis is required to conduct a thorough oral examination.
-Definitive oral examination:
This is performed in the second appointment. An oral examination should be accomplished in the following sequence:
1. visual examination:
The remaining natural teeth are evaluated for the presence of any caries and restored teeth are evaluated with regard to their number, signs of recurrent caries and evidence of decalcification. The selection of abutment teeth to receive rest seats must be made before restorative treatment has begun. Amalgam and tooth coloured restorative materials are more likely to fail under forces of occlusion than a cast metal restoration or porcelain, when rest seats are incorporated.in addition to observation of occlusal relationship.
2. Examination of Teeth, investing Structures, and Residual Ridges
The teeth periodontium and residual ridges can explored by instrumentation and visual means to detect the following:
caries susceptibility, The number of restored teeth, signs of recurrent caries, and evidence of decalcification , periodontal disease, gingival inflammation, the degree of gingival recession ,mucogingival relationship pocket depths, assessment of attachment levels, furcation involvement, mucogingival problems, and tooth mobility. the number of teeth remaining, the location of the edentulous areas, and the quality of the residual ridge.
3. Thorough and Complete Oral Prophylaxis
An adequate examination can be accomplished best with the teeth free of accumulated calculus and debris. Also, accurate diagnostic casts of the dental arches can be obtained only if the teeth are clean.
4.radiographic examination:
This will include panoramic and periapical radiographs. The objectives of radiographic examination are as follows:
○ Locate areas of infection and any other pathology.
○ Reveal the presence of root fragments, foreign
objects, bone spicules and irregular ridge formations.
○ Display the presence and extent of caries.
○ Evaluate existing restorations with respect to presence of recurrent caries ,marginal leakage and overhanging gingival margins.
○ Evaluate root canal fillings and to permit their evaluation as future prognosis(the design of the removable partial denture may hinge on the decision to retain or extract an endodintically treated tooth).
○ Evaluate periodontal condition, alveolar support of
abutment teeth, the length and morphology of roots. evaluate the relative amount of alveolar bone loss suffered through pathogenic processes, and the amount of alveolar support remaining.
5. Vitality Tests of Remaining Teeth:vitality tests should be given particularly to teeth to be used as abutments and those having deep restorations or deep carious lesions. this should be done both thermal and electric means.
6.Determination of Height of the Floor of the Mouth
Locate inferior borders of lingual mandibular major connectors.
7. Impressions for making accurate diagnostic casts to be mounted for occlusal examination


Diagnostic casts:
A diagnostic cast should be an accurate reproduction of the teeth adjacent tissues and the edentulous arch.
A diagnostic cast is usually made of dental stone because of its strength, and it is less easily abraded than is dental plaster.
(Impression is made using irreversible hydrocolloid alginate).
Purposes of Diagnostic Casts:
1. Analysis of the existing occlusion when opposing casts are occluded .
2. permit a topographic survey of the dental arch that is to be restored by means of a removable partial denture.
3. Diagnostic casts are used to permit a logical and omprehensive presentation to the patient of present and future restorative needs.
4. Individual impression trays may be fabricated on the diagnostic casts.
5. Diagnostic casts may be used as a constant reference as the work progresses.
6. Unaltered diagnostic casts should become a permanent part of the patient's record

Differential diagnosis

Following assimilation of all the diagnostic data, a decision has to be made whether the partially edentulous condition is to be rehabilitated with a fixed or removable partial denture. The indications and contraindications for these two treatment modalities will be discussed in coming lecture.
When only a few teeth remain, a decision is to be made regarding removal of all teeth and construction of complete dentures.
A complete denture may be indicated for the following reasons:
• Poor prognosis of remaining teeth.
• Only anterior teeth remain and they are unaesthetic.
• Patient desires to extract the remaining teeth.
• Malalignment of remaining teeth.
• Economic reasons.
Treatment planning
The treatment of partially edentulous patient can be divided into six phases.
Phase I:
• Emergency treatment to control pain or infection.
• Collection and evaluation of the diagnostic data – diagnostic casts and radiographs.
• Developing a design and formulating a treatment plan.
Phase II
• Preparation of mouth.
Phase III
• Preparation of abutment teeth.
• Final impressions and fabrication of master cast.
Phase IV
• Fabrication of removable partial denture.
Phase V
• Denture insertion.
• Postinsertion instructions.
Phase VI
• Maintenance and recall.