Diagnosis and Treatment Planning in Removable Partial Denture Patients
Removable Partial Denture (RPD): Prosthesis that replaces some teeth in a
partially dentate arch. It can be removed from the mouth and replaced at
will.
Purpose and Uniqueness of Dental Treatment:
is to respond to the patient’s
needs both
1. Those perceived by the patient and
2. Those demonstrated through the clinical examination and pt.
interview.
The delineation of pt. uniqueness includes 4 distinct processes:
1. A systematic pt. interview to understand the pt. desires and chief
complaints and history behind them.
2. A diagnostic clinical examination to ascertain the pt. dental needs.
3. Developing a treatment plan that reflects the best management of
desires and needs.
4. Executing (accomplishing) appropriately sequenced treatment plan.
Patient Interview:
The fundamental objective of pt. interview is to listen carefully to what the
pt. has stated in order to gain a clear understanding of why the pt. is
presenting to this evaluation (chief complains).
Patient interview involves asking about:
1. Clinical symptoms of pain
2. Difficulty with function
3. Appearance
4. Problems with an existing prosthesis
5. Symptoms related to the teeth, periodontium, jaws or previous dental
treatment.
6. Oral habits (Bruxism, Clenching & Thrusting )
The formats of the pt. interview should follow a sequence:
1. Chief complaint and its history
2. Medical history review
3. Dental history review, (especially related to previous prosthodontic
experience)
4. Pt. expectations.
Shared decision making:
The dentist responsibility is to help the pt. to participate in a process
of identifying the best decision for course of treatment.
Oral examination:
A complete oral examination should precede any treatment decision.
I-
Preliminary clinical examination (to determine the need for
management of acute needs). It should be accomplished in the
following sequence:
1. Visual evaluation of teeth, periodontium and residual ridge (by
instrumentation, visual examination and palpation). The objectives are to
reveal
many of the signs of oral and dental diseases like caries, and
tooth sensitivity to percussion ( may be due to tooth movement
caused by an unstable occlusion or ill-fitting prosthesis, tooth or
restoration in traumatic occlusion, periapical or pulpal
abscesses, acute pulpitis, gingivitis or periodontitis or cracked
tooth syndrome)
No. of remaining teeth
no. and condition of restored teeth
Teeth mobility (may be caused by trauma from occlusion,
inflammatory changes in the periodontal ligament or loss of
osseous support)
Furcation involvement.
extruded or malposed teeth,
decalcification
Periodontal, gingival and mucosal conditions (any ulceration,
swelling, or color change)
Location, no. and length of edentulous areas
Quality of residual ridge, sharp or prominent bony areas; soft or
hard tissue undercuts, and/or enlarged tuberosities.
Presence of tori and other bony exostoses
reduced interarch space,
unfavorable occlusal planes,
Determination of the depth of floor of the mouth by using a
periodontal probe
Occlusal relationships.
2. Vitality test of abutment teeth
3. Pain relief and temporary restorations: objectives:
to relieve discomfort arising from tooth defects
to determine the extent of caries
to arrest further caries activity
4. Oral prophylaxis: to thoroughly and completely clean the teeth from
accumulated calculus and debris.
5. Radiographic survey: objectives:
To locate areas of infections or pathosis
To reveal the presence of tooth fragments, foreign objects, bony
spicules, irregular ridge forms.
To reveal the presence and extent of caries, recurrent caries,
marginal leakage and overhanging gingival margins.
To reveal the prognosis of present endodontic filling
To reveal the periodontal conditions
To evaluate the alveolar support of abutment teeth
Objectives of diagnostic casts:
Analyzing of existing occlusion
Permit a topographic surveying
Permit a logical and comprehensive presentation to the patient
Fabrication of special (custom) trays
Used as a constant references as the work progresses
Considered as a permanent record of the patient.
II-
The second (definitive) diagnostic appointment should be used to
complete the collection and evaluation of diagnostic data. It
includes the following:
1. Mounted diagnostic casts
2. Definitive oral examination
3. Consultation requests
4. Development of treatment plane
Mounting the diagnostic casts:
A. If the occlusion is harmonious and the proposed prosthesis is a tooth-
borne, a simple hand articulation of diagnostic casts is required
B. If the occlusion is not harmonious and/ or the proposed prosthesis is a
tooth/ tissue borne, mounting of diagnostic casts is necessary.
Objectives of mounting the diagnostic casts:
1. To reveal malpositioned teeth, low-hanging tuberosities, compromised
interarch space, and defective restorations.
2. To permit evaluation of occlusal relationships from facial and lingual
aspects.
3. Helpful in patient education.
4. Provide a record of the patient's condition before treatment.
To accomplish proper positioning of the diagnostic casts on a dental
articulator, the casts must be properly related to one another, and to the
opening/closing axis of the articulator.
The mounting procedure may be divided into three distinct phases:
A) Orientation of the maxillary cast to the condylar elements of an
articulator
exactly as the maxillary arch is related to the patient's
condyles by means of a facebow transfer.
B) Orientation of the mandibular cast to the maxillary cast at the patient's
centric jaw relation by means of an accurate centric relation record.
C) Verification of these relationships by means of additional centric
relation records and comparison of occlusal contacts on the articulator
with those in the mouth.
Evaluation of diagnostic data
All diagnostic data must be collected before an effective evaluation can be
made. The practitioner must correlate intraoral findings with those of the
radiographic survey, the mounted casts, the survey and analysis of the
diagnostic casts, and other relevant information. Results should be used in
the development of a sound treatment plan.
Goals (objectives) of ultimate porsthodontic treatment plan:
a) Disease management
b) Preservation and restoration of remaining teeth and oral tissues.
c) Coordinated prosthetic treatment.
d) Restoration of esthetics and function
.
Types of definitive RPD:
a) Tooth borne
b) Tooth/Tissue borne
Note: the temporary RPD is a tissue borne prosthesis
Indications for a RPD treatment:
a) Long edentulous span
b) Reduced periodontal support of the remaining teeth
c) Need for cross arch (bilateral) stabilization
d) Excessive bone loss of the residual ridge
e) Distal Extension Situations (no abutment tooth posterior to the
edentulous area)
f) Patient desires
g) Childhood
h) Physically or emotionally handicapped patients.
i) Economic Considerations
What are the ideal requirements of the abutment tooth?
a) Free from caries or restorations
b) Favorably contoured crown
c) Crown of adequate length
d) Healthy periodontal status
e) Long root with large surface area
f) Good vertical and horizontal position within the arch
g) Stable opposing occlusion