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Diagnosis and Treatment Planning for Removable Partial Dentures

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Title: Diagnosis and Treatment Planning for Removable Partial Dentures


1
Diagnosis and Treatment Planning
  • Dr. Shujah A Khan
  • MDS Resident Proshtodontics
  • DIKIOHS, DUHS

2
Purpose and Uniqueness of Treatment
  • The purpose of dental treatment is to respond to
    a patients needs, both the needs perceived
    by the patient and those demonstrated
    through a clinical examination and patient
    interview
  • The delineation of each patients uniqueness
    occurs through the patient interview and
    diagnostic clinical examination process.

3
  • Interviewing includes four distinct processes
  • Understanding patients desires or chief
    concerns/complains regarding his/her condition.
  • Ascertaining the patients dental needs through a
    systematic interview process
  • Developing a treatment plan that reflects the
    best management and desires
  • Executing appropriately sequenced treatment with
    planned follow-up.

4
  • Provision of the best care for a patient may
    involve no treatment, limited treatment or
    extensive treatment, and the dentist must be
    prepared to help patients decide the best
    treatment option given his or her individual
    circumstances.

5
Patient Interview
6
Patient Interview
  • Patients present for professional evaluation
  • To address some perception of an abnormality that
    requires correction
  • To maintain optimum oral health.

7
  • The interview is an opportunity to develop
    rapport with the patient and it involves
    listening to and understanding the patients
    chief complaint or concern about his or her oral
    health.
  • To ensure thoroughness the dentist should follow
    a sequence that follows
  • Chief complaint and its history
  • Medical history review
  • Dental history review
  • Patient expectations

8
Shared Decision Making
  • We should carefully consider what the patient
    needs to hear from us
  • Using a communication model shared decision
    making
  • Gives structure to a process where the provider
    and the patient identify together the best course
    of care.

9
Clinical Examination
10
Objectives of Prosthodontic Treatment
  1. Elimination of disease
  2. Preservation, restoration and maintenance of the
    health of the remaining teeth and oral tissues
  3. The selected replacement of lost teeth
  4. Restoration of function in a manner that ensures
    optimum stability and comfort in an esthetically
    pleasing manner.

11
Oral Examination
  • A complete oral examination should precede any
    treatment decisions.
  • It should include visual and digital
    examination of the teeth and surrounding tissues
    with a mouth mirror, explorer, and periodontal
    probe, vitality tests of critical teeth, and
    examination of casts correctly oriented on a
    suitable articulator

12
Sequence for Oral Examination
  1. Relief of pain and discomfort and caries control
    by placement of temporary restorations
  2. Thorough and complete oral prophylaxis

13
  • Complete intraoral radiographic survey
  • Locate areas of infection and other pathosis
  • Reveal the presence of roots or foreign objects,
    bone spicules, irregular ridge formations
  • Reveal the presence and extent of caries
  • Permit evaluation of existing restorations
  • Reveal presence of root canal fillings and permit
    their evaluation
  • Permit evaluation of periodontal conditions
    present and establish need and possibilities for
    treatment
  • Evaluate the support of abutment teeth, their
    number, morphology of roots

14
  • Impressions for accurate diagnostic casts to be
    mounted for occlusal examination
  • Examination of teeth, investing structures, and
    residual ridges
  • During the examination, not only each arch but
    also its occlusal relationship with the opposing
    arch must be considered separately. A
    situation that looks simple when the teeth
    are apart may be complicated when the
    teeth are in occlusion.
  • Vitality tests of remaining teeth
  • Determination of height of floor of the mouth to
    locate inferior borders of lingual mandibular
    major connectors

15
Diagnostic Casts
  • A diagnostic cast should be an accurate
    reproduction of all the potential features that
    aid diagnosis.
  • These include the teeth locations, contours,
    and occlusal plane relationship the residual
    ridge contour, size, and mucosal
    consistency and the oral anatomy delineating the
    prosthesis extensions (vestibules, retromolar
    pads, pterygomaxillary notch, hard/soft
    palatal junction, floor of the mouth, and
    frena)

16
Purposes of the Diagnostic Casts
  • Diagnostic casts are used to supplement the oral
    examination by permitting a view of the
    occlusion from the lingual, as well as from the
    buccal, aspect.
  • Analysis of the existing occlusion is made
    possible when opposing casts are occluded, as is
    a study of the possibilities for improvement by
    occlusal adjustment, occlusal reconstruction, or
    both.
  • Diagnostic casts are used to permit a topographic
    survey of the dental arch that is to be
    restored by means of a removable partial
    denture.

17
  • Diagnostic casts are used 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.
    Occluded and individual diagnostic casts can be
    used to point out to the patient
  • Evidence of tooth migration and the existing
    results of such migration
  • Effects of further tooth migration
  • Loss of occlusal support and its consequences
  • Hazards of traumatic occlusal contacts
  • Cariogenic and periodontal implications of
    further neglect

18
  1. Individual trays may be fabricated on the
    diagnostic casts for final impressions
  2. Diagnostic casts may be used as a constant
    reference as the work progresses
  3. Unaltered casts should become a permanent part of
    the patients record

19
Mounting Diagnostic Casts
  • For diagnostic purposes, casts should be related
    on an anatomically appropriate articulator to
    best understand the role occlusion may have in
    the design and functional stability of the
    removable partial denture.
  • This becomes increasingly important as the
    prosthesis replaces more teeth.
  • If the patient presents with a harmonious
    occlusion and the edentulous span is a
    tooth-bound space, simple hand articulation
    is generally all that is required.

20
Jaw Relationship Records
  • All mouth-preparation procedures depend on this
    analysis.
  • Failure to make this decision correctly may
    result in poor prosthesis stability, discomfort,
    and deterioration of the residual ridges and
    supporting teeth
  • It is recommended that deflective occlusal
    contacts in the maximum intercuspal and eccentric
    positions be corrected as a preventive measure.
  • It is not a requirement to interfere with an
    occlusion simply because it does not completely
    conform to a relationship that is considered
    ideal.

21
Diagnostic Findings
22
Diagnostic Findings
  • The information gathered in the patient interview
    and clinical examination provides the basis for
    establishing whether treatment is indicated,
    and if so, what specific treatment should be
    considered.
  • More than one treatment option can be considered,
    and financial implications need to be considered
    against long-term expectations if the best
    decision is to be reached

23
Interpretation of Examination Data
  • The interpretation of these diagnoses serves as
    the basis for decisions that will ultimately
    identify the suggested treatment

24
  • Radiographic Interpretation
  • Disease Validation
  • Tooth Support
  • Bone Density
  • Index Areas
  • Alveolar Lamina Dura
  • Root Morphology
  • Third Molars

25
Periodontal Considerations
  • The condition of the supporting bone must be
    evaluated, with specific attention to reduced
    bone support and mobility patterns recorded.
  • Oral hygiene habits must be determined, and
    efforts made to educate the patient relative to
    plaque control.

26
Caries Risk Assessment Considerations
  • The need for protective restorations must be
    considered.

Evaluation of the Prosthesis Foundation Teeth
and Residual Ridge
  • An evaluation of the prosthesis foundation
    is required to ensure that an appropriately
    stable base of sound teeth and/or residual
    ridge(s) is provided to maximize prosthesis
    function and patient comfort

27
Surgical Preparation
  • Grossly displaceable soft tissues covering basal
    seat areas and hyperplastic tissue should be
    removed to provide a firm denture foundation.
  • Mandibular tori should be removed if they will
    interfere with the optimum location of a lingual
    bar connector or a favorable path of
    placement.
  • Any other areas of bone prominence that will
    interfere with the path of placement should be
    removed also.

28
  • Extraction of teeth may be indicated for one the
    following three reasons
  • If the tooth cannot be restored to a state of
    health
  • A tooth may be removed if its absence will permit
    a more serviceable and less complicated removable
    partial denture design. Teeth in extreme
    malposition..
  • A tooth may be extracted if it is so
    unesthetically located as to justify its removal
    to improve appearance.

29
Analysis of Occlusal Factors
  • The goal of artificial tooth placement is to
    harmonize with the functional parameters of the
    existing occlusion providing bilateral,
    simultaneous functional contact.
  • The dentist must decide whether it is best to
    accept and maintain the existing occlusion or to
    attempt to improve on it by means of occlusal
    adjustment and/or restoration of occlusal surfaces

30
Fixed Restorations
  • There may be a need to restore
    modification spaces with fixed restorations
    rather than include them in the removable partial
    denture, especially when dealing with isolated
    abutment teeth.

31
Orthodontic Treatment
  • Occasionally, orthodontic movement of malposed
    teeth followed by retention through the use of
    fixed partial dentures makes possible a better
    removable partial denture design mechanically
    and esthetically than could otherwise be used.

32
Determining Type of Mandibular Major Connector
  • One of the criteria used to determine the
    use of the lingual bar or linguoplate is
    the height of the floor of the patients mouth
    when the tongue is elevated

Need for Reshaping Remaining Teeth
  • Surveying ?

33
Differential Diagnosis FPDs or RPDs
  • Indications for use of Fixed Restorations
  • Tooth bounded edentulous regions
  • Modification spaces
  • Anterior modification spaces
  • Replacement of unilaterally missing molars
    (Shortened Dental Arch)

34
  • Indications for Removable Partial Dentures
  • Distal extension situations
  • After recent extractions
  • Long span
  • Need for effect of bilateral stabilization
  • Excessive loss of residual bone
  • Unusually sound abutment teeth
  • Abutments with guarded prognosis
  • Economic considerations

35
Choice Between Complete Dentures and Removable
Partial Dentures
  • One of the more difficult decisions to make for
    the partially edentulous patient involves making
    the choice of a complete denture over a removable
    partial denture.
  • Many factors need to be considered when one is
    making such a decision these generally fall
    under the categories of tooth-related
    factors, factors of comparative functional
    expectations between prostheses, and
    patient-specific factors.

36
Clinical Factors Related to Metal Alloys Used for
RPD Frameworks
  • The cast framework offers significant advantages
    over the all acrylic-resin removable partial
    denture.
  • Stellite alloy
  • Practically all cast frameworks for removable
    partial dentures are made from a chromium-cobalt
    (Cr-Co) alloy. The popularity of Cr-Co alloys has
    been attributed to their low density (weight),
    high modulus of elasticity (stiffness), low
    material cost, and resistance to tarnish.

37
  • The more common alloys contain 60 to 63 Co, 29
    to 31.5 Cr, and 5 to 6 Mo, with the
    balance including Si, Mn, Fe, N, and C. The
    addition of controlled amounts of nitrogen (lt.5)
    is reported to improve physical properties.
  • Titanium is also used as a removable
    partial denture (RPD) frame material however,
    production difficulties continue to hinder its
    widespread use.

38
  • Commercially pure (CP) titanium and titanium in
    alloys containing aluminum and vanadium, or
    palladium (Ti-O Pd), should be considered
    potential future materials for removable
    partial denture frameworks. Their versatility and
    well-known biocompatibility are promising
    however, long term clinical trials are needed to
    validate their potential usefulness

39
Summary
  • In selecting materials, it must be
    remembered that fundamentals do not change.
    These are inviolable.
  • It is only methods, procedures, and
    substancesby which the dentist effects the best
    possible end resultthat change.
  • The responsibility of the decision still rests
    with the dentist, who must evaluate all factors
    in relation to the results desired. In any
    instance therefore, the dentist must weigh
    the problems involved, compare and evaluate the
    characteristics of different potential materials,
    and then make a decision that leads to delivery
    of the greatest possible service to the patient.

40
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