1- Diagnosis and treatment planning for removable prosthodontics

1- Diagnosis and Treatment Planning
For Removable Prosthodontics

Dr. Amal Fathy Kaddah
Professor of Prosthodontic,
Faculty of Dentistry,
Cairo University.
Diagnosis and Treatment Planning
For Removable Prosthodontics

‫الصخر‬ ‫في‬ ‫تحفر‬ ‫المطر‬ ‫قطرة‬
‫بالتكرار‬ ‫ولكن‬ ‫بالعنف‬ ‫ليس‬
A rain drop digs in the rock
Not by violence but by repetition

EXAMINATION, DIAGNOSIS,
TREATMENT PLANNING
AND
PROGNOSIS for DENTURE CONSTRUCTION

VISIT 1
Examination, Diagnosis and
treatment planning and
Primary impression

Diagnosis:
Is the determination of the nature, location
and cause of a disease
Treatment plan:
Is the sequence of procedures planned for
the treatment of a patient after diagnosis
Prognosis:
A forecast (prediction) of the expected outcome
of the situation.

Proper diagnosis is the key of
good prognosis

Diagnostic Procedures
II- Clinical Examination
III- Investigations:
Radiographic Evaluations
Mounting the Diagnostic Casts
Surveying of the study casts
IV- Treatment Planning
I- Patient’s interview

1. Patient’s history.
a- Personal and Social details.
b. Chief complaints and Reason for attendance
c- Previous Medical history
d- Previous Dental history
2. Patient evaluation
a. Expectations
b. Attitudes
I- Patient’s interview

1- Patient’s History
A. Personal and Social Details
B. Chief complaints and Reason for attendance
C. Dental History
D. Medical and surgical History

A. Personal & Social Details
Name - Address - Tel. Number
Age - Sex
Wind instrument players
Public speakers and singers
Attendance
Special treatment needs
Occupation & Socio-economic Class
Psychological conditions

Patient data
These data must be recorded so that
correct naming can be made and the
patient can be contacted when
required.

• The age of the patient gives an
indication of his/her ability to use
dentures.
• Young patients are adaptable to
change, i.e. their tissues heal rapidly &
have good resistance.
Age:

• Old patients found to be difficult to
adapt to new situations.
• Tissue repair is often slow, & in many
cases they show more bone resorption
in their alveolar ridges.
Age:

Sex/Gender:
• Esthetic is first priority for
women than men, however,
younger men are also concerned
about esthetics.

Occupation
• Teeth are more important to some
people than to other.
• The higher the social position, the
more demanding the patient is about
the esthetics.

(House Classification)
Philosophical patients
Exacting patients
Hysterical patients
Indifferent patients
Psychological conditions and Mental Attitude

Philosophical Patients (Truth-seeking)
Exacting Patients (Demanding )
Best mental attitude-Definite- incentive- thoughtful - Learns
to adjust rapidly- Clear-cut -kind-caring Good prognosis
Good as philosophical- needs great care, effort & explanations,
Good prognosis.
(Might doubt ability of dentist to provide a good prosthesis)

Hysterical Patients (Panic-stricken)
Indifferent Patients (Uncaring, cool)
Unstable- Excitable, Apprehensive, hypertensive, needs
medical consultation (neurosis or psychosis), needs
additional help during and after treatment
Poor prognosis
Uninterested- depressed-lack of motivation- no
cooperation-unfavorable prognosis

The dentist should meet the
mind of the patient before he
meets the mouth of the
patient”
De Van - 1942

I- Patient’s History
A. Personal and Social Details
B. Chief complaints and Reason for attendance
C. Dental History
D. Medical and surgical History

- Restore Appearance
- Restore Function
- Maintain Health
- Replace teeth
- Replace restorations
- Old restorations: number, quality, experience
B. Chief complaint and Reason For
Attendance

• The patient should describe the complaints
as they see them, this will enable the
dentist to know what concerns the patient.
• Also, it gives an idea about the patient
personality.
B. Chief complaint and Reason For
Attendance

Previous dental history Provide valuable information
which includes:
1) Oral health care carried out by the patient.
2) Presence of abnormal habits as clenching
and bruxism.
3) Reasons for loss of natural teeth
C. Dental History

 If due to caries  oral hygiene procedures should be
emphasized to the patient to prevent further loss of the
remaining natural teeth.
 If due to periodontal disease  etiologic factors causing
the disease should be treated and controlled to prevent
bone resorption and protect the remaining natural teeth
from further stresses induced by partial dentures.
Reasons for loss of natural teeth

4) Evaluation of the last denture.
5) Cause of failure of previous denture.
6) Patient expectations and reasons for
requesting new dentures.

Cause of failure of previous denture
a . Esthetics.
b . Comfort.
c . Masticatory performance.
d . Speech.
e . Gagging Reflex during previous dental
treatment.

• The involuntary contraction of the muscles of the soft
palate that result in retching.
• If it is an active one, it can compromise the dental
treatment plane.
• It Could be due to: Iatrogenic factors (caused by ill-fit
old denture) or Psychological factors.
• Patients who show severe gagging should be seen by
a specialist.
Gagging (retching, sick, vomit, throw-up):

(Evaluating the general health and
systemic condition and Medications
which can affect prosthodontic treatment
includes)
D. Medical History and General Health

 Thorough & accurate past & present medical
history related to future dental treatment must
be obtained.
 With particular attention to allergies, drug
reaction, medications, and hemorrhagic
tendencies. which bear a direct relationship to
the successful wearing of dentures.
D. Medical History and General Health

 Take the necessary precautions to prevent contamination
and transmission of infectious diseases.
 Consider the effect of systemic diseases on denture
supporting structures whether teeth, bone or soft tissues.
 Consider the side effects of medications taken by the
patient on the oral tissues and saliva. For example: any
medical condition or medication that have a impact on
salivation
Evaluating the general health and systemic
condition help:

Systemic diseases which may affect
prosthodontic treatment includes
Some chronic diseases facing difficulties
in wearing of dentures because of a low
tissue tonus and tolerance to mechanical
irritation.

These include:
 Blood pressure
 Angina
 Infarction
 Rheumatic fever
Cardiovascular system disturbances

Respiratory System diseases
Tuberculosis
 Asthma
 Dyspnoea
 Edema

Gastrointestinal Tract disturbances
Ulcers
Jaundice
Nausea and Vomiting
Diarrhea or Constipation
Cirrhosis

Endocrinal diseases
 Hypothyroidism
Affects metabolism and quality of bone which is the
main denture supporting structure.
 Hyperparathyroidism
Diseases which affect the shape and size of the ridges
 Steroids
 Diabetes

Patients with uncontrolled diabetes always suffer from:
 Bleeding and various degrees of gingival and
periodontal diseases.
Uncontrolled Diabetes

Poor tissue tolerance
Increased rate of bone resorption
requiring frequent denture relining.
Loose teeth due to periodontal
disease and loss of alveolar bone.

 Reduced salivary flow which affect retention of
the prosthesis, discomfort and increase caries
susceptibility.
 Red and sore tongue.
 Decreased resistance to infection which require
strict oral and denture hygiene during and after
denture construction.

Anemia
Bleeding disorders
Erythema Multiforme
Blood dyscrasias
Hematopoietic Disorders such as

 Anemia and blood diseases may show oral
manifestations in the form of pale and week
mucosa, gum bleeding, red and sore tongue and
reduced salivary flow.
 Unnecessary extensive tissue coverage is not
recommended.
Blood dyscrasias

Bone diseases
Some bone diseases cause enlargement of bone which
affect the fit of the prosthesis.
 Paget's diseases causes maxillary tuberosity
enlargement.
 Acromegaly causes enlargement of the
mandible.

The most important features are:
1. Pain
2. Dysfunction of the muscles of mastication
3. Restricted mandibular movement
4. Noises from the temporomandibular joints (TMJ) during jaw
movement.
5. Although TMD is not life-threatening, it can be detrimental
to quality of life, because the symptoms can become
chronic and difficult to manage.
Temporomandibular joint disturbances

• Arthritic changes in the TMJ may
cause changes in occlusion and
difficulties encountered during jaw
relation record.
Arthritis

Transmissible diseases
 Hepatitis, influenza, Tuberculosis (TB) or
AIDS could be transmitted by contact with
patient's blood or saliva or through contaminated
instruments as trays.
 Investigation of these diseases is important to
prevent contamination and cross infection.

Infection control procedures
 Wearing disposable gloves
 Masks for protection against splatter of blood and saliva.
 Adequate sterilization of dental instruments using
autoclave.
 Disinfection of surfaces and equipment by scrubbing with
detergent solutions
 Contaminated disposable materials should be discarded in
plastic bags and sharp items in puncture resistant
containers.

Diseases which affect the patient’s physical capacity to
control dentures, These include:
 Parkinson’s disease
 Facial paralysis (neuralgia)
 Epilepsy
 Convulsions
Neurological Disturbances

• This can be seen in how a patient walks, moves
& handles him/herself.
• Patient with good neuromuscular coordination
can be expected to learn to manipulate dentures
quickly & adapt easily to new dentures.
Neuromuscular ability or Coordination

•Complicate the recording of the
maxillomandibular relations.
Parafunctional & Uncontrolled Jaw
Movements

• If the facial muscles are too tense or too loose, manipulation
will be difficult, the lips & cheeks may be easily displaced
the dentures.
Muscle Tone
• A face that has poor tissue tone, with loose or wrinkled
tissues can not be made to appear youngful by new dentures.
• Excessive facial muscle droopiness (flabbiness or slackness)
affects both esthetics & the patient’s ability to control
denture.

Medications which can affect
prosthodontic treatment
includes

i) Antihypertensive drugs
 Diuretic agents used in the treatment of
hypertension cause decrease in saliva and
dry mouth.
ii) Endocrine therapy
 Cause sore mouth and discomfort.
iii) Psychiatric treatments
iv) Tranquilizers

v) Dilantin
Partial dentures for epileptic patients on
dilantin therapy should not cause
irritation for gingival tissues to avoid
further gingival hypertrophy

The Prophet (peace be upon him) said:

2- Patient’s Evaluation
a. Expectations
b. Attitudes

The first diagnosis you should obtain is
patient evaluation
Does your patient have realistic expectation
Can you expect cooperation in all treatment
aspects?
Expectations

Does the patient have a positive or negative
attitude
Should this patient be treated with a removable
partial denture?
For example the need for dentures has been
explained to the patient and the necessity for
improvement of oral care to preserve the remaining
teeth has been emphasized.

When the patient returns for perio or operative
procedure there is no improvement in oral care.
In such situation it may be better to delay the
treatment because the prerequisite of oral
cleanliness is not met.

Patient must have the will to use the
dentures. Not just have the need but
also the will and physical ability to
use the denture.

II-Clinical Examination
Extra oral Intra-oral
Face
TMJ Examination
Hard tissue
Soft tissue

Front View Profile View
Face form and contour
Lip length and support
Angle of the mentolabial Sulcus
Vertical dimension of old
denture wearers
Size - Form – Shape of
the face
Arch relationship
Juvenile Appearance of the
patient
Face
Extra Oral Examination

• Size, form and contour of the face
• Arch relationship
Help in proper selection of teeth.
Proper Occlusion
Facial Examination

1.Normal lip length: Short or Long lip.
2.Normal lip line and natural vermilion border of
the upper lip
3.Nasal folds and sulcus
4.Angle of the mentolabial Sulcus
5.Facial wrinkles
6.Ridge – Lip Relationship
7.Vertical dimension of old denture wearers
An edentulous patient should be examined facially in
front and profile views.

Lip length might be:
1.Short lips, will expose all upper anterior teeth &
much of labial flange of the denture base.
2.Long lips, make it difficult to show sufficient
tooth and usually they hide upper anterior teeth&
denture base.
Lips:

It may be noted that
1.The fullness and normal contour of
the upper lip is lost due to the lack of
support by the loss of teeth
2.The normal lip line and natural vermilion
border of the upper lip is changed due to
this falling in and the philtrum looks
unsupported.
3.The nasal folds are deepened, the mental
tip is exaggerated and facial wrinkles may
result if the person has been without teeth
for sometime.

Maxillo-Mandibular Relationship
Ridge relations:
1 . Buccolingual relation (normal or cross bite).
3 . Anteroposterior relations and denture stability.

Acute dentoalveolar
abscess
Extra oral Pathosis
Normal Facial Contour

•Lymph nodes:
Any palpable or tender lymph
nodes about the face, joints or
neck should be noted and their
cause determined.

Clinical Interpretation Radiographic Interpretation
Digital Examination
Clicking or Pop sounds
on jaw Opening
Panoramic
Corrected Cephalometric
Tomography
TMJ Examination
Transcranial Radiography
Computerized Tomography
MRI
Jaw opening capacity

I-Visualization
III- Radiographs
IV- Study casts
II- Palpation
 Face
 Mid-Line Deviation
 Levels of shoulders
Clinical Examination
•Muscles
•Condyles

Examination of the TMJs
•Mandibular Range of Motion
•Identification of TMJ
•Palpation of the TMJs
•Sounds
•Loading of the TMJs

Mandibular Range of Motion
Jaw opening capacity
Measure the space between the upper and lower front teeth when
the mouth is open to its widest position (normal is 35-50 mm).

Mouth opening deviation
Tenderness Mouth opening deviation
Identification of TMJ

Abnormalities are indicated by
1. Reduced capacity to open
2. Opening with pain in the muscles or TMJ
joints
3. Opening towards one side rather than
straight down.
4. Hypermobility

Reduced capacity to open:
1 . Constriction of oral orifice with
edentulous period.
2 . Difficulty in tray insertion and impression
making
3 . Instability of the lower denture due to
muscular tightness.

Palpation of the TMJ on both sides of the face with the
mouth open wide and closed. Pain or tenderness over the
joint is an indication of an inflammation in the joint capsule
or within the joints
Digital Examination

Palpation of
the TMJ
A click may be felt beneath the doctor's fingers.
That too indicates an abnormal state

Identification of the TMJ Sound
Using a medical stethoscope or the
Electrosonograph (ESG)
TMJ Sounds
1- Clicking, Popping or Thud
2- Crepitation or Grating Sound

Temporomandibular Joint Disorders
I. T.M Joint Articular Disorders
II- Masticatory Muscle Disorders

TMJ Sound
•Crepitating or Grating Sound
•Clicking, Popping or Thud Due to:
•Deviation in Form
•Hypermobility
•Incoordination
•Disc Displacement With Reduction
Inflammatory & non-inflammatory
(degenerative) Disorders

Disc Derangement Disorders
•Disc Displacement With or without
Reduction
•Deviation in form (Articular surface
defects, thinning and perforation)

3-Displacement of the disc condyle complex TMJ
Hypermobility & dislocation)
4-Inflammatory & non-inflammatory (degenerative)
Disorders
5-Ankylosis
7-Fractures

Inconsistent clicking or clicking
during opening and/or closing
Opening and closing click in the
same position of mandibular mov.
Late opening click, deflection
toward the contralateral side
Late Closing Click, Opening click
Deviation in Form
Hypermobility
Muscular Incoordination
Disc Displacement With Reduction

Loading of the TMJs
Selective loading of the
TMJ can be useful in
confirming the presence
of pathology in the joint.
Test for the endfeel: difference between
passive and active maximum mouth opening.

Loading of the TMJs
When inflammation is present increasing
pressure on the joint usually causes an
increase in discomfort

Additional Testing Consultations
- Radiographs
- Diagnostic Nerve Block
- EMG
- Jaw Tacking
- Ultrasonography
- Thermography
- Vibrational Analysis
Three-dimensional
reconstruction of the
TMJ image

‫ان‬َ
‫س‬ْ
‫اإلح‬‫اء‬َ
‫ز‬َ
‫ج‬ْ‫ل‬َ
‫ه‬
‫ان‬َ
‫س‬ْ
‫اإلح‬ً‫ال‬‫إ‬

Intra Oral Examination
Visual
Examination
Digital
Examination

Hard tissue
Soft tissue
Saliva
Oral hygiene
index
Intra Oral Examination

Oral Mucosa
and Gingiva
Soft tissue
Frena Muscle’s
tone
Tongue
Peripheral
seal area
and Throat
form
Edentulous
area

Should carefully examined the mucosa covering
• Lips, cheeks
• Floor of the mouth
• Tongue
• Hard and soft palates, tonsillar areas
• Residual alveolar ridges
Oral Mucosa and Gingiva

Denture bearing surface
Frenum location Amount of attached gingiva
Height of soft tissue contour
Gingiva - Frena

Border Tissues:
a . Buccal , lingual vestibules.
b . Peripheral seal area ,
its importance in retention
c . Tissue displacement (impression
procedures).
e . The floor of the mouth.
f . The freni (shape, strength).
g . The width of the vestibule and the
denture flange thickness

Edentulous Area
Denture bearing surface examination
a. Mucosa thickness, topography, Color, inflammation,
abrasion, edema of mucosa and soft tissue.
b. Ideal resiliency of the ridges.
c. Flabby and hypertrophied ridges.

Mild Inflammatory changes, The color varies
from pink in healthy mucosa to red in inflamed
tissues.
Swelling or ulceration
 Remove the cause
 Some tissues will recover with simple rest
(by keeping the denture out)
Pathologic changes in the oral mucosa:

 Inflammatory changes, swelling or ulceration
 Flabby tissues overlying severely resorbed ridges will
not provide adequate denture support and cause
denture instability.
 Treatment: Conservative: by tissue rest, massage or
resilient soft liner
Surgical excision
Pathologic changes in the oral mucosa:

 Inflammatory papillary hyperplasia.
 Epulis fissuratum.
 Denture stomatitis characterized by burning
sensation, generalized erythema of the tissues
covered by the denture.
 Presence of displaceable soft tissues under ill
fitting or poorly designed dentures.
 Reactions of tissues to previous denture which includes:

Functional Problems
Instability
Window Tray
Impression Technique

 Residual ridge especially in absence of posterior
abutment provides partial denture support.
 High, well formed ridge covered by firm mucosa
provides support, retention and stability.
Evaluation of the residual ridge for proper treatment
plan of

Evaluation of the residual ridge for proper
treatment plan of
Knife edge or flat ridge are not supposed
to provide adequate denture support and
require special precautions.

Tongue
 The size and position.
 The coordination and mobility.
 Exam the lateral and inferior surfaces
of the tongue for disease or abnormality.
 Relation of the tongue to the occlusal plane should be
examined.
 Large flat tongue exhibiting excessive mobility produce great
displacing forces.
Observe

• It plays a major role in the retention of the
mandibular denture.
• Large tongue occurs when all teeth lost for a
long period of time.
• Impression making is difficult with this type of
tongue and denture stability is difficult too
Tongue

The tongue plays an important role in
complete denture prognosis:
1 . Size, shape and resting position,
2 . Tongue size, and impression.
3 . Tongue size, and peripheral seal and
retention.
4 . Tongue and arrangement of teeth

Tongue Position
 Normal tongue positions
 Retracted or awkward tongue
positions

Muscle tone
1 . Physiologic tonicity of muscles
differs from a patient to another.
2 . Irreversible return of muscle
flaccidity.
3 . Difficult jaw relation registration.

The Post-Dam Area:
a . Extension
b . Location.
c . Width and depth.
Throat form:
a . Had a bearing on the post dam area
b . Class I , II , III throat form , its effect on the width
of post dam.
c . Location of the torus palatinus.
d . Fovea palatini .

Posterior palatal seal
Pterygomaxillary seal
•AVL and PVL
Butterfly in shape

There are variations in the angulation between
the movable and immovable palates
Is the width of area between the
distal border of the hard palate
& the anterior border of the
movable tissues of the soft
palate.
Throat form

A wide posterior palatal seal is most favorable
because a large seal can be placed
Class I  Gentle Curvature
Class II  Medium Curvature
Class III Abrupt Curvature
Throat form

Hard tissue
Tori
Undercut
Remaining
Natural Teeth
Ridge
Relationship
Bearing area:
Arch form and Ridge
Contour

 N0 - Form- Position of the teeth,
 Crown condition
 Caries and periodontal status
 Existing Restoration Occlusion Centric
and eccentric
 VDO, and occlusal plane
Remaining Natural teeth

Vitality test Percussion
Mobility
Pocket Evaluation
Access, mouth opening

 Number of carious cavities.
 Number of restored teeth.
 Presence of recurrent caries
 All these indicate caries index of the patient.
 Treatment vary from simple conservative
treatment to protective restorations in the form
of full coverage in patients susceptible to caries.
1- Evaluation of caries activity

Badly decayed Indicated for Extraction

2- Evaluation of existing restorations
 Presence of a deficient restoration
necessitates its removal and replacement.
 Amalgam restorations especially on the
abutments should be evaluated to
determine their efficiency.
 Restorations on the buccal surfaces of
teeth that were in contact with old clasp
arms should be checked for wear or
deficient margins.

Evaluation of existing restoration
Evaluation of
anterior Overlap

 Teeth especially abutments should be
tested to detect any pulpitis or necrotic
pulp using electric pulp tester or
thermal tests.
 Presence of pulp disease indicate the
importance of endodontic treatment.
3- Evaluation of pulp

 Endodontically treated abutments and
teeth with large intra-coronal
restorations are brittle and may
fracture when subjected to stresses
and therefore should be protected by
full crowns.
3- Evaluation of pulp

 Teeth are sensitive to percussion due to irritation
of the periodontal ligament fibers caused by
periapical abscess, pulpitis, periodontitis or
traumatic occlusion.
 Percussion sensitive teeth should not be used as
abutments except after diagnosis, elimination of
the causative factor and treatment of the tooth.
4- Evaluation of teeth for sensitivity to percussion

Mobility of teeth caused by
traumatic occlusion or due to
inflammatory changes in the
periodontal ligament is reversible.
5- Evaluation of teeth mobility

 Mobility of teeth caused by loss of
alveolar bone support is irreversible and
in such case, the tooth cannot be used
as an abutment and the adjacent tooth
should be evaluated as partial denture
abutment.
5- Evaluation of teeth mobility

 Class I  tooth demonstrates greater than normal movement
but <1 mm in any direction.
 Class II  tooth moves 1 mm from normal position in any
direction.
 Class III  Tooth moves more than 2 mm in any direction
including rotation and depression.
 Poor prognosis and require extraction.
 May be due to inflammatory changes in PDL, traumatic
occlusion and loss of alveolar bone support.
Classification of teeth mobility

 The periodontium of teeth especially
abutments should be evaluated, as partial
denture placed in the presence of active
periodontal disease will contribute to 
rapid progress of the disease  loss of the
remaining natural teeth.
6- Evaluation of the periodontium

Periodontal disease may be in the form:
 Gingivitis: diagnosed by change in color,
contour and texture of gingiva and presence
of inflammatory exudates.
 Deep Periodontal pockets: revealed by
probing and measured by a periodontal
probe.
6- Evaluation of the periodontium

Gingival recession and loss
of attached gingiva.
Root furcation involvement.

Weak teeth are:
Having poor crown / root ratio.
Teeth with furcation involvement.
Hopeless teeth which cannot be
restored to normal health.
7- Evaluation of weak teeth

Treatment:
 Splinting to a neighboring strong teeth, but
this may weaken the strong tooth due to
movement allowed by weak tooth.
 Using tooth as an over-denture abutment to
help in support, stability and retention.
7- Evaluation of weak teeth

Need of Orthodontic Treat.
Teeth related to pathologic
lesions

Remaining teeth
Supernumerary teeth

Extraction of tooth if:
 All ways of treatment were considered and the tooth
is untreatable.
 Absence of tooth permits simple uncomplicated
partial denture design.
 Tooth is un-esthetically located and its removal will
improve the appearance.

Arch Form and Contour
and
Ridge Relationship

It might be:
1. Large.
2. Average.
3. Small.
The larger the arch, the greater the advantage
for retention, stability and support.
Arch Size (Bearing Area)

1. Size of the bearing area and force
transmitted.
2. Selection of small posterior teeth
with small bearing area.
Arch Size (Bearing Area)

 Measured by a graduated probe from free gingival margin
to active floor of the mouth.
 The patient should be instructed to raise his tongue to
raise the floor of the mouth to its highest functional level.
Estimation of the depth of the lingual sulcus

Estimation of the depth of the lingual sulcus
If space available 8 mm or more  lingual bar.
If space available less than 8 mm  lingual plate.

Generally, they are classified into:
1. Square
2. Tapering
3. Ovoid.
Square arch is the best form to prevent
rotational movements
Arch Form

Vault shape and denture retention.
• Flat,
• U-shape,
• V-shape.
The vault

Cross-section, resorption,
sharpness, spines, should be
evaluated.
Smooth - Irregularities
Ridge Form and Contour

It varies between upper & lower arches & from one area of
the arch to another arch. It can be divided into:
1. Normal ridge (I, II).
2. Knife-edge ridge
(narrow V-shaped class III)
3. Flat ridge (resorbed ridge class IV)
4. Irregular or undercut ridge (bulbous class V).

Undercuts and denture insertion
without surgical interference.
Maxillary tuberosity should be
evaluated.

Slope of Retromolar Pad
Mylohyoid Ridge
Lingual Pouch
Painful Areas.
Evaluation of the form of
the residual ridge and
bony prominences
When surgery is indicated , it must be done conservatively.

The mental foramen occupies a more
superior position Relief

Tori and bony abnormalities
 Tori, bony exostosis or undercuts
should be detected
 The partial denture should be
designed to avoid crossing any
bony protuberances otherwise
surgical treatment may be
planned.

Torus Palatinus
affecting major
connector contours
Bony protuberance, found along the median palatal
suture (Torus Palatinus) or on the lingual side of
the mandible at premolar area (Torus
Mandibularis).

1. None.
2. Small (does not interfere with denture construction).
3. Large (demands surgical removal).

Mid-palatal suture
Sharp bony spicules
Poor base adaptation
Fulcrum on bony structures

Undercuts
Undercut Tuberosities
Labial undercut
Distolingual undercut
 Gross bone undercut

If the ridge is severely undercut,
the flange cannot be placed to
the depth of the vestibule,
otherwise the denture will not
seat or ulceration will occur
Undercuts

A denture border short of the
mylohyoid ridge digs into the
residual ridge and causes
pain. If shortened, the denture
border will impinge again
upon the ridge.
Undercuts

Severe Undercut Tuberosities
•Fitting Surface cut away with no reduction of
periphery.
•Alveoloplasty + New buccal or labial flange.
•Undercut on one side insert in one side then rotate.
Unilateral undercut

Ridge Relationship
It could be:
1. Normal. Buccolingual relation (normal or cross bite)
2. Retrognathic. wide maxilla and narrow mandible
3. Prognathic. Cross bite relation between wide mandible
and narrow maxilla

Denture stability
Occlusion
Setting of teeth >> Cross bite relation
Ridge Relationship

The vertical distance between ridge
crests may be:
1. Favorable inter-ridge space.
2. Limited inter-ridge space.
3. Excessive inter-ridge space.
Inter-arch space (Inter-ridge distance)

Limited inter-ridge space.
Too small space, short teeth , less esthetic >>
overdenture is contraindicated
Excessive inter-ridge space.
Too large space, less favorable, more leverage, less
stability >> Cuspless teeth
Inter-arch space (Inter-ridge distance)

The quality and quantity of saliva
are affected by age, drugs and
systemic conditions.
Saliva

Normal amount & consistency of saliva
(Thin- watery saliva), provides comfort to
the patient, retention of the denture and
good oral and denture hygiene. (cohesive
and adhesive properties of saliva are
ideal).
Saliva

Excessive saliva. It complicates
impression procedure & minimizes
retention.
Insufficient saliva, which reduces
retentive qualities of the dentures.
Saliva

Copious thick ropy saliva causes difficulties in
impression procedures and denture retention.
 In Dry mouth  wearing dentures is uncomfortable
to the patient because of the dragging effect of
denture base on the tissues and during function.
Medications promoting salivary secretions and
frequent intake of fluids are mandatory.
Saliva

Oral Hygiene Habits
Check for the presence of abnormal
hygiene habit, smoking

Bad Habits
Tongue thrusting
Clenching, bruxism
Check for the presence of abnormal and Parafunctional
habits as clenching, bruxism, GI reflux or Bulimia,
smoking, hygiene habit, or tongue thrusting

Objectives
Detect, locate and plan for the treatment
of any abnormality or pathologic changes
in the form of root fragments, foreign
bodies, un-erupted molars, cysts and
tumors.
III-Radiographic Examination

Periapical radiograph
Bitewing radiograph
Degora radiograph
Panoramic radiograph
 Cone beam CT scan "Computed Tomography".
 MRI "Magnetic Resonance Imaging"
If we are planning for implant procedures:

Objectives of MRI, CT and Cone beam
Identify periapical pathology.
Gives accurate and reliable assessment of bone
"quality and width" and location of anatomic
structures.
Adequate vertical bone height.
Adequate space above inferior alveolar nerve or
below maxillary sinuses.
Identify radio-opaque or radiolucent lesions.

Remaining Natural Teeth
Bone quality and quantity
Root Fragments
Cysts
Bony spicules
Irregular Ridge
Edentulous Area

Periapical Radiographic
Root Fragments
Cysts
Bony spicules
Irregular Ridge
I-Edentulous Area
Bone quality and
quantity:
Bone Nature, Degree of
calcification, Stress
bearing quality
Pathology

Evaluation of the Edentulous area
 The ridge is evaluated as regards to height and
quality of bone.
 Ridge bone exhibiting close trabecular pattern,
narrow inter-trabecular spaces and adequate
height:
Withstand additional load.
Provide good support.

Periapical Radiographic
Pathology
II- Remaining Natural Teeth
Caries
restorations
RCT
Apical pathology
1. Crowns
2. Roots: number,
shape curvature,
3. Bone: height, density
4. Vital structures

• Crowns: caries, restorations
• Roots: number, shape curvature, RCT
• Bone: height, density, apical pathology
• Vital structures: Successors, IAC, MS
Evaluation of the condition of the remaining natural teeth

1. The presence and extent of caries and
2. The relation of carious lesions to the
pulp and periodontal attachment
• Badly decayed Indicated for Extraction
Periapical x – rays

3- Evaluation of existing restorations:
evidence of recurrent caries, marginal
leakage, and overhanging gingival
margins

4. Evaluation of root canal fillings

5. Evaluation of areas of infection and Teeth
related to pathologic lesions

6- Cracked tooth and root fracture

7- Retained teeth

8- Impacted teeth

 Length, size and form of the root
- Multi-rooted teeth, teeth with large, long and
divergent roots can resist stresses induced
by the partial denture as forces will be
distributed through greater number of
periodontal ligament fibers.
9-Evaluate the prospective abutments

 Crown root ratio
• The abutment is expected to have good prognosis if
the ratio between its clinical crown and root is not
greater than 1:1.
• Teeth with poor crown root ratio can be prepared and
their crowns reduced in length to be used as partial
over-denture abutment.
9-Evaluate the prospective abutments

 Condition of the lamina dura
 Lamina dura is a thin layer of cortical bone lining the sockets of
teeth and provides attachment for the periodontal ligament
fibers.
 Teeth may exhibit partial or total absence of lamina dura due to:
 Systemic diseases as hyperparathyroidism
and Paget's disease.
 Pressure falling on the teeth due to
traumatic occlusion.

 Periodontal ligament space
Widening of the periodontal ligament space
together with thickening of the lamina dura
indicate:
• Teeth mobility.
• Traumatic occlusion.
• Tooth with heavy function.

Bone index areas
Areas of alveolar bone which
reveal the reaction of bone around
teeth which are subjected to
additional stresses

Bone index areas
 Positive bone factor:
Signs of positive bone response.
Heavy cortical layer.
Normal bone height and normal periodontal
ligament space.
 Negative bone factor:
 Retrograde bone changes (getting worse).

Intra oral radiograph
Occlusal view
Occlusal x – ray

Extra oral radiograph
Radiographic Examination For the Remaining
Natural Teeth and for Edentulous Ridge
Panoramic x-rays

• The presence of root fragments, foreign
objects, bone spicules and irregular ridge
formations

Pulpal necrosis and endodontic failure

Lateral Oblique
Jaw Fracture

Comparison between computed Tomogram,
magnetic resonance image and Three-dimensional
reconstruction of the TMJ image

Primary impression
Mounted the diagnostic
casts and occlusal
analysis
Next Lecture

•Study Casts
Mounted Diagnostic Casts and Occlusal Analysis
•Intraoral Occlusal
Analysis

Examination of the Occlusion
Stability of Occlusion / Occlusal Interferences
• Morphologic Malocclusion
Open Bite
Laterally Forced Cross Bite
• Occlusal wear, Occlusal Facets
• Functional Malocclusion

•Importance of the Occlusal Analysis of
Mounted Cast
•How To Make Mounting
- Face bow Record
- Methods and Materials of CJRR

GAGGING
An involuntary series of uncoordinated spasmatic
movements of the swallowing muscles due to stimulation
of the swallowing receptors situated in the posterior
pharyngeal wall.
Causes:
1. Systemic disorders.
2. Psychologic factors.

Managements
Pre-prosthetic managements.
The use of medications.
During clinical procedures.

During clinical procedures
1. Encourage physical and mental relaxation and Tell
the patient that little difficulty will be encountered.
2. Seat the patient in upright position.
3. Ask the patient to breathe deeply.
4. Direct the patient attention to other subject.
5. Use proper amount of the impression material.
6. Seating the posterior part of the upper tray first.

During clinical procedures
7. Start with the lower impression first.
8. Select the proper impression material , with fast
setting time.
9. Use local surface anesthesia .
10.Bead the posterior border of the tray .
11.Mix the impression material out of the sight of the
patient.

12.Speak loudly and clearly to the patient.
13.Never say the word GAG.
14.Ask the patient to rinse with astringent
before the procedure.
15.With impression procedures tilt the
patient head forward.

1- Diagnosis and treatment planning for removable prosthodontics

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1- Diagnosis and treatment planning for removable prosthodontics