Diagnosis and Treatment Planning of Removable Partial Denture

“Problems related to RPDs may be associated
with errors in diagnosis and treatment planning,
including inadequate mouth preparation “
- McCord JF et al Dent
Update 2003; 30: 88–97
1

Diagnosis and treatment
planning of removable partial
denture
Presentation by:
Dr. Vanshree Sorathia
MDS Prosthodontist Totalno. of slides:129

Outline of presentation……
• Definition
• Examination and evaluation of diagnostic data
-First appointment
-Second appointment
• Development of treatment plan
• Prosthodontic diagnostic index (PDI)
• Partial edentulism checklist
• Choice between CD/RPD/FPD
• Clinical factors related to framework material
• SOAP summary
3

Definition
Diagnosis:
The determination of the nature of
a disease.
Treatment plan:
The sequence of procedures
planned for the treatment of a
patient after diagnosis.
Prognosis:
A forecast as to the probable result
of a disease or a course of therapy.
The Glossary of Prosthodontic Terms, 9th edition. J. Prosthet Dent 2017 May;
117(5S):e1-e105.
4

Patient interview Clinical examination Treatment planning
McCracken, Removable partial prosthodontics, 11th edition, Elsevier 2005. 5

Examination and evaluation of
diagnostic data
First appointment
6

1. Organizing the examination
Objective: To assess the patients general health.
Stewart, Rudd, Kuebker, Clinical removable partial prosthodontics, 2nd edition,
AIPD 2002. 7
2. Health questionnaire
Effective examination if two appointments are
used.

3. Patient interview
Objectives:
1. To Establish Rapport with the patient.
2. To Gain Insight Into The Psychologic Makeup of
the patient.
In 1961, Dr M. M. Devan stated, “ We should meet
the mind of the patient before we meet the mouth of
the patient.”
Stewart, Rudd, Kuebker, Clinical removable partial prosthodontics, 2nd
edition, AIPD 2002. 8

Psychological makeup of patient
• House classification
AIPD 2002.
9

Revised house classification
Gamer et al, M. M. House mental classification revisited: Intersection of particular
patient types and particular dentist’s needs, J Prosthet Dent 2003;89:297-302. 10

4. Evaluating the effect of physical
problems on treatment
i. Diabetes
edition, AIPD 2002.
11

ii. Arthritis
AIPD 2002.
12

iii. Hyperparathyroidism
AIPD 2002. 13

iv. Hyperthyroidism
edition, AIPD 2002.
14

v. Paget’s disease
Shafer’s – Textbook of oral pathology, 7th edition, Elsevier 2014. 15

vi. Acromegaly
AIPD 2002.
16

vii. Pemphigus Vulgaris
AIPD 2002.
17

viii. Parkinson’s disease
AIPD 2002.
18

ix. Epilepsy
edition, AIPD 2002.
19

x. Cardiovascular disorders
• Acute or recent myocardial infarction
• Unstable or recent onset of angina pectoris
• Congestive heart failure
• Uncontrolled arrhythmia
• Uncontrolled hypertension
AIPD 2002.
20

Uncontrolled hypertension
o Xerostomia- diuretics
o Lichenoid reactions – ACEIs
o Burning mouth sensations – ACEIs
o Gingival hyperplasia- CCBs
21

xi. Cancer
AIPD 2002. 22

xii. Transmissible disease
AIPD 2002. 23

xiii. Osteoporosis
AIPD 2002.
24

5. Evaluating the effect of drugs on
the treatment
i. Antihypertensive drugs
• Orthostatic hypotension
• Diuretics – decrease in saliva
AIPD 2002.
25

ii. Anticoagulants
Post surgical bleeding.
iii. Endocrine therapy
Extremely sore mouth.
AIPD 2002. 26

iv. Saliva inhibiting drugs
AIPD 2002. 27

6. Ascertaining patient’s expectation of
treatment
• Realistic ??
AIPD 2002. 28
7. Obstacles to successful interview
• Non attentive dentist
• Choice of words

8. Structure of interview
i. Dental history
1) Chief complaint
2) History of present illness
3) Primary reason for loss of teeth
4) Previous denture experience and duration
5) Primary reason for needing the denture
6) Pretreatment records

ii. Diet
iii. Oral hygiene habits – methods and frequency.
iv. Parafunctional habits – bruxism and
clenching.
Tongue thrusting habit.
v. Other habits – smoking, tobacco chewing.

9. Cursory examination
• Detection of problems requiring immediate
attention
• Evaluation of oral hygiene
• Evaluation of caries susceptibility
• Detection of oroantral and oronasal
communication
AIPD 2002.
31

10. Oral prophylaxis
AIPD 2002. 32

11. Radiographs
AIPD 2002.
33

12. Diagnostic impressions and casts
AIPD 2002. 34

Examination and evaluation of
diagnostic data
Second appointment
35

Mounted diagnostic casts
Objective:
edition, AIPD 2002.
36

Three distinct phases of the procedure:
• Orientation of the maxillary cast to
the condylar elements of articulator
by means of a facebow transfer.
• 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.
AIPD 2002. 37

Facebow transfer
Preparation of bite fork
Orientation of facebow to bite fork
and reference points.
Orientation of facebow to articulator
Attachment of maxillary cast to
articulator
AIPD 2002.
38

Centric jaw relation record
• Bone to bone relation
• Repeatedly recorded and verified
edition, AIPD 2002.
39
Pain in TMJ
or
musculature
Proprioceptive
reflex
Psychologic
stress
Ramfjord and Ash
1971

Media for recording centric jaw relation
• Wax: modelling, alu wax
• Zinc oxide eugenol paste
• Plaster of paris
• Dental stone
• Acrylic resin
• Modelling plastic
• Poly ether bite registration paste
AIPD 2002. 40

Verification of mounting
Can be considered correct if:
1. The cusp tips of both casts fit the jaw relation
record accurately and,
2. The condylar ball remains in contact with the
posterior stop of the condylar path on both
sides.
AIPD 2002. 41

DEFINITIVE ORAL EXAMINATION
42

Extraoral examination
• Facial form
• Facial profile
• Facial symmetry
• Muscle tone
• Complexion
• Eyecolor
• Lips – thickness, support, length, stability.
• Lymphnode examination
• Neuromuscular cordination
43

• Temporomandibular joint
44

1. Evaluation of caries and existing
restoration
AIPD 2002.
47

2. Evaluation of pulp
AIPD 2002.
48

3. 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

4. Evaluation of mobile teeth
 As an abutment tooth – poor prognosis
 The causes for mobility:
o Trauma from occlusion- reversible
o Inflammatory changes in the periodontal ligament- may be
reversed if the inflammation is eliminated
o 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.
AIPD 2002. 50

Indications for splinting of abutment teeth
i. Reduced support because of
o Periodontal disease
o Teeth with short ,tapered roots
ii. One or two widely placed retainable teeth –
mandibular canine.
iii. Maintain continuity of arch – pier abutment.
AIPD 2002. 51

5. Evaluation of periodontium
AIPD 2002.
52

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.
AIPD 2002.
53

• Root scaling and planning
AIPD 2002. 54

• Gingivectomy
edition, AIPD 2002.
55

• Periodontal flap procedures

• Free gingival graft
AIPD 2002. 57

6. Evaluation of oral mucosa
• Pathologic changes
Tissue reactions to the wearing of a prosthesis
o Palatal papillary hyperplasia

o Epulis fissuratum
o Denture stomatitis
Stewart, Rudd, Kuebker, Clinical removable partial prosthodontics,
2nd edition, AIPD 2002. 59

7. Evaluation of hard tissue
abnormalities
• Torus palatinus • Torus mandibularis
AIPD 2002. 60

• Exostoses and undercuts • Mandibular / Maxillary
tuberosity

Indication of surgical removal of undercut:
• If relieving the denture base or reducing the
length of denture border would,
1. Significantly reduce the support for and
stability of prosthesis.
2. Create a bothersome food impaction area.
3. Affect function, compromise esthetics or
cause discomfort for patient.
AIPD 2002
62

8. Evaluation of soft tissue
abnormalities
1. Labial and lingual frena
Stewart, Rudd, Kuebker, Clinical removable partial prosthodontics,
2nd edition, AIPD 2002. 63

2. Hypertrophic lingual frenum
3. Unsupported and hypermobile gingiva
AIPD 2002.
64

9. Evaluation of quality and quantity
of saliva
AIPD 2002. 65

10. Evaluation of space for major
connector
• The width of lingual bar – 5 mm.
• The superior border – should be located 3 mm
below the free gingival margins of the mandibular
teeth to avoid damage to the gingival tissues.
• Inferior border – above active floor of mouth.
• When the space is less than 7 mm- lingual plate is
indicated.

11. Evaluation of radiographic
survey
AIPD 2002. 67
Existing restorations Root fragments
Unerupted third molar

 Radiographic evaluation of prospective abutment
teeth:
AIPD 2002.
68
a. Root size, length and form
 Large and longer roots short.
 Divergent > tapered/ conical roots.
 Multi-rooted and divergent > single-
rooted and fused.
 Position of roots of adjacent tooth.

b. Crown root ratio
o Long cone paralleling technique.
o Poor prognosis- 1:1 ratio and furcation involvement.
o Can be corrected.
AIPD 2002.
69

c. Lamina dura
AIPD 2002. 70
Absence
Normal
Thickening

d. Periodontal ligament space
AIPD 2002. 71

e. Bone index area
Areas of alveolar bone that support the teeth
known to have been subjected to a larger than
normal workload.
Positive
Negative

If there is a positive response of alveolar bone and
PDL to increased forces, the patient has “positive
bone factor”.
Signs of positive bone factor
• A supportive trabecular
pattern
• Heavy cortical layer
• Dense lamina dura
• Normal bone height
• Normal periodontal ligament space.
AIPD 2002.
73

If retrograde bone changes occur, the patient has
“negative bone factor”.
Signs of negative bone factor
• Loss of laminadura
• Loss of bone height
• Widening of PDL space
• Apical or furcation radiolucency
AIPD 2002.
74

Teeth subjected to greater than normal stress
and provide good index information include:
o Abutment teeth of a fixed or removable partial
denture.
o Teeth involved in occlusal interferences.
o Teeth receiving greater occlusal stress because
of loss of adjacent teeth.
o Tipped teeth with occlusal contact.
AIPD 2002.
75

12. Evaluation of mounted
diagnostic casts
a. Interarch distance
o Enlarged tuberosity.
o Surgical correction.
o Healing period 7-10 days
o Bony- 2-3 weeks.
AIPD 2002.
76

b. Occlusal plane
o Irregular ( extrusion of one or more unopposed
teeth).
o Malposed ( extrusion of an entire segment of
an arch with concomitant drop of alveolar
process).
AIPD 2002. 77

a) IRREGULAR OCCLUSAL PLANE
o Moderately extruded tooth – 2mm of enameloplasty.
o >1 or 2mm –
Extracoronal cast metallic restoration
Crown lengthening
Minor tooth movement procedure
o Severely extruded: contacting opposite ridge-
Extraction and alveoloplasty
Endodontic treatment – overdenture abutment.
AIPD 2002. 78

b) MALPOSED OCCLUSAL PLANE
o Posterior segment osteotomy
o Anterior segment osteotomy
- Severe protrusion
- Deep vertical overlap
AIPD 2002. 79

 Traumatic vertical overlap - Akerly
classification(1977)
Type 1:
The mandibular incisors
extrude and impinge into
the palate.
Type 2:
impinge into sulci of the
maxillary incisors.
Akerly, W. B., Prosthodontic treatment of traumatic overlap of the anterior teeth.
The Journal of Prosthetic Dentistry, 1977;38(1), 26–34.
80

Type 3:
Both maxillary and
mandibular incisors incline
lingually with impingement
of the gingival tissues of each
arch.
Type 4:
move or extrude into the
abraded lingual surfaces the
maxillary anterior teeth.
The Journal of Prosthetic Dentistry, 1977;38(1), 26–34. 81

Clinical symptoms of traumatic vertical
overlap
• Abrasion
• Mobility
• Migration of the teeth
• Inflammation , ulceration of the gingiva and
palatal mucosa
The Journal of Prosthetic Dentistry, 1977;38(1), 26–34. 82

c. Malrelation of jaws
• Severe malrelation of the jaws can preclude
the restoration of adequate function and
esthetics.
• Several maxillary and mandibular osteotomy
procedures are useful in correcting these
problems.
AIPD 2002. 83

d. Tipped or malposed teeth
o Limited orthodontic procedures.
o Orthodontic appliances, rubber ligature used to
correct the position.
AIPD 2002. 84

e. Occlusion
• 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.
AIPD 2002.
85

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
AIPD 2002. 86

Decision to treat at centric relation
or maximum intercuspation
The clinical situations that indicate construction
of prosthesis at centric jaw relation:
i. Coincidence of centric relation and centric
occlusion.
ii. Absence of posterior tooth contacts
(opposing missing teeth).

iii. Situation in which all posterior contacts are
to be restored with cast restorations.
iv. Only few remaining posterior contacts.
v. Symptoms of traumatic occlusion of the
anterior teeth.
vi. Clinical symptoms of occlusal trauma.
AIPD 2002.
88

Clinical factors related to metal
alloys used for CPD framework
The choice of alloy should be based on following
factors:
a. Weighed advantages or disadvantages of the
physical properties of alloy
b. Dimensional accuracy with which the alloy can
be cast and finished
c. Availability of the alloy
d. Versatility of the alloy

 Comparable characteristics of gold alloys and chromium –
cobalt alloys:
o Each is well tolerated by oral tissues.
o Esthetically - equally acceptable.
o Enamel abrasion - insignificant on vertical tooth surfaces.
o A cast to wrought wire or its components may be soldered.
o Accuracy in casting - clinically acceptable.
o Soldering procedures for the repair of frameworks can be
performed on each alloy

Diagnostic wax-up
AIPD 2002. 92
• Provides a guide for tooth preparation and
problems that may be encountered in
positioning cusps and in establishing
acceptable occlusal contacts.

Consultation required
• If any Speciality opinion is required.
AIPD 2002. 93

Treatment plan
The objectives of any prosthodontic treatment may be
stated as follows:
• The elimination of disease.
• The preservation, restoration, and maintenance of the
health of the remaining teeth and oral tissues.
• The selected replacement of lost teeth; for the purpose
of restoration of function comfort and in esthetically
pleasing manner.
John Osborne, George Alexander Lammie, Partial Dentures, 4th edition,
CBS publishers 1985. 94

Development of treatment plan
AIPD 2002. 95
Phase I Phase II Phase III
Phase IV Phase V

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.
AIPD 2002. 96

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.
AIPD 2002. 97

Phase 3 :
Pre prosthetic surgical procedures.
Definitive endodontic procedures.
Definitive restoration of teeth, including
placement of cast metallic restorations.
Fixed partial denture construction.
patient.

Phase 4:
Construction of removable partial denture.
patient.

Phase 5:
Post insertion care.
Periodic recall.
patient.
AIPD 2002. 100

Prosthodontic diagnostic index (PDI)
Based on diagnostic findings, The American
College of Prosthodontists (ACP) has developed a
classification system for partial edentulism:
o Criteria 1: Location and extent of the edentulous
area(s)
o Criteria 2: Abutment conditions
o Criteria 3: Occlusion
o Criteria 4: Residual ridge
McGarry et al. Classification System for Partial Edentulism. Journal of
Prosthodontics, September 2002;11(3):181-193. 101

Benefits:
A tool for improved diagnostic
consistency.
Standardized criteria for substantial
interoperator consistency in patient
classification.
Improved professional communication.
An objective method for patient
screening.
Prosthodontics, September 2002;11(3):181-193.
102

A standardized and documented
aid for decision making related to
referral for specialty care.
A basis for insurance
reimbursement commensurate
with complexity of care.
Standardized criteria for outcomes
assessment in private,
institutional, and research settings.

Criteria 1 : Location and extent of the edentulous
area(s)
Class I
Ideal or minimally compromised edentulous area –
single arch and one of the following:
• Any anterior maxillary edentulous area – not exceed 2
incisors.
• Any anterior mandibular edentulous area – not exceed 4
incisors.
• Any posterior maxillary or mandibular edentulous area
– not exceed 2 PM or 1 PM and 1 molar.

Class II
Moderately compromised edentulous area –
edentulous areas in both arches and one of the
following:
• Any anterior maxillary edentulous area – not
exceed 2 incisors.
• Any anterior mandibular edentulous area – not
exceed 4 incisors.
• Any posterior maxillary or mandibular edentulous
area – not exceed 2 PM or 1 PM and 1 molar.
• A missing maxillary or mandibular canine.

Class III
Substantially compromised edentulous area.
• Any posterior maxillary or mandibular
edentulous area greater than 3 teeth or 2
molars.
• Any edentulous areas including anterior and
posterior areas of 3 or more teeth.

Class IV
Severely compromised edentulous area
Any edentulous area or combination of
edentulous areas requiring a high level of patient
compliance.
Congenital or acquired maxillofacial defects.

Criteria 2 : Abutment conditions
Class I
• Ideal or minimally compromised abutment conditions.
• No preprosthetic therapy indicated.
Class II
• Moderately compromised abutment condition.
• Abutments in 1 or 2 sextants have insufficient tooth
structure to retain or support intracoronal restorations.
• Abutments in 1 or 2 sextants require localized adjunctive
therapy (periodontal, endodontic, or orthodontic
procedures).

Class III
• Substantially compromised abutment
condition.
• Abutments in 3 sextants – insufficient tooth
structure to retain or support intracoronal or
extracoronal restorations.
• Abutments in 3 sextants – require more
substantial localized adjunctive therapy.

Class IV
• Severely compromised abutment condition.
• Abutments in 4 or more sextants – insufficient
tooth structure to retain or support intracoronal
or extracoronal restorations.
• Abutments in 4 or more sextants – require
extensive adjunctive therapy.

Criteria 3 : Occlusion
Class I
• Ideal or minimally compromised occlusal
characteristics
• No preprosthetic therapy required
• Class 1 molar and jaw relationships are seen
Class II
• Moderately compromised occlusal characteristics
• Occlusion requires localized adjunctive therapy
(enameloplasty or premature occlusal contacts)
• Class 1 molar and jaw relationships are seen

Class III
• Substantially compromised occlusal
characteristics.
• Entire occlusion must be reestablished, but
without any change in the occlusal vertical
dimension.
• Class II molar and jaw relationships are seen

Class IV
• Severely compromised occlusal characteristics.
• Entire occlusion must be reestablished,
including changes in the occlusal vertical
dimension.
• Class II, division 2 and Class III molar and jaw
relationships are seen.

Criteria 4 : Residual ridge characteristics
Radiographic height of the residual mandibular
alveolar bone –
Class I – bone height ≥ 21 mm – measured at the most
reduced vertical dimension of the mandible on
panoramic radiograph.
Class II 16-20 mm bone height
Class III 11-15 mm bone height
Class IV ≤ 10 mm of mandibular radiographic bone
height.

Partial edentulism checklist
115

Choice between CD/RPD/FPD
Indications for fixed restorations:
• Tooth bounded edentulous regions.
• Additional modification spaces in Class III
modification 1 situation.
• Nonreplacement of missing molars.
.
McCraken WL, Differential diagnosis: fixed or removable partial dentures,
JADA Dec 1961;63.
117

Indications for removable partial dentures:
• Free end saddle.
• After recent extraction.
• Long span.
• Need for effect of bilateral bracing.
• Excessive loss of residual bone.
• Unusually sound abutment tooth.
• Economic consideration.
McCraken WL, Differential diagnosis: fixed or removable partial dentures,
JADA Dec 1961;63.
118

SOAP summary
• The four components of a SOAP note are -
Subjective, Objective, Assessment, and Plan.
• The SOAP note format is used to standardize
medical evaluation entries made in clinical
records.
• The SOAP note is written to facilitate improved
communication among all involved in caring for
the patient and to display the assessment,
problems and plans in an organized format.
John Osborne, George Alexander Lammie, Partial Dentures,
4th edition, CBS publishers 1985. 119

Importance of written treatment plan
 Plan the amount of time and appointment schedule.
 Provides information to the patient.
 Estimate the professional fees for the treatment.
 Coordinate the schedule for dental laboratory
procedures.
 Meet the legal requirements of informed consent.
John Osborne, George Alexander Lammie, Partial Dentures, 4th edition,
CBS publishers 1985. 120

References
1. The Glossary of Prosthodontic Terms, 9th edition. J.
Prosthet Dent 2017 May; 117(5S):e1-e105.
2. Stewart, Rudd, Kuebker, Clinical removable partial
prosthodontics, 2nd edition, AIPD 2002.
3. McCracken, Removable partial prosthodontics, 11th
edition, Elsevier 2005.
4. George Graber, Color Atlas of Dental Medicine. Vol 2
Removable Partial Dentures, Thieme 1988.
121

5. John Osborne, George Alexander Lammie, Partial
Dentures, 4th edition, CBS publishers 1985.
6. McGarry et al. Classification System for Partial
Edentulism. Journal of Prosthodontics, September
2002;11(3):181-193.
7. Dunn BW, Treatment Planning For Removable Partial
Dentures, J. Pros Den March- April 1961;11(2).
8. McCord JF, Grey JA, Winstanley RB, Johnson A, A
Clinical Overview of Removable Prostheses: 1.
Factors to Consider in Planning a Removable Partial
Denture, Dent Update 2002; 29: 376-381
122

9. McCord JF, Grey JA, Winstanley RB, Johnson A, A Clinical
Overview of Removable Prostheses: 5. Diagnosis and
Treatment of RPD Problems, Dent Update 2003;30:88-97.
10. Gamer et al, M. M. House mental classification revisited:
Intersection of particular patient types and particular dentist’s
needs, J Prosthet Dent 2003;89:297-302.
11. Steffel VL, Planning removable partial dentures, J. Pros Den
May-June 1962;12(3).
12. McCraken WL, Differential diagnosis: fixed or removable
partial dentures, JADA Dec 1961;63.
123

13. Akerly, W. B., Prosthodontic treatment of traumatic
overlap of the anterior teeth. The Journal of
Prosthetic Dentistry, 1977;38(1), 26–34.
14. Shafer’s – Textbook of oral pathology, 7th edition,
Elsevier 2014.
124

125
“Planning without action is futile, action
without planning is fatal.”
- Cornelius Fichtner

Diagnosis and Treatment Planning of Removable Partial Denture

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Diagnosis and Treatment Planning of Removable Partial Denture

Similar to Diagnosis and Treatment Planning of Removable Partial Denture (20)

More from Dr. Vanshree Sorathia

More from Dr. Vanshree Sorathia (9)

Recently uploaded

Recently uploaded (20)

Diagnosis and Treatment Planning of Removable Partial Denture