DIAGNOSIS AND TREATMENT PLANNING FOR REMOVABLE PARTIAL DENTURES

Introduction 1) The restoration of partially edentulous mouth presents the challenge to re-establish masticatory efficiency, esthetics and comfort in a manner which will promote and perpetuate oral health. 2) As the remaining teeth and edentulous ridges have to sustain greater stress than that intended by nature, the preservation of these tissues is one of the permanent objectives. ) !any of the dentures which are planned to give lengthy service become temporary appliances because important biomechanical factors were ignored during planning. ") #f the relationship between the biologic behaviour of the oral structures and the mechanical influence of the denture is not recogni$ed, the denture often contribute towards rapid

disintegration of tissues. %) A successful partial denture cannot be produced by the s&illful application of techni'ue alone. #t must be conceived and

constructed upon the &nowledge of oral and dental anatomy, biology, histology, pathology, physics and their allied sciences if the oral tissues are to be preserved. () )efore any rehabilitation procedures are attempted, pertinent information must be gathered to provide the evidence necessary to arrive at an accurate diagnosis and develop a round treatment plan. OBJECTIVES OF PROSTHODONTIC TREATMENT i) ) ) *limination of disease

+atients who see& treatment are only concerned with replacement of missing teeth. The dentists primary obligation to the patient is to emphasi$e the importance of restoring the mouth to a total state of health. The e,tent to which lost function can be restored depends on tissue tolerance of the individual, as influenced by age, general health and health of oral tissues.

#n order to fulfill these objectives, the diagnosis and treatment planning should follow a particular se'uence. ORAL EXAMINATION #t should be complete and include, -isual and digital e,amination of teeth and surrounding tissues. *,amination with mouth mirror, e,plorer and a periodontal probe. A complete intraoral roentgenographic survey. -itality test of critical teeth. *,amination of casts correctly oriented on an adjustable articulator. Se uence o! or"# e$"%in"tion 1. -isual e,amination. #t will reveal many of the signs of dental disease, consideration of caries susceptibility is of primary importance. The number of restored teeth present, signs of recurrent caries and evidence of decalcification should be noted. /nly those patients who demonstrate good oral hygiene and low caries susceptibility may be considered as good ris&s for partial

denture treatment. /therwise prophylactic measures such as crowning of abutment teeth have to be though of evidence of periodontal disease, inflammation of gingival areas and degree of gingival recession should be observed. 0epths of periodontal poc&ets should be determined and teeth mobility by digital e,amination. /ne should &eep in mind that the e,tent of damage to the supporting structures by periodontal disease can e,actly be determined only by roentgenographic interpretation. The number of teeth remaining, the location of edentulous areas and the 'uality of residual ridge will have a definite bearing on the proportionate amount of support that the partial denture will receive from teeth and edentulous areas. +alpation can indicate the nature of supporting bone that has been resorbed and replaced by displaceable fibrous connective tissue. This is common in ma,illary tuberosity regions. 1emovable partial dentures cannot be supported ade'uately by tissue that are easily displaced. These tissues must be treated non surgically or surgically. The presence of tori or other e,ostoses must be detected. The difference in displaceability of soft tissues covering midpalatal

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raphae and soft tissues covering residual ridges must be determined. #f not it will lead to a roc&ing, unstable uncomfortable denture. Ade'uate relief of palatal major connectors must be planned. 2. 1elief of pain and discomfort and placement of temporary restorations. #t is advisable not only to relieve discomfort arising from tooth defects but also to determine as early as possible the e,tent of caries and to arrest further caries activity until definite treatment can be instituted. )y restoring tooth contours with temporary restorations, the impression will not be torn on removal from the mouth and a more accurate diagnostic cast may be obtained. . 2omplete intraoral roentgenographic survey The objectives of roentgenographic e,aminations are. a) To locate areas of infection and other pathoses. b) c) d)

". A thorough and complete oral prophyla,is An ade'uate e,amination can be accomplished best with the teeth free of accumulated calculus and debris. Accurate diagnostic casts can also be obtained only if the teeth are clean. 2ursory e,amination may precede an oral prophyla,is, but a complete oral e,amination should be deferred until the teeth have been thoroughly cleaned. %. *,ploration of teeth and investing structures They are e,plored by instruments and digital e,amination. /cclusal relationships and tooth mobility have to be determined. A situation that loo&s simple when the teeth are apart may be complicated when the teeth are in occlusion. *.g.. e,trusion of a tooth or teeth into an opposing edentulous area may complicate the replacement of teeth in the edentulous area or it may create cuspal interference. 3istory and diagnostic charts should be filled out at this time.

(. -itality tests of remaining teeth #t should be carried out particularly on teeth to be used as abutments and on those having deep restorations or deep carious lesions. This may be done either by thermal or electrical means. DIAGNOSTIC CASTS #t should be an accurate reproduction of the teeth and adjacent tissues. The impression for the diagnostic cast is usually made with an irreversible hydrocolloid in a perforated impression tray. The diagnostic cast should be made of dental stone because of its strength and the fact that it is less easily abraded than dental plaster. Mountin& Di"&no'tic C"'t' Although some diagnostic casts may be occluded by hard, occlusal analysis is much better accomplished when casts are mounted on a semiadjustable or adjustable articulator. The casts have to be mounted in relation to the a,is orbital plane to interpret plane of occlusion in relation to hori$ontal plane. The facebow is a relatively simple device used for orienting the ma,illa. The

addition of an adjustable infraorbital pointer on the facebow and the addition of an orbital plane indicator to the articulator ma&es possible the transfer of cast in relation to a,is orbital plane. This permits to orient the ma,illary cast on the articulator in the same comfortable relationship of the ma,illa to the 5ran&fort plane on the patient. A facebow used to transfer the arbitrary hinge a,is is termed the arbitrary face bow and the one used to transfer true hinge a,is is termed &inematic face bow. An occlusal rim has to be used in face-bow transfer procedures involving 2lass # and ## partially edentulous situations. J"( re#"tion')i* record' !or di"&no'tic c"'t' /ne of the first critical decisions to be made in a removable partial denture service involves the selection of hori$ontal jaw relationship 6centric relation or ma,imum intercuspal position). All mouth preparation procedures depend on this relationship. #f most natural posterior teeth remain and there is no evidence of T!7 disturbances, neuromuscular dysfunction or deflective occlusal contacts, the proposed restoration may safely be fabricated with ma,imum intercuspation of remaining teeth.

9hen most of the natural centric stops 6posterior teeth) are missing, the restoration should be fabricated so that ma,imum intercuspal position is in harmony with centric relation. The centric relation position is recorded by the use of an interocclusal medium without bringing the teeth into contact. Tooth contact is not allowed because malaligned teeth or interfering cusps tend to guide the mandible out of centric relation, displacing the heads of the condyles from their proper positions in the glenoid fossae. Pur*o'e' o! di"&no'tic c"'t' 1. They are used to supplement oral e,amination by permitting a view of the occlusion from lingual as well as buccal aspect. The degree of overclosure, the amount of interocclusal space needed and the possibilities of interference to location of rests may also be noted sometimes, the mandibular anterior teeth are on a higher plane compared to mandibular posterior teeth. This is a disturbing condition and a destructive process is unavoidable with advancing age. #n some caries, an increase in vertical height of lower posterior teeth can be induced by placing an occlusal splint in the palate with occlusal contact available only in the anterior area. :ood results are obtained by constantly wearing such an appliance over a limited period of time. These patients must be
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followed carefully to establish the correct intercuspation of opposing teeth. 2. 3armonious occlusal plane and curve of spee The loss of one or more teeth without immediate replacement results in loss of contact between the appro,imating teeth within the arch and an elongation of teeth in the opposing arch. Treatment planning in such cases is complicated by a lac& of harmony of the curve of spee and occlusal plane with the path of movement of the T!7. The path of movement of the condyle is fi,ed whereas the cusp rise in the anterior part of the segment can be reconstructed by the dentist to aid in establishing a harmonious intercuspation of the posterior teeth. The procedure is to have the study casts mounted on an adjustable articulator with correct condylar settings for both centric and eccentric functional positions. Then with inlay wa,, build the teeth of the study casts to the contour that will produce balanced occlusion throughout functional e,cursions. The dentist can then determine the teeth that will need a decrease or an increase in vertical dimension and cusp rise necessary to create a curve of spee and a plane of occlusion for posterior 'uadrants.

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. 0iagnostic casts permit a topographic survey of the dental arch that is to be restored by means of a removable partial denture. The cast in 'uestion may be surveyed to determine the parallelism or lac& of parallelism of tooth surfaces involved to establish their influence on the design of the partial denture. The need to study parallelism of tooth and tissue surface of each dental arch is to determine. a) +ro,imal tooth surfaces which can be made parallel to serve as guiding planes. b) 1etentive and non-retentive areas of abutment teeth. c) Areas of interference to placement and removal from such a survey a path of placement may be selected that will satisfy the re'uirements of parallelism and retention to the best mechanical, functional and esthetic advantage. ". 0iagnostic casts can be used to ma&e the patient understand regarding the present and future restorative needs. /ccluded or individual diagnostic casts can be used to point out. a) *vidence of tooth migration, b) effects of further tooth migration, c) 3a$ards of traumatic occlusal contacts.

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%. 0iagnostic casts may be used as a constant reference as the wor& progress. +enicilled mar&s indicating the type of restorations. The areas of tooth surfaces to be modified, the location of rests and the design of partial denture framewor&, as well as path of placement and removal, all may be recorded on the diagnostic cast. (. #ndividual impression trays may be fabricated on diagnostic casts for ma&ing final impression. This is fabricated on the duplicate diagnostic cast after wa, bloc&out. INTERPRETATION OF EXAMINATION DATA Roent&eno&r"*)ic inter*ret"tion 1adiographic interpretation most pertinent to partial denture construction are those relative to prognosis of remaining teeth that may be used as abutments. The 'uality of the alveolar support of an abutment tooth is of prime importance because the tooth will have to withstand greater stress loads when supporting a dental prosthesis, especially greater hori$ontal forces. Abutment teeth adjacent to distal e,tension bases are subjected not only to vertical and hori$ontal forces but to tor'ue as well.

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V"#ue o! inter*retin& +one den'it, The 'uality and 'uantity of bone in any part of the body is often evaluated by roentgenographic means. #t is essential to emphasi$e that changes in bone calcification upto 2%- <= cannot be recogni$ed by ordinary roentgenographic means. >o the dentist should reali$e that roentgenographic evidence shows the results of changes that have ta&en place and may not necessarily represent the present condition. ?ormally the interradicular trabecular spaces usually tend to decrease in si$e as the e,amination of bone is proceeded from root ape, towards coronal portion. The normal interpro,imal crest is ordinarily shown by a thin white line crossing from lamina dura of one tooth to the adjacent tooth. ?ormal bone usually responds favourably to ordinary stresses. Abnormal stresses may create a reduction in the si$e of the trabecular pattern particularly in that area of bone directly adjacent to the lamina dura of affected tooth. This decrease in si$e of the trabecular pattern is regarded as bone-condensation which is an improvement in bone 'uality.

An increased thic&ness of periodontal space ordinarily suggests varying degrees of tooth mobility. >uch teeth have to be evaluated clinically. @-ray evidence plus clinical findings may suggest the inadvisability of using such a tooth as an abutment. 1ounding off of the intercrestal bone is the first evidence of periodontal disease. The level of the bony crest is considered normal when it is within 1.%mm from the 2*7 of the adjacent teeth. Teeth that have been subjected to abnormal bonding because of loss of adjacent teeth or teeth that have withstand tipping forces in addition to occlusal loading may be better ris&s as abutment teeth than those that have not been called on to carry an e,tra occlusal load. #f occlusal harmony can be improved and unfavourable forces minimi$ed such teeth may be e,pected to support the prosthesis without difficulty. The reaction of bone to additional stresses may be positive or negative. A positive response is indicated by a heavy trabecular pattern and dense lamina dura. ?egative response is the reverse. 1oot morphology. !orphologic characteristics of the roots determine to a great e,tent to ability of the abutment teeth to resist successfully additional rotational forces that may be placed on them. Teeth with multiple and divergent roots will resist stresses better than teeth with fused and conical roots since the resultant forces are distributed through

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a greater number of periodontal fibres to a larger amount of supporting bone. PERIODONTAL CONSIDERATIONS /ne must evaluate the condition of the gingiva, loo&ing for ade'uate $ones of attached gingiva as well as presence or absence of poc&ets. #f mucogingival involvements, osseous defects or mobility patterns are recorded, the causes and potential treatment must be determined. /ral hygiene habits. *fforts must be made to educate the patient relative to pla'ue control. The patient must be advised of importance of regular maintenance appointments after reconstruction. 2aries activity. The past and present caries activity must be determined and need for protective restorations may be considered. The decision to use full coverage is based on the age of the patient, evidence of caries activity and patientAs oral hygiene habits. 3igh and fre'uent consumption of sugars can lead to root caries, caries around restorations or clasps of partial dentures. *,cellent protection from caries can be provided by fluoride applications.

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?eed for surgery or e,tractions. :rossly displaceable soft tissues covering basal seat and hyperplastic tissues should be removed to provide a firm denture foundation. !andibular tori should be removed if they will interfere with optimum location of lingual bar connector or a favourable path of placement. *,traction of teeth may be indicated for one of the following reasons. 1) #f the tooth cannot be restored to a state of health. 2) Teeth in e,treme malposition may be removed. An e,ception to the removal of a malposed tooth would be when a distal e,tension basal have to be made rather than a more desirable tooth supported base. #f alveolar support is ade'uate, a posterior tooth should be retained. ) A tooth should be e,tracted if it is unesthetically located and if the e,traction of the same would improve appearance.

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DIFFERENTIAL DIAGNOSIS - FIXED OR REMOVABLE PARTIALD ENTURES Indic"tion' !or !i$ed re'tor"tion' 1) Tooth bound edentulous regions. Any edentulous space 6short span) bounded by teeth suitable for use as abutments should be restored with a fi,ed partial denture. 2) Additional modification spaces in 2lass ### modification 1 situation. A removable partial denture is better supported and stabili$ed when a modification area on the opposite side of the arch is present such an edentulous area need not be restored by a fi,ed dentures. Additional modification spaces particularly those involving single missing teeth are better restored separately by means of fi,ed dentures. )y doing so the denture is made less complicated by not having to include other abutment teeth for support and retention. The teeter-tetter effect of the denture is also avoided. 9hen an edentulous space e,ists anterior to a bone-standing abutment tooth, this tooth is subjected to trauma by movements of distal e,tension partial denture far in e,cess of its ability to withstand such

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stresses. The splinting of the line abutment to the nearest tooth is mandatory. >plinting is best accomplished in such a situation by means of a fi,ed partial denture uniting two teeth on either side of the edentulous space. The abutment crowns should be contoured for retention and support of the partial denture. Indic"tion' !or re%o."+#e *"rti"# denture' Although a removable partial denture should be considered only when a fi,ed restoration is contraindicated, there are several specific indications for the use of a removable restoration. 1) Bong span. A long edentulous span would have abutment teeth which cannot bear the trauma of hori$ontal and diagonal occlusal forces. Also because of ridge resorption, the pontics may have to be placed in e,treme labial inclination for lip support. #n such cases a removable partial denture which provides favourable esthetics and cross arch stabili$ation is indicated. 2) ?eed for effect of bilateral stabili$ation. #n a mouth wea&ened by periodontal disease, a fi,ed restoration may jeopardi$e the future of involved abutment teeth. The removable partial denture on the other hand may act as a periodontal splint through its effective cross-arch stabili$ation of teeth wea&ened by periodontal disease.

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) *,cessive loss of bone in posterior area. The pontic of a fi,ed partial denture must be related to the residual ridge in such a manner that the occlusal contact with the mucosa is gentle. 9henever e,cessive resorption has occurred, teeth supported by a denture base may be arranged in a more acceptable bucco-lingual position than is possible with a fi,ed partial denture. ") 9here a future change in denture design is anticipated. #f the prognosis of an abutment tooth is 'uestionable or if it becomes unfavourable while under treatment. #t might be possible to compensate for its impending loss by a change in denture design. %) 0istal e,tension caries. CHOICE BET/EEN COMPLETE DENTURE AND

REMOVABLE PARTIAL DENTURE The loss of remaining teeth can be terrible psychologic shoc& to patients. The dentist should e,plore every possibility of saving them. 1) #n most instances it may be more desirable for the patient to retain loose or bro&en teeth. #n other patients it may be that their health can be improved if remaining teeth are removed.

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2) The age of the patient can be a factor. #f the patient is young and bone is not fully calcified, the remaining teeth should probably be saved. ) Bimitations of ma,illary removable partial denture . when ade'uate interridge space and sufficient number of healthy natural teeth are available in strategic-locations, the prognosis for a removable partial denture is highly favourable. These conditions are not always present. #nterridge space is reduced by mandibular teeth which have e,tended above the plane of occlusion. An increase in vertical dimension is not possible as it has not been altered. #f the remaining ma,illary teeth are e,tracted,

biomechanical problem is created by distal e,tension bases. :ravity magnified by leverage becomes a major antiretentive factor. The crown contours of ma, canines do not provide undercuts for clasp retention and lingual surfaces are not suitable for rest preparation, space for rest on lingual surface is lac&ing because of opposing mandibular teeth 6deep bite).

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2rowning of the tooth to create a usable retentive undercut and to provide cingulum rest re'uires a labial veneer for cosmatic reasons 6Adds to the cost of restorations).

#f ma,illary canines must be used as abutments, a clasp arm and denture flange are often prominently displayed at the corner of the mouth.

MAXILLAR0 COMPLETE DENTURES have many advantages over removable partial dentures in such a situation. 2entric occlusion and centric relation can be made to coincide at proper vertical relation. A deep vertical overlap of anterior teeth can be reduced and a hori$ontal overlap modified. Cnesthetic appearance of clasp arms and denture flanges can be avoided. ?eed to grind natural teeth to create rest seats is eliminated. Thus prognosis is improved for all remaining teeth and supporting bone.

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