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Diagnosis of partially edentulous patients

Dr. Mostafa Ibrahim Fayad


Lecture of Removable Prothodontics Al-Azhar University British University Dr.mostafa.fayad@gmail.com

Indications for a removable partial denture in preference to a fixed partial denture


A. B. C. D. Edentulous areas too long for a fixed prosthesis. Need to restore soft and hard tissue contours. Absence of adequate periodontal support. Structurally or anatomically compromised abutment teeth.
1. 2. 3. Lack of clinical crown height. Lack of sound tooth structure. Unfavorable position, contour or inclination.

E. F. G. 1.

Need for cross-arch stabilization. Restoration of an extension base. Anterior esthetics. Attitude and desires of patient.

Diagnosis:
It is the determination of the nature, location, and causes of diseases.

To assemble all appropriate information about the patients medical and dental history and conduct clinical examination including evidence from radiographs and mounted diagnostic casts to

achieve good prognosis

Diagnosis of partially edentulous pt. includes:


Patient History. Clinical examination ( Extraoral and Intraoral) Radiographs Mounted Diagnostic Casts Occlusal plane analysis. Surveying of the diagnostic cast. Pre-extraction record.

Treatment plan.

1. Patient history
Personal and Social history. Chief complaints Medical history. Dental history. Mental attitudes

Personal and Social history.


Name - Address - Tel. N0 Age - Sex Occupation and Socio-economic Class Public speakers and singers Wind instrument players Psychological conditions

Chief complaints
Reason for attendance (Patient's requests and desires).

Medical history.
Diabetes Arthritis Pagets disease Acromegaly Parkinsons disease Pemphigus vulgaris Epilepsy Cardiovascular diseases Cancer Transmissible diseases

1. Smoking
has been known to be associated with a variety of oral conditions including: Periodontal disease. Bone & tooth loss. Peri-implantitis. Dental implant failure. The effect of tobacoo is due to: 1. resistance to inflammation. 2. resistance to infection. 3. Impaired wound healing. 4. Calcium absorption.

. Patients who are unable to sustain a high level of plaque control e.g Parkinsonism

Dental history.
The cause of teeth loss Patient' experience during and following previous partial denture construction. Expectation of treatment: Chewing habits: preferred side for chewing. This will determine the amount of support, retention and bracing of the denture on each side. Para functional habits: clinching and bruxism.

Mental attitudes
House's Classification Based on patients mental attitude,

philosophical patients. (Well adjusted and easygoing) Exacting patients. (Precise in everything they do) Hysterical patients. (Are emotionally unstable and convinced that they will never be able to wear a prosthesis) Indifferent patients. (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the examination?

PATIENT EVALUATION
EXTRAORAL EXAMINATION INTRAORAL EXAMINATION

PATIENT EVALUATION

Gait Complexion and Personality Cosmetic Index

II-Clinical Examination
Extra oral
Facial Examination TMJ Examination

Intra-oral
Visual Examination Digital Examination

Radiographic Examination

Extra oral Examination


A- Facial Examination

Front View
Angle of the mentolabial Sulcus

Profile View
Size - Form Shape of the face Juvenile Appearance of the patient

Vertical dimension of old denture wearers

Extra oral Examination


B- TMJ Examination
Clinical Interpretation
DigitalExam.

Radiographic Interpre.

Panoramic Corrected Cephalometric Clicking or Pop sounds Tomography on jaw Opening Transcranial Radiography Computerized Tomography MRI

EXTRAORAL EXAMINATION
Facial examination:
Facial Form Facial Features

Lip Examination TMJ Examination Neuromuscular Examination

Intra oral exam

Intra Oral Examination


For Partially Edent. pt

A- Visual Examination
Edentulous Area
Colour- Contour-Ridge Relationship -Tongue ToriUndercutThroat formSaliva- Frena Att.

Remainimg Natural Teeth


N0 - Form-Location-CariesExisting RestorationPeriodontium-PositionsOcclusion.

Intra Oral Examination


B- Digital Examination
Edentulous Area
Firmness -IrregularitiesTongue- Tuberosities- Slope of Retrom.Pad- Mylohyoid RidgeLingual Pouch-Painful Areas.

Remainimg Natural Teeth Vitality test- Percussion

Mobility- pocket
Evaluation

The following should be examined


1-Oral Hygiene 2-Carious lesions and existing restorations 3-Evaluation of the periodontium 4-Tooth mobility 5-Sensitivity to percussions 6- vitality tests of individual teeth 7- Atrition 8- Occlusion 9. Ridge Morphology 10- Arch form 11- Interarch space 12-Evaluation of the space for the mandibular major connector 13. Maxillo-mandibular relationship 14-Para-functional habits 15-Mouth opening 16- Oral mucosa 17- Hard tissue abnormalities 18- Soft tissue abnormalities 19- Occlusal relationships 20- Temporomandibular joint (TMJ) examination 21- Quality and quantity of saliva 22-Tounge size and mobility 23- Examination of old denture

1-Oral hygiene of the patient


The ultimate success of dental treatment relies on the home care of the patient as well as the technical procedures performed by the dentist

Oral Hygiene
The patient must have a high standard of plaque control .

2-Carious lesions and existing restorations


Any caries should be restored prior to PD fabrication. Patient with caries index should have the abutment teeth crowned. Existing restoration should be examined : o whether rest will be all on amalgam or partly on amalgam and tooth structure. o Amalgam or composit on labial or buccal surface are liable to wear by action of retentive clasp arm.

3-Evaluation of the periodontium


Examination findings that indicate the need for PL treatment includes: Gingivitis. Pocket depth in excess of 3 mm. Calculous deposits. Furcation involvement. Marginal exudate upon probing or application of digital pressure.

4-Tooth mobility
Causes: Trauma from occlusion (usually reversible). Inflammation in PL (usually reversible). Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is questionable!!!! So many clinicians prefer to use a mobile tooth as an overdenture abutment

5-Sensitivity to percussions
All remaining teeth should be tested for sensitivity to percussion Possible causes: 1. Tooth in traumatic occlusion. 2. Periapical or pulpal abscess. 3. Periodontitis. 4. Cracked tooth.

The cause must be identified and treated before partial denture construction

6- vitality tests of individual teeth

Loss of teeth drifting and migration


deflective occlusal contact increased muscular response bruxism and excessive tooth wear

7-Attrition

Types of wear
1. Attritional wear (due to rubbing of opposing teeth). 2. Wear from erosion. Carbonated beverages (Coke-Swishing). Amalgam restoration will be raised above the eroded surface. GERD. Most pronounced on the lingual surface of molars (depends on the patients sleeping position) Regurgitation (Self induced projectile vomiting ) mostly wear appears in the upper anterior segment Bulemia. 3. Abrasive wear (tobacco chewers and toothpaste abuse)

A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
The VDO is maintained even when rapid abrasive wear occurs. As the occlusal surface of teeth wear, the dento alveolar process elongates by progressive remodeling of the alveolar bone

!!!!!!!

Actually loss of VDO occurs in 2 situations:


1. Severe bruxism aggressive bruxers can destroy tooth structure at a greater rate than extrusion can compensate for. large number of teeth are lost remaining teeth and supporting (alveolar) bone are unable to withstand even normal biting forces, and begin to tip sideways, resulting in over-closure of the jaws (collapsed bite).

2.

8- Occlusion
A situation that looks simple when the teeth are apart may be complicated when the teeth are in occlusion.

Occlusion is better evaluated on a mounted diagnostic casts.

9. Ridge Morphology
Ridge morphology will give an indication about the bone available and the need for augmentation

10. Arch form


It is either ovoid, tapered or square.

11-Interarch space
For fixed restorations 7 mm in the posterior region and 8-10 in the anterior region. For removable restoration at least 12 mm. An increased space is not a problem in removable restoration but is a problem in fixed due to increased crown height lateral forces on the implant increased failure rate.

Management of inadequate interarch space:


Excessive interarch space: Onlay bone graft may be used before implant placement to decrease the interarch space if fixed restoration is to be made. Decreased interarch space: Treatment of the overerrupted opposing teeth. If opposing teeth are adequate. Osteoplasty and/or soft tissue reduction of the implant region is made.

12-Evaluation of the space for the mandibular major connector


A minimum of 8 mm vertical space must be available if a lingual bar major connector is planned. It is measured using a periodontal probe. The space will determine the type of major connector to be used

13. Maxillo-mandibular relationship


Arch relationship often concern implant placement in the anterior regions of the mandible and maxilla. In cases of Angle class III cases it is anticipated that maxillary implants are placed more lingual than the original incisal tooth position which will compromise esthetics, speech and function. This will require overcontouring of the final restoration to place the incisal 2/3 in an ideal position cantilever force on the implant. Management: use of additional implants and Increase the anteroposterior distance between implants to compensate for the increased load on the implant specially in mandibular excursion.

In case of angle class II cases: Managed by anterior cantilever on implants in the mandibular arch but this requires: Increase number of implants. Increase in the anteroposterior distance between implants

14-Para-functional habits
Bruxusm. Clenching. Tongue thrust.

Bruxism It is the vertical and horizontal non


functional grinding of teeth.

Clenching It is the force exerted from one occlusal


surface to the other without any movement.

Parafunctional tongue thrust Is the


unnatural force of the tongue against the teeth during swallowing.

15-Mouth opening

Tongue Position
Normal tongue positions Retracted or awkward tongue positions

23-Examination of old denture:


a- the design and quality of construction should be noted Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces. evaluate whether the denture is still fit accurately against the teeth and under lying mucosa or not

4. Radiographic examination

1. Caires
Clinical findings must be correlated with radiographic examination to reveal: Severity and extent of caires. Number of lesions.

2-Presence of root fragments


If roots are deeply embedded and has no evidence of pathologic changes, it is advisable to keep them under observation rather than to remove it to avoid excessive bone removal.

3- Root canal filling


An abutment tooth with inadequate root canal filling must be retreated. Not all periapical radiolucencies related to a root canal filling is a pathological condition. It may be fibrous healing. So it must be correlated with the clinical finding.

4-Locate areas if infection

5-Lamina dura
Resorption of LD occurs where there is pressure and apposition occurs when there is tension. Loss of lamina dura may be due to: 1. Systemic disorders as hyperparathyrodism or Pagets disease. 2. Excessive pressure on the tooth. Thickening of lamina dura may be due to: The tooth is under heavy function and the patient has high resistance.

The cause of change in the lamina dura must be corrected or the abutment will have poor prognosis

6- The quality of alveolar support


Abutment teeth providing support to a prosthesis will have to withstand greater load specially in a horizontal direction so it must have good bone support. If the C/R ratio is 1:1 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas


Index areas are those areas of bone that disclose the reactions of bone to additional stresses Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response Although it is a favorable bone response, the excessive stresses must be relieved because at any time if the patients resistance is decreased bone resorption may occur

If the bone responds to extra loading by increasing bone density the patient is said to have +ve bone factor and vice versa

8-Periodontal ligament space


Thickness of lamina dura with widening of the periodontal ligament space indicates:
Mobility Occlusal trauma Heavy function

If the tooth is not mobile this signs may indicate a favourable response to heavy occlusal forces. So we predict that this tooth will have a good prognosis as a PD abutment

9-Root length, size and form


Teeth with long, multiple and divergent roots will resist stresses better than teeth with fused and conical roots because the resultant forces are distributed through a greater number of periodontal fibers to a larger amount of supporting bone

10-Proximity of roots
If the roots of adjacent teeth are in close proximity and display little interproximal bone, moderate irritation or forces may be destructive. So additional abutment must be used to support the PD

11-Third molar
If its size, shape and position appears favorable, it should be retained to avoid a free end saddle condition.

5-Evalation of the mounted diagnostic casts

The diagnostic casts should be mounted on a semiadjustable articulator with:


Face bow transfer. Centric relation record at the correct vertical dimension. Protrusive and lateral records.

1-Interarch distance
Loss of interarch space is frequently caused by a large maxillary tuberosity. A segment of teeth that has been unopposed for a prolonged period will overerrupt carrying the alveolar process with it. Subsequent removal of these teeth will produce a situation in which it is impossible to establish an acceptable occlusal plane.

Surgical correction

2- Diagnostic surveying
To determine: 1. Parallelism or lack of parallelism of tooth surface involved . 2. Areas of interferences to path of placement and removal. 3. Esthetic effects of the selected path of insertion.

3-0cclusal plane
Most partially edentulous pts. have occlusal interferences due to drifting and migration of natural teeth which require occlusal equilibration.

Treatment of irregular occlusal plane Treatment ranges from simple enameloplasty

1. 2. 3. 4. 5.

extraction of the tooth. If a single tooth is overerupted it may be treated by: Simple enameloplasty if overerruption is within 2 mm. Reduction and crowning if dentine will be exposed. RCT, reduction and crowning. RCT and reduction of the tooth to be used as an overdenture abutment. in severe overeruption it may be necessary to remove the tooth and recontour the surrounding bone.

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Treatment of malpositioned occlusal plane


Extrusion of an unopposed segment of teeth usually occurs with downward growth of the associated alveolar process causing obvious space problem malposition of the occlusal plane

Orthognathic surgery (Anterior or posterior segment osteotomy(

Tipped or malposed teeth


May occur if an edentulous space is present mesial to a posterior tooth. it may be: 1. Orthodontically repositioned. 2. Adjusted with a crown. 3. Onlay rest.

5.Occlusal equilibriation

Occlusal equilibration is

the selective grinding or occlusal reshaping of teeth to eliminate premature or deflective occlusal contacts that interfere with the physiologic function of the TMJ.

Clinically: 1. Wear facets. 2. Tooth mobility. 3. Muscle spasm, pain and TMD Radiographically: 1. Widening in the periodontal membrane space. 2. Periapical radiolucency. 3. Bone condensation. 4. Bone resorption. 5. Root resorption.

Occlusal interferences is manifested as follows:

Areas of interferences are detected either:


Manually : 1. Ribbons. 2. Marking papers. 3. Waxes. 4. Pastes, sprays and paint-on materials. Computer assisted analysis: E.G: T-scan

The T-Scan III uses a sensor that record occlusal contacts on a thin film and relays the information to a computer to obtains the actual occlusal contact time and force data for each tooth and graphically illustrate it.

T-scan III

Diagnostic equilibriation
Occlusal equilibration should be first made on accurately mounted diagnostic cast, and all steps should be recorded then duplicated in the patient mouth.

when do we decide to treat a partially edentulous patient at centric relation or maximum intercuspal position?

The following situations suggest that prosthesis should be constructed at centric relation: 1. Coincidence of CR and CO. 2. Absence of posterior teeth contact. 3. When all posterior teeth contact are to be made by fixed restoration. 4. Few remaining posterior contacts. 5. Clinical symptoms of occlusal trauma (TMJ disorder)

Examination of the articulated study casts

Importance of the study casts:


Evaluate several prosthodontic criteria in the absence of the patient. Evaluate the current occlusion. The relationship of the edentulous area to the adjacent natural teeth and opposing arch. Position of the potential natural abutments, parellelism and esthetic considerations.

Number of missing teeth. Inter-arch space analysis. -Perform wax up and surgical template. -Perform the provisional prosthesis. -Ridge mapping. -Future comparison.

Proper Diagnosis is the Key of Best Prognosis


Adjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support -Tissue Conditioning -Nutritional Counseling Prosthodontic Care

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