diagnosis and treatment planning for partially edentulous patients11

8/18/2019 Diagnosis and Treatment Planning for Partially Edentulous Patients11

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Diagnosis AndDiagnosis And

Treatment Planning forTreatment Planning forPartially EdentulousPartially Edentulous

PatientsPatients Guided by:Guided by:

Dr.NidhiDr.Nidhi

DuggalDuggal

Presented By:-Presented By:-

Kanika aitlyKanika aitly

P.G.P.G.

se!ond yearse!ond year


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"ontent:"ontent:

General information (name, age, sex,General information (name, age, sex,occupation)occupation)

Chief complaintChief complaint

Recording the relevant medical history.Recording the relevant medical history.Recording the relevant dental history.Recording the relevant dental history.

Performing a thorough visual and manualPerforming a thorough visual and manual

extra-oral and intra-oral examination.extra-oral and intra-oral examination.Radiographic examination.Radiographic examination.

Treatment planning Treatment planning


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Who is a partially edentulous orWho is a partially edentulous or

potentially edentulous patient?potentially edentulous patient? AA #artially edentulous#artially edentulous

#atient#atient is one $ho hasis one $ho has

su%ered a #artial losssu%ered a #artial loss

of the natural dentition&of the natural dentition&

$ith some healthy teeth$ith some healthy teeth

remaining in one orremaining in one or

both the ar!hesboth the ar!hes..

e.g. patient !ithe.g. patient !ith Restored teethRestored teeth

de"uate inter- ridgede"uate interridge

distance.distance.

#niform occlusal plane.#niform occlusal plane.

$iscrepancies correcta%le %y$iscrepancies correcta%le %y

mouth preparation.mouth preparation.

33


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AA #otentially edentulous#otentially edentulous

#atient#atient is one $hoseis one $hose!onditions of remaining all!onditions of remaining all

or fe$ teeth ' theiror fe$ teeth ' their

su##orting #eriodontium issu##orting #eriodontium is

su!h that it $arrants asu!h that it $arrants a

total balan!e situation .total balan!e situation .

e.g. patient !ithe.g. patient !ith Grossly carious remainingGrossly carious remaining

teeth !ith multiple rootteeth !ith multiple root

stumps.stumps.

Chronic periodontitis !ithChronic periodontitis !ith

multiple mo%ile teeth &multiple mo%ile teeth &generali'ed %one loss.generali'ed %one loss.

Gross occlusal disharmonyGross occlusal disharmony

44


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A patient is often renderedA patient is often rendered

partially edentulous due to loss of one or morepartially edentulous due to loss of one or moreteeth due to:teeth due to: Failure to maintain oral hygiene & plaque-control measuresFailure to maintain oral hygiene & plaque-control measures TraumaTrauma

Parafunctional habitsParafunctional habits Congenitally missing teethCongenitally missing teeth

55


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Effects of partial edentulismEffects of partial edentulism

sthetic alterationsthetic alteration

Tipping & migration of remaining teeth Tipping & migration of remaining teeth

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xtrusion of opposing teeth in the edentulous space.xtrusion of opposing teeth in the edentulous space.

andi%ular deviationandi%ular deviation

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*oss of facial support*oss of facial support

+hortening of face height & overclosure+hortening of face height & overclosure

*oss of alveolar %one*oss of alveolar %one

Reduced masticatory eciencyReduced masticatory eciency

$ecreased self esteem$ecreased self esteem

ltered speechltered speech*oss of maxillary anterior teeth may prevent the clear*oss of maxillary anterior teeth may prevent the clear

reproduction of certain sounds, particularly the / and 0/. Thereproduction of certain sounds, particularly the / and 0/. The

replacement of missing maxillary anterior teeth !ill ma1e areplacement of missing maxillary anterior teeth !ill ma1e a

signi2cant contri%ution to the "uality of speechsigni2cant contri%ution to the "uality of speech..

88


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Aims of iagnosis & treatmentAims of iagnosis & treatment

planningplanning To assess the To assess the disease statusdisease status of the patientof the patient

General3medical statusGeneral3medical status

$ental status$ental status

To evaluate the To evaluate the e%e!t of systemi! !onditionse%e!t of systemi! !onditions on theon thesu!!ess of treatment(#rosthesis.su!!ess of treatment(#rosthesis.

To To anti!i#ate #otential di)!ultiesanti!i#ate #otential di)!ulties !hich may %e!hich may %e

encountered during treatment.encountered during treatment.

To To anti!i#ate the #rognosisanti!i#ate the #rognosis of the treatment orof the treatment or

prosthesis.prosthesis.

To explain the To explain the #ossible treatment strategies& the#ossible treatment strategies& the

limitations and result to the #atientlimitations and result to the #atient to gain histo gain his

cooperation and con2dencecooperation and con2dence

4eed for4eed for alteration of treatment #lanalteration of treatment #lan to serve theto serve the

patient %etter.patient %etter.99


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!"#ECT$%E !F P'!T(!!)T$C!"#ECT$%E !F P'!T(!!)T$C

T'EAT*E)T F!' A PA'T$A++,T'EAT*E)T F!' A PA'T$A++,EE)T+! PAT$E)T EE)T+! PAT$E)T Muller De Van stated “ The perpetual preservation of whatMuller De Van stated “ The perpetual preservation of what

remains is more important than the meticulous replacement ofremains is more important than the meticulous replacement of

what is lost.”what is lost.” To To eliminate the diseaseeliminate the disease.. To To #reser*e the remaining teeth and oral tissues in#reser*e the remaining teeth and oral tissues in

a healthy statea healthy state..

+atisfactory replacement of missing natural teeth &+atisfactory replacement of missing natural teeth &

tissues to improvetissues to improve masti!atory fun!tion& estheti!s&masti!atory fun!tion& estheti!s&#honeti!s and !omfort#honeti!s and !omfort %esides%esides o*erall healtho*erall health, general, general

and psychological !ell %eing of the patient.and psychological !ell %eing of the patient.

1010


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+u!!essful Prosthodonti! Treatment for a+u!!essful Prosthodonti! Treatment for aPatient de#ends u#on :Patient de#ends u#on :

n accurate diagnosisn accurate diagnosis or analysis made after aor analysis made after anum%er of examination procedures as5num%er of examination procedures as5

edical historyedical history $ental history$ental history xtra 6 oral & intra 6 oral examinationxtra 6 oral & intra 6 oral examination Radiographic examinationRadiographic examination +tudy of mounted diagnostic casts+tudy of mounted diagnostic casts n inspection of any existing dental prosthesisn inspection of any existing dental prosthesis

Treatment plan 5 Treatment plan 5 +hould %e highly+hould %e highly indi*iduali,ed for ea!h #atientindi*iduali,ed for ea!h #atient,,

depending upon his pro%lems & needs.depending upon his pro%lems & needs.

1111


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e!ordinge!ording

generalgeneralinformationinformation::


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44

GG

+7+78CC#PT9848CC#PT984

C:9 C8P*94TC:9 C8P*94T

C;#94T$ 94TR09


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"hief !om#laint:"hief !om#laint:

Chief complaint and duration shouldChief complaint and duration should

%e recorded as far as possi%le in the%e recorded as far as possi%le in the

patients o!n !ords and inpatients o!n !ords and in

chronological order.chronological order.Patients must tell !hat pro%lems theyPatients must tell !hat pro%lems they

had !ith their old dentures.had !ith their old dentures.

These complaint !ill act as a guidance These complaint !ill act as a guidancefor the dentist in the area of greatestfor the dentist in the area of greatest

concern to the patient.concern to the patient.


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:*T: :9+T8R=:*T: :9+T8R=

There are > %asic techni"ue for There are > %asic techni"ue for

o%taining the information5o%taining the information5

?.?. $irect interrogation %y the dentist$irect interrogation %y the dentist

@.@. Comprehensive "uestionnaireComprehensive "uestionnaire

>.>. Com%ination of %othCom%ination of %oth


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1)1) Direct interrogation technique:Direct interrogation technique: This type of techni"ue is guided %y the This type of techni"ue is guided %y the

tone of the patient ans!ers and can %etone of the patient ans!ers and can %e

very revealing.very revealing. $isadvantage5$isadvantage5

-time consuming-time consuming

-relies heavily on the s1ill and-relies heavily on the s1ill andexperience ofexperience of the dentist the dentist

-easy to forget-easy to forget


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@)@) Questionnaire approach:Questionnaire approach:

;uic1 method;uic1 method

9t can %e 2lled %y patient in !aiting room9t can %e 2lled %y patient in !aiting room $isadvantage5$isadvantage5

-sometimes patient do not read them-sometimes patient do not read them

carefully carefully

-important information is often-important information is often

s1ipped outs1ipped out or left out or left out

-some patient may not %e a%le to-some patient may not %e a%le to

read theread the small print common tosmall print common tothese formsthese forms

-may not understand %y some-may not understand %y some

patientspatients


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>)>) Combination of both:Combination of both: 9t is the %est system9t is the %est system

orm is 2lled %y the patients and thenorm is 2lled %y the patients and then

ver%ally revie!ed %y the dentist.ver%ally revie!ed %y the dentist.


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ealth historyealth historyin!ludes :in!ludes :

?.?. edical historyedical history

@.@. $ental history$ental history


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/edi!al istory:/edi!al istory:Aasic aim is to determine any conditionAasic aim is to determine any condition

that might aBect the procedure andthat might aBect the procedure andout come of the treatment.out come of the treatment.

Ay %eing a!are of medical condition.Ay %eing a!are of medical condition.$entist can %e ready in case of any$entist can %e ready in case of anymedical emergencies arising duringmedical emergencies arising duringthe course of treatment.the course of treatment.

9n case patient having a transmissi%le,9n case patient having a transmissi%le,suita%le procedure precaution can %esuita%le procedure precaution can %emade to decontaminate the operatorymade to decontaminate the operatoryas !ell as prevent its transfer.as !ell as prevent its transfer.


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Diabetes mellitus :-Diabetes mellitus :- +hort appointments+hort appointments

Patient must %e instructed to have aPatient must %e instructed to have anormal diet %efore dental appointment.normal diet %efore dental appointment. 9f patient !ill %e empty9f patient !ill %e empty

stomachstomach

00 sudden decrease in normalsudden decrease in normal

glucose level glucose level

00 :ypoglycemia:ypoglycemia

$ue to excessive uid loss, dryness of$ue to excessive uid loss, dryness ofmouth occurs.mouth occurs.


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$ryness of mouth !ill cause 5$ryness of mouth !ill cause 5

- $iculty in che!ing- $iculty in che!ing

- #lceration3mucosal soreness- #lceration3mucosal sorenesspatient/s physician should %e consultedpatient/s physician should %e consulted

for the alternate drugs.for the alternate drugs.

+alivary su%stitute should %e given.+alivary su%stitute should %e given.e.g. mil1e.g. mil1

gents can %e use to stimulate salivarygents can %e use to stimulate salivaryo! for e.g. sugar free candies etc.o! for e.g. sugar free candies etc.

Aeverages that may produce moreAeverages that may produce moresaliva such as !ater !ith lemon,saliva such as !ater !ith lemon,lemonade etc. can %e used.lemonade etc. can %e used.


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Rapid rate of %one resorption canRapid rate of %one resorption can

occur therefore tissue rest should %eoccur therefore tissue rest should %e

maximi'ed.maximi'ed.$entist should recall patient$entist should recall patient

fre"uently to correct occlusion andfre"uently to correct occlusion and

monitor %one sta%ility.monitor %one sta%ility. 9t can eBect the !ound healing9t can eBect the !ound healing

capa%ility and therefore must %ecapa%ility and therefore must %e

ta1en into consideration ifta1en into consideration ifpreprosthetic surgery is planned.preprosthetic surgery is planned.


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Anaemia:Anaemia:$ue to nutritional de2ciency dryness of$ue to nutritional de2ciency dryness of

mouth and distur%ance of tastemouth and distur%ance of tastesensation is present.sensation is present.ucosal tissue %ecome suscepti%le toucosal tissue %ecome suscepti%le to

denture trauma.denture trauma.Ridge may %e lose and a%%y.Ridge may %e lose and a%%y.ucostatic impression techni"ue isucostatic impression techni"ue is

used.used.

Prosthodontic considerations 5-Prosthodontic considerations 5- - Constant monitoring of denture- Constant monitoring of denture

sta%ilitysta%ility and occlusion is re"uired toand occlusion is re"uired to

minimi'eminimi'e pressure areas.pressure areas.


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- Poor denture retention results from- Poor denture retention results fromlac1lac1 of saliva.of saliva.

y#ertension:y#ertension:

Clinical signs and symptoms5-Clinical signs and symptoms5-- Areathlessness on exertion- Areathlessness on exertion

- ngina on eBort- ngina on eBort

- Palpitation- Palpitation- pistaxis- pistaxis

- :eadache- :eadache

- $i''iness- $i''iness


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Prosthodontic considerations5-Prosthodontic considerations5-

- voidance of hypertension- voidance of hypertension

episodes isepisodes is important.important.

- Pre-medication should %e used- Pre-medication should %e used

!hen!hen necessary.necessary.

- ppointment should %e short and- ppointment should %e short and

stress less.stress less.

- $entist should have a reassuring- $entist should have a reassuring

andand considerate attitude.considerate attitude.


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+ali*ary gland disorders:+ali*ary gland disorders:

Clinical signs and symptoms5-Clinical signs and symptoms5-

- 7erostomia- 7erostomia

- Painful and %urning mucosa- Painful and %urning mucosa

- ucosal sensitivity- ucosal sensitivity

Prosthodontic consideration5-Prosthodontic consideration5-

-


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Bell1s #alsy:Bell1s #alsy: Clinical signs and symptoms5-Clinical signs and symptoms5-

- acial paralysis !ith mouth dra!n over to- acial paralysis !ith mouth dra!n over toopposite side.opposite side.

- +aliva runs out from the angle of mouth.- +aliva runs out from the angle of mouth.

- 9n oral cavity, num%ness in aBected side.- 9n oral cavity, num%ness in aBected side.

- 9na%ility to feel collected food in %uccal- 9na%ility to feel collected food in %uccalsulcus.sulcus.

Prosthodontic considerations5Prosthodontic considerations5

- $entist should not over stretched the angle- $entist should not over stretched the angleofof mouth.mouth.

- +hould add sucient %ul1 to %uccal surface- +hould add sucient %ul1 to %uccal surface

contour of maxillary RP$ to support accidcontour of maxillary RP$ to support accid

muscle.muscle.


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Parkinsonism:Parkinsonism:

Clinical sign and symptom5-Clinical sign and symptom5- - 9mpaired movement- 9mpaired movement

- uscular rigidity- uscular rigidity

- Tremor- Tremor- +lo!ness- +lo!ness

- *imited range of movement.- *imited range of movement.

- +peech diculty- +peech diculty - 9ncreased salivation- 9ncreased salivation

- $iculty in mastication- $iculty in mastication


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Prosthodontic considerations5-Prosthodontic considerations5-

- $entist should teach careful oral- $entist should teach careful oral

hygiene,hygiene,

use tissue conditioner,use tissue conditioner,

%alance%alance occlusion, and use non-occlusion, and use non-anatomic teeth.anatomic teeth.

- Retention is impaired from increased- Retention is impaired from increased

salivation.salivation.- aximum peripheral extension- aximum peripheral extensiondecreasesdecreases denture retention.denture retention.

- Patients lac1s muscular coordination to- Patients lac1s muscular coordination tocontrol RP$s.control RP$s.

- Dudgment of vertical dimension of- Dudgment of vertical dimension ofocclusion is dicult %ecause of tremorsocclusion is dicult %ecause of tremors

and hypertonicity of muscles.and hypertonicity of muscles.


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Dental history:Dental history: Period of #artial edentulism:Period of #artial edentulism:

dentulous ridges resor% !ith time.dentulous ridges resor% !ith time.

fter extraction, ridge remodeling occurs !hichfter extraction, ridge remodeling occurs !hich

converts the freshly extracted alveolar %one intoconverts the freshly extracted alveolar %one into

the characteristic shape such as high !ellthe characteristic shape such as high !ellrounded ridge, 1nife edge etc.rounded ridge, 1nife edge etc.

9n a%ove given characteristic shapes high !ell9n a%ove given characteristic shapes high !ell

rounded ridge is the most favora%le for denture.rounded ridge is the most favora%le for denture.

Rapid rate of ridge remodelling occurs in the ?Rapid rate of ridge remodelling occurs in the ?stst fe! month of extraction, therefore, rapidfe! month of extraction, therefore, rapid

loosening can %e expected if the dentures areloosening can %e expected if the dentures are

constructed soon after total extraction.constructed soon after total extraction.


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istory of tooth loss:istory of tooth loss:Poor ridges can %e expected if teethPoor ridges can %e expected if teeth

!ere lost due to periodontal disease.!ere lost due to periodontal disease.

9f there is early loss of lo!er posterior9f there is early loss of lo!er posterior

teeth due to !hich supraeruption ofteeth due to !hich supraeruption of

the opposite arch posterior teeth canthe opposite arch posterior teeth canoccur.occur.

This !ill result in a overhanging This !ill result in a overhanging

tu%erosity in later stage.tu%erosity in later stage. history of severe dental caries raises history of severe dental caries raises

suspicions of current as !ell as pastsuspicions of current as !ell as past

neglect or nutritional pro%lems.neglect or nutritional pro%lems.


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Pre*ious denture:Pre*ious denture: Reason should %e as1ed for the failure ofReason should %e as1ed for the failure of

the previous denture.the previous denture. This !ill guide the dentist to avoid similar This !ill guide the dentist to avoid similar

pro%lem in the construction of ne! denture.pro%lem in the construction of ne! denture. Therefore, existing denture should %e Therefore, existing denture should %e

examined thoroughly. Ay the examinationexamined thoroughly. Ay the examination

!e come to 1no! a%out5!e come to 1no! a%out5 -$enture experience-$enture experience

-$enture care-$enture care

-Para functional ha%its of the patients.-Para functional ha%its of the patients.

Patients !ho 1eep changing dentures in aPatients !ho 1eep changing dentures in ashot period of time are dicult to satisfyshot period of time are dicult to satisfyand ris1y to deal !ith.and ris1y to deal !ith.


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Psy!hologi!alPsy!hologi!al

E*aluationE*aluation


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Determining the le*el ofDetermining the le*el of

moti*ation:moti*ation: +elf motivated patient have %etter chance+elf motivated patient have %etter chance

of success than a patient !ho has %eenof success than a patient !ho has %een

motivated.motivated.

/ental Attitude:/ental Attitude:

ollo!ing e"uation depicts theollo!ing e"uation depicts the

prosthodontic therapy for edentulousprosthodontic therapy for edentulous

patients.patients.

Clinical s1ill E Fno!ledge +uccessful careClinical s1ill E Fno!ledge +uccessful care


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Aut the modern e"uation forAut the modern e"uation for

prosthodontic treatment no!prosthodontic treatment no!

includes %oth technical and patientincludes %oth technical and patientmanagement s1ill, !ith the latermanagement s1ill, !ith the later

%eing %ased on a 1een understanding%eing %ased on a 1een understanding

of the patient/s mental attitude.of the patient/s mental attitude.


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$r. milus house proposed a general$r. milus house proposed a generalclassi2cation of patients mental attitudes.classi2cation of patients mental attitudes.

This classi2cation is %ased on extensive This classi2cation is %ased on extensiveclinical experience and personality5clinical experience and personality5

"lassi2!ation:"lassi2!ation:

Philosophic:Philosophic: Aest mental attitudeAest mental attitude


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Indierent:Indierent:

:ave little concern for their teeth or oral:ave little concern for their teeth or oralhealth.health.

:ave little appreciation for the eBorts of:ave little appreciation for the eBorts of

their dentist.their dentist.

Patients re"uire more time for theirPatients re"uire more time for their

instruction on the value and use ofinstruction on the value and use of

denture.denture.

Their attitude can %e very discouraging Their attitude can %e very discouragingto dentist.to dentist.


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Critical:Critical:

inds faults !ith every thing that is done forinds faults !ith every thing that is done forthem.them.

4ever happy !ith their previous dentist4ever happy !ith their previous dentist%ecause the previous dentist did not follo!%ecause the previous dentist did not follo!

their instruction.their instruction. irm control of these patients is essential.irm control of these patients is essential. These patients can %e traumatic in a dental These patients can %e traumatic in a dental

practice if they are not properly controlled.practice if they are not properly controlled.

edical consultation is al!ays advisa%le foredical consultation is al!ays advisa%le forcritical patients %efore treatment is started.critical patients %efore treatment is started.


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Skeptical:Skeptical:

These patient had %ad results !ith previous These patient had %ad results !ith previous

treatment and are therefore dou%tful thattreatment and are therefore dou%tful that

any one can help them.any one can help them.

8ften they !ill have a recent series of8ften they !ill have a recent series of

personal tragedies such as loss of a spouse,personal tragedies such as loss of a spouse,%usiness pro%lems, or other things not%usiness pro%lems, or other things not

directly related to their denture pro%lems.directly related to their denture pro%lems.

They thin1 the !orld is against them and They thin1 the !orld is against them and

dou%t the a%ility of any one helping them.dou%t the a%ility of any one helping them. They need 1ind and sympathetic help as They need 1ind and sympathetic help as

much as they need ne! dentures.much as they need ne! dentures.


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$entist should ta1e more time then$entist should ta1e more time then

usual, in ma1ing examination ofusual, in ma1ing examination ofthese patients, since care andthese patients, since care and

attention !ill help the patient %eginattention !ill help the patient %egin

to develop con2dence in the ne!to develop con2dence in the ne!

dentist.dentist.


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A##li!ation 3f The ouseA##li!ation 3f The ouse

"lassi2!ation:"lassi2!ation:$entist should learn to detect patient$entist should learn to detect patient

attitudes and reactions duringattitudes and reactions duringdiagnostic appointments. +o, thatdiagnostic appointments. +o, that

dentist should modify their o!ndentist should modify their o!nattitude and reactions %y !hichattitude and reactions %y !hichmutual con2dencemutual con2dence can %e esta%lished.can %e esta%lished.

$entist must have a$entist must have a sense of realsense of real

concern for the health, comfort andconcern for the health, comfort and!elfare!elfare of their patients to esta%lishof their patients to esta%lishthe mutual con2dence.the mutual con2dence.


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9nternational prosthodontic !or19nternational prosthodontic !or1

shop identi2es follo!ing factorsshop identi2es follo!ing factors

!hich produce an adaptive or!hich produce an adaptive or

maladaptive response5maladaptive response5


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actors for a favora%le adaptive response toactors for a favora%le adaptive response to

remova%le partial denture5remova%le partial denture5

Trust and con2dence in the dentist Trust and con2dence in the dentist

Previous favora%le experience !ith aPrevious favora%le experience !ith a

dentist.dentist.

Positive attitude and a%ility to cope !ithPositive attitude and a%ility to cope !ithchangechange

Realistic expectation of the patientRealistic expectation of the patient

Good general healthGood general health


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actors producing a maladaptive response toactors producing a maladaptive response toremova%le partial denture5remova%le partial denture5

*ac1 of trust in the dentist*ac1 of trust in the dentist Poor communication %et!een dentist andPoor communication %et!een dentist and

patientpatient Previous negative experiencePrevious negative experience #nrealistic expectation#nrealistic expectation nxiety and lo! tolerance to painnxiety and lo! tolerance to pain Poor health and senilityPoor health and senility

Poor muscle coordinationPoor muscle coordination Poor learning a%ilityPoor learning a%ility Psychological disorder.Psychological disorder.


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"lini!al e4amination"lini!al e4amination

of the #atients:of the #atients:?)?) xtra oralxtra oral

@)@) 9ntra oral9ntra oral


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E5TA 3A6:E5TA 3A6:

7a!ial e4amination:7a!ial e4amination:9t includes the evaluation of facial form and9t includes the evaluation of facial form andfacial pro2le.facial pro2le.

a)a) acial form:acial form: :ouse and loop, rush and isher, and:ouse and loop, rush and isher, and


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- +"uare tapering- +"uare tapering

- Tapering- Tapering

- 8void- 8void


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%)%) acial pro!le:acial pro!le:

ngle classi2ed facialngle classi2ed facialpro2le as5pro2le as5

-class-class 9 6 normal or9 6 normal or

straightstraight pro2le pro2le

-class 99 6 retrognathic-class 99 6 retrognathic

pro2lepro2le

-class 999 6 prognathic-class 999 6 prognathic

pro2lepro2le


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Tem#oromandibular 8ointTem#oromandibular 8oint

9T/ :9T/ : TD should %e evaluated TD should %e evaluated

for the follo!ing5for the follo!ing5

- Pain and tenderness- Pain and tenderness

in the muscles ofin the muscles of

mastication and TD.mastication and TD.

- sounds during- sounds during

condyler movementscondyler movements

- limited of- limited of

mandi%ularmandi%ular

movementmovement

i B i f %


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Patient suBering from one or more a%ovePatient suBering from one or more a%ove

symptoms are considered to %e suBering fromsymptoms are considered to %e suBering from

a TD disorder.a TD disorder.

TD is often associated !ith P$+. TD is often associated !ith P$+.

I cardinal symptoms are5I cardinal symptoms are5

+ub8e!ti*e sym#toms+ub 8e!ti*e sym#toms 3b8e!ti*e3b 8e!ti*e

sym#tomssym#toms Pain clic1ingPain clic1ing

muscle tenderness limited Ha!muscle tenderness limited Ha!

movementmovement

TD is innervated %y the masseteric TD is innervated %y the masseteric

nerve and the auriculotemporal nerve.nerve and the auriculotemporal nerve.


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The auriculotemporal The auriculotemporal

nerve sends sensorynerve sends sensory

2%ers to the facial2%ers to the facial

nerve, !hich ma1esnerve, !hich ma1esit dicult to determineit dicult to determine

the source of pain inthe source of pain in

this region.this region.

Auriculotemporal nerve (A)


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The internal The internal

pterygoid andpterygoid and

masseter musclesmasseter musclesform a sling for theform a sling for the

mandi%le andmandi%le and

external pterygoidexternal pterygoid

muscle hold themuscle hold themandi%ular condylemandi%ular condyle

and dis1 in aand dis1 in a

position ofposition of

e"uili%rium on thee"uili%rium on the

articular eminence.articular eminence. A – internal pterygoid muscleB – masseter muscle


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ll > muscles and the temporalll > muscles and the temporal

muscle may %ecome rigid %ecause ofmuscle may %ecome rigid %ecause ofocclusal disharmonies.occlusal disharmonies.

9t is a physiological protective9t is a physiological protective

reaction of the %ody to protect thereaction of the %ody to protect themasticatory system.masticatory system.

This can %e easily ascertained %y This can %e easily ascertained %y

palpating the rigidity of the musclespalpating the rigidity of the muscles

and comparing them to the ones ofand comparing them to the ones of

the contralateral side of the Ha!.the contralateral side of the Ha!.


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or anterior 2%ers ofor anterior 2%ers of

the temporalthe temporal

muscle, themuscle, the

fore2nger is placedfore2nger is placed

on the chee1on the chee1

opposite theopposite theinsertions of theinsertions of the

muscle on themuscle on the

coronoid process.coronoid process.

The other fore2nger The other fore2ngeris placed inside theis placed inside the

chee1 opposite thechee1 opposite the

contralateral 2nger.contralateral 2nger.


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The masseter and The masseter and

internal pterygoidinternal pterygoid

muscles aremuscles are

palpated !ithpalpated !ithfore2ngers offore2ngers of

each hand, oneeach hand, one

on the chee1 andon the chee1 and

one opposing it inone opposing it inthe mouth.the mouth.


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xternal pterygoidxternal pterygoidmuscle cannot %emuscle cannot %e

palpated.palpated.

Patients !ithPatients !ithocclusalocclusal

disharmoniesdisharmonies

exhi%it tendernessexhi%it tenderness

in the region of thein the region of thehamular notch.hamular notch.


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ode of treating the TD includeode of treating the TD include

occlusal e"uili%rium, intraoralocclusal e"uili%rium, intraoral

prostheses, exercise, drug therapy,prostheses, exercise, drug therapy,

surgery, tc.surgery, tc. 9n case of any disorder, treatment9n case of any disorder, treatment

!ith an R.P.$ should not %e initiated!ith an R.P.$ should not %e initiated

until a state of e"uili%rium exists.until a state of e"uili%rium exists.


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94TR 8R* 794T984594TR 8R* 794T9845

Good lighting, a clean mouth mirror, aGood lighting, a clean mouth mirror, asharp explorer, and a cali%ratedsharp explorer, and a cali%rated

periodontal pro%e are re"uired for theperiodontal pro%e are re"uired for the

examination.examination.


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3ral hygiene status3ral hygiene status

The dentist o%serves The dentist o%serves

!hether the patient!hether the patient

follo!s excellent,follo!s excellent,fair, or poor oralfair, or poor oral

hygiene practices,hygiene practices,

as evidenced %y theas evidenced %y the

presence of food,presence of food,%acterial pla"ue or%acterial pla"ue or

calculus.calculus.

ll h i i h d i


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ll the remaining teeth and tissuesll the remaining teeth and tissues

receive consistent and meticulousreceive consistent and meticulous

cleaning.cleaning. 9f there is lac1 of oral hygiene, then9f there is lac1 of oral hygiene, then

the treatment plan must include oralthe treatment plan must include oral

health care instruction.health care instruction.*ocation of unusual accumulation of*ocation of unusual accumulation of

pla"ue, calculus or food de%rispla"ue, calculus or food de%ris

should %e recorded so that theseshould %e recorded so that these

areas may %e rechec1ed atareas may %e rechec1ed at

su%se"uent examination.su%se"uent examination.

; t i l f d; t i l f d


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;nter#ro4imal food;nter#ro4imal food

im#a!tion:im#a!tion: There are t!o type of interproximal food There are t!o type of interproximal food

impaction5-impaction5-

"ertical food impaction:"ertical food impaction: - $ue to forceful- $ue to forceful

!edging of food against!edging of food against

the gingival tissues andthe gingival tissues and

into the interproximalinto the interproximal

spaces through occlusalspaces through occlusal

pressure.pressure.


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#ori$ontal food impaction:#ori$ontal food impaction:

- $ue to forceful !edging of- $ue to forceful !edging of

food %et!een the teeth %y thefood %et!een the teeth %y the

tongue, lips, and chee1.tongue, lips, and chee1.

$entist should note !hether food$entist should note !hether food

impaction %et!een @ particular teethimpaction %et!een @ particular teethis the result of faulty marginal ridgeis the result of faulty marginal ridge

relations, faulty contact areas, or arelations, faulty contact areas, or a

plunger cusp in the opposingplunger cusp in the opposingdentition.dentition.


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fter elimination of all active cariousfter elimination of all active carious

lesions, Jlesions, Jtrial periodtrial periodK isK is

recommended, during this period,recommended, during this period,

patients oral hygiene practices andpatients oral hygiene practices and

suscepti%ility to disease aresuscepti%ility to disease are

reevaluated %efore prosthodonticreevaluated %efore prosthodontictreatment is %egin.treatment is %egin.

#nless an exceptional level of pla"ue#nless an exceptional level of pla"ue

control can %e achieved, thecontrol can %e achieved, theprognosis for treatment !ill %e poor.prognosis for treatment !ill %e poor.


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Periodontal health:Periodontal health:

8ral mucosa consist of > 'ones58ral mucosa consist of > 'ones5

%asticator& mucosa:%asticator& mucosa:

(gingiva and covering of the hard(gingiva and covering of the hard

palate)palate)

Speciali$ed mucosa:Speciali$ed mucosa:

(dorsum of tongue)(dorsum of tongue)

'ining mucosa:'ining mucosa:

(lining the remainder of oral cavity)(lining the remainder of oral cavity)

(ingia:(ingia: oraloral


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(ingia:(ingia: oraloral

mucosa that coversmucosa that covers

the alveolarthe alveolar

processes of theprocesses of the Ha!s and surrounds Ha!s and surrounds

the nec1 of thethe nec1 of the

teeth.teeth.:ealthy gingiva are:ealthy gingiva are

coral pin1 in color,coral pin1 in color,

stippled, andstippled, and

presence of varyingpresence of varying

degrees of melanindegrees of melanin

pigmentation maypigmentation may

%e seen.%e seen.


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Red, smooth,Red, smooth,

shiny gingivashiny gingiva

may indicate themay indicate the

presence ofpresence of

gingivitisgingivitis..


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%arginal gingia:%arginal gingia:

9t turns red, due to any infection.9t turns red, due to any infection.Alunting and thic1ening may %eAlunting and thic1ening may %e

o%served.o%served.

Pronounced JfestooningK !ill createPronounced JfestooningK !ill createpro%lems if clasps or otherpro%lems if clasps or other

component of an R.P.$ frame !or1component of an R.P.$ frame !or1

must pass over them.must pass over them.

estooning also tend to trap de%risestooning also tend to trap de%ris

and hinder the cleaning of toothand hinder the cleaning of tooth

surfaces in the gingival area.surfaces in the gingival area.

h d i i


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*ttached gingia: *ttached gingia: 9t is normally stippled.9t is normally stippled.

The %ands of attached gingiva should The %ands of attached gingiva should%e several millimeters !ide.%e several millimeters !ide.

9t is essentially important that the9t is essentially important that the

patient have an ade"uate 'one ofpatient have an ade"uate 'one ofthis tissue around the teeth that arethis tissue around the teeth that arepotential a%utments of an R.P.$.potential a%utments of an R.P.$.

Gingival recession are occasionallyGingival recession are occasionally

associated !ith the loss of attachedassociated !ith the loss of attachedgingiva.gingiva.


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Aase of the gingival sulcus andAase of the gingival sulcus andperiodontal poc1ets is pro%ed at >periodontal poc1ets is pro%ed at >

points on the %uccal surface and >points on the %uccal surface and >points on the lingual surface.points on the lingual surface.

Periodontal health can also %ePeriodontal health can also %edetermined radiographically.determined radiographically.

The amount of hori'ontal or vertical The amount of hori'ontal or vertical%one loss is measured on a%one loss is measured on aradiograph.radiograph.

This record is essential in determining This record is essential in determiningthe type of periodontal therapy, thatthe type of periodontal therapy, thatmay %e re"uired.may %e re"uired.

D f biliD f bilit f ll %ilf ll %il


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Degree of mobilityDegree of mobility of all mo%ileof all mo%ileteeth should %e recorded.teeth should %e recorded.

scale commonly used for classifying scale commonly used for classifyingmo%ility is given %elo!5mo%ility is given %elo!5

Class 9Class 9 6 tooth demonstrate greater6 tooth demonstrate greaterthan normal movement, %ut less thanthan normal movement, %ut less than? mm of movement in any direction.? mm of movement in any direction.

Class 99Class 99 6 tooth moves ? mm from6 tooth moves ? mm fromnormal position in any direction.normal position in any direction.

Class 999Class 999 6 tooth moves more than6 tooth moves more than@mm in any direction, including the@mm in any direction, including therotation or depression.rotation or depression.


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Teeth exhi%iting class 999 mo%ility Teeth exhi%iting class 999 mo%ility

have an extremely poor prognosishave an extremely poor prognosisand usually !ill re"uire extraction.and usually !ill re"uire extraction.


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3ral mu!osa:3ral mu!osa:

ucosa of the palate, edentulousucosa of the palate, edentulous

ridges, tongue, chee1s, oor of theridges, tongue, chee1s, oor of the

mouth and vesti%ules should %emouth and vesti%ules should %e

examined.examined.*ocation and appearance of any*ocation and appearance of any

ulceration, area of inammation orulceration, area of inammation or

suspicious lesions are recorded.suspicious lesions are recorded. 9rritation due to rough teeth or %y an9rritation due to rough teeth or %y an

existing prosthesis should %e noted.existing prosthesis should %e noted.


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Candida al%icansCandida al%icans infection isinfection is

fre"uently associated !ith thefre"uently associated !ith thepresence of papillary hyperplasia ofpresence of papillary hyperplasia of

the palate.the palate.

9nammed tissues provide a !rong9nammed tissues provide a !rongrecording !hile ma1ing anrecording !hile ma1ing an

impression.impression.


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esidual ridge 9. :esidual ridge 9. :

Ridges are visually inspected andRidges are visually inspected and

palpated.palpated.

+i'e and shape of the ridges and height+i'e and shape of the ridges and heightand location of the adHacent muscleand location of the adHacent muscle

and soft tissue attachments are noted.and soft tissue attachments are noted.

Ridges are descri%ed as5 high, at,Ridges are descri%ed as5 high, at,narro! or !ide.narro! or !ide.

ccording toccording to BranemarkBranemark et alet al in ?LMNin ?LMN


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ccording toccording to Branemark Branemark et alet al in ?LMN,in ?LMN,

ridges !ere classi2ed on the %asis of %oneridges !ere classi2ed on the %asis of %one

"uantity and %one "uality %y radiographic"uantity and %one "uality %y radiographic

meansmeans

B3NE :B3NE :

Class 5 most of the alveolar %one is present.Class 5 most of the alveolar %one is present.Class A5 moderate residual ridge resorptionClass A5 moderate residual ridge resorption

occurs. occurs.

Class C5 advanced residual ridge resorptionClass C5 advanced residual ridge resorption

occurs. occurs.

Class $5 moderate resorption of the %asal %oneClass $5 moderate resorption of the %asal %one

isis present. present.

Class 5 extreme resorption of the %asal %one.Class 5 extreme resorption of the %asal %one.

B3NE B3NE


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B3NE B3NE

Class ?5 lmost the entire Ha! is composed ofClass ?5 lmost the entire Ha! is composed ofhomogenous compact %one. homogenous compact %one.

Class @5 thic1 layer of compact %oneClass @5 thic1 layer of compact %one

surrounds asurrounds a core of dense tra%ecularcore of dense tra%ecular

%one.%one.

Class >5 thin layer of cortical %one surroundsClass >5 thin layer of cortical %one surrounds

aa core of dense tra%ecular %one. core of dense tra%ecular %one.

Class I5 thin layer of cortical %one surroundsClass I5 thin layer of cortical %one surroundsaa core of lo! density tra%ecular %one. core of lo! density tra%ecular %one.

AT?33D+ "6A++;7;"AT;3NAT?33D+ "6A++;7;"AT;3N:


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AT?33D+ "6A++;7;"AT;3N:AT?33D+ "6A++;7;"AT;3N:

8rder 95 pre-extraction.8rder 95 pre-extraction.

8rder 995 post extraction.8rder 995 post extraction.

8rder 9995 high, !ell rounded.8rder 9995 high, !ell rounded.

8rder 905 1nife edge.8rder 905 1nife edge.

8rder 05 lo!, !ell rounded.8rder 05 lo!, !ell rounded.

8rder 095 depressed.8rder 095 depressed.


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irmness of the overlying mucosa isirmness of the overlying mucosa is

determined %y palpation.determined %y palpation.Crest and sides of the ridges shouldCrest and sides of the ridges should

%e palpated to detect the presence%e palpated to detect the presence

of sharp spines or ledges of %one.of sharp spines or ledges of %one.Ridges those are at, narro!, sharp,Ridges those are at, narro!, sharp,

sensitive or covered !ith a%%ysensitive or covered !ith a%%y

tissue !ill not function !ell, as areastissue !ill not function !ell, as areasof support.of support.

Th diti ill i iThese conditions !ill compromises in


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These conditions !ill compromises in These conditions !ill compromises in

denture comfort and function.denture comfort and function.

andi%ular R.R tend to exhi%it theseandi%ular R.R tend to exhi%it theseundesira%le characteristics moreundesira%le characteristics more

fre"uently than maxillary R.R.fre"uently than maxillary R.R.

nlarged, hyperplastic tu%erositiesnlarged, hyperplastic tu%erositiesfre"uently found in the maxillary arch,fre"uently found in the maxillary arch,

!hich can %e a%%y or spongy or if!hich can %e a%%y or spongy or if

they intrude into the inter ridge space,they intrude into the inter ridge space,are planned for surgical removal.are planned for surgical removal.

trophic mucous mem%rane commonlytrophic mucous mem%rane commonly


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trophic mucous mem%rane commonlytrophic mucous mem%rane commonlyfound on R.R of elderly or malnourishedfound on R.R of elderly or malnourishedpatients.patients.

This type of mucosa appears to %e thin, This type of mucosa appears to %e thin,smooth and transparent, some!hatsmooth and transparent, some!hatresem%ling layer of plastic food !rap.resem%ling layer of plastic food !rap.

trophic mucous mem%rane sometimestrophic mucous mem%rane sometimes%urns or hurts spontaneously and%urns or hurts spontaneously andusually sensitive to pressure, intolerantusually sensitive to pressure, intolerantof pressure from denture, easilyof pressure from denture, easily

%ruised and slo! to heal after inHury.%ruised and slo! to heal after inHury. These conditions can %e cured %y These conditions can %e cured %y

medical and nutritional therapy.medical and nutritional therapy.

ToriTori:


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Tori:Tori:

$entist should note,$entist should note,if there is anyif there is any

presence of palatalpresence of palatal

or lingual tori.or lingual tori.

Generally, small toriGenerally, small tori

do not have to %edo not have to %e

removed !hen aremoved !hen apatient is treatedpatient is treated

!ith R.P.$.!ith R.P.$.Maxillary tori

The maHor connectors ofThe maHor connectors of


86/160

The maHor connectors of The maHor connectors of

R.P.$ are modi2edR.P.$ are modi2ed

according to theseaccording to these

anatomical anomalies.anatomical anomalies.

9f the tori is very large or9f the tori is very large or

mushroom shaped, or ifmushroom shaped, or ifthey !ill other!isethey !ill other!ise

interfere !ith comfort,interfere !ith comfort,

function or speech, theyfunction or speech, they

should %e surgicallyshould %e surgicallyremoved %eforeremoved %efore

prosthodontic treatmentprosthodontic treatment

is started.is started.

Mandibular tori


87/160

E.aluation of space for mandibular ma/or connectorE.aluation of space for mandibular ma/or connector

eight of @oor of mouth 9tongue ele*ated ineight of @oor of mouth 9tongue ele*ated in

relation to lingual gingi*al sul!i measuredrelation to lingual gingi*al sul!i measured

$ith a #eriodontal #robe$ith a #eriodontal #robe..

e!orded measurements are transferred to diagnosti! !aste!orded measurements are transferred to diagnosti! !ast

and then to master !ast after mouth #re#arations areand then to master !ast after mouth #re#arations are

!om#leted. 6ine !onne!ting marks indi!ates lo!ation of!om#leted. 6ine !onne!ting marks indi!ates lo!ation of

inferior border of ma8or !onne!torinferior border of ma8or !onne!tor..

To determine if at least Mmm of space %et!een To determine if at least Mmm of space %et!een

the gingival margins of teeth and elevated oorthe gingival margins of teeth and elevated oor

of mouth is present.of mouth is present.

8787


88/160

*ingual %ar*ingual %ar

*inguoplate*inguoplate

*ingual %ar maHor connector is indicated if at least Mmm of*ingual %ar maHor connector is indicated if at least Mmm of

space is availa%le.space is availa%le.

*inguoplate maHor connector if there is less than Mmm of*inguoplate maHor connector if there is less than Mmm of

space.space.

8888

3!!lusion:3!!lusion:


89/160

The existing teeth The existing teeth

should %e examined forshould %e examined forocclusion.occlusion.

Teeth should have a Teeth should have a

good cusp to fossagood cusp to fossa

relationship.relationship. Premature contacts inPremature contacts in

normal closure andnormal closure and

deective occlusaldeective occlusal

contacts that cause thecontacts that cause themandi%le to slidemandi%le to slide

protusively or laterallyprotusively or laterally

must %e corrected.must %e corrected.

The presence ofThe presence of


90/160

The presence of The presence of

supraeruptedsupraerupted teeth intoteeth into

opposing edentulousopposing edentulousspaces that disrupt thespaces that disrupt the

continuity or the orientationcontinuity or the orientation

of the occlusal plane of the dentalof the occlusal plane of the dentalarches and interridge space %et!eenarches and interridge space %et!eenmaxillary tu%erosity and the retromolarmaxillary tu%erosity and the retromolararea should %e reevaluated.area should %e reevaluated.

Reesta%lishment of a relatively regular,Reesta%lishment of a relatively regular,straight plane of occlusion is important.straight plane of occlusion is important.

Correction of this pro%lem eventuallyCorrection of this pro%lem eventually


91/160

re"uires one of the follo!ing treatmentre"uires one of the follo!ing treatment

alternatives5alternatives5

a) +elective grinding of the cusps.a) +elective grinding of the cusps.

%) Restoration !ith a cro!n at the proper%) Restoration !ith a cro!n at the proper

height.height.

c) Gross reduction and restoration, oftenc) Gross reduction and restoration, often

involving endodontic treatment.involving endodontic treatment.

d) xtraction of the oBending tooth.d) xtraction of the oBending tooth.

$eep/ or excessive anterior vertical $eep/ or excessive anterior vertical


92/160

overlap (over%ite more than >mm) ofoverlap (over%ite more than >mm) of

anterior teeth often results in pro%lemsanterior teeth often results in pro%lems

in the design and 2tting of R.P.$s andin the design and 2tting of R.P.$s andmay also %e a sign of posterior occlusalmay also %e a sign of posterior occlusal

collapse, !ith its accompanying loss ofcollapse, !ith its accompanying loss of

interarch space.interarch space.%normal hori'ontal overlap (overHet)%normal hori'ontal overlap (overHet)

may %e diagnostic of a%normalmay %e diagnostic of a%normal

s!allo!ing or tongue thrust ha%itss!allo!ing or tongue thrust ha%its!hich can lead to diculties in !earing!hich can lead to diculties in !earing

R.P.$s.R.P.$s.

$ue to the loss of some of the teeth,$ue to the loss of some of the teeth,


93/160

drifting of the remaining teethdrifting of the remaining teeth

occurs, results in malposed teeth andoccurs, results in malposed teeth and

traumatic occlusion, !ith mandi%ulartraumatic occlusion, !ith mandi%ularguidance %eing forced upon !ea1guidance %eing forced upon !ea1

teeth.teeth.

Common signs of traumatic occlusionCommon signs of traumatic occlusionare mo%ile teeth or excessiveare mo%ile teeth or excessive

attrision of the occlusal surfaces.attrision of the occlusal surfaces.

Teeth that exhi%it a%normal mo%ility Teeth that exhi%it a%normal mo%ilityduring lateral Ha! movements oftenduring lateral Ha! movements often

have an unfavora%le prognosis.have an unfavora%le prognosis.


94/160

$entist should also at this time loo1$entist should also at this time loo1for any parafunctional ha%it li1efor any parafunctional ha%it li1e

%ruxism%ruxism oror clenching of teethclenching of teeth..

9f a parafunctional ha%it is veri2ed or9f a parafunctional ha%it is veri2ed oreven strongly suspected, the patienteven strongly suspected, the patient

must %e counseled regarding themust %e counseled regarding the

eBects of the ha%it and if necessary,eBects of the ha%it and if necessary,treatment for the adverse ha%ittreatment for the adverse ha%it

should %e instituted.should %e instituted.

Tongue:Tongue:


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Tongue:Tongue:- Tongue should %e examined for5- Tongue should %e examined for5

a)a) +9O5+9O5 - *arge tongue decreases the sta%ility of denture- *arge tongue decreases the sta%ility of dentureand ma1es impression ma1ing dicult. Tongueand ma1es impression ma1ing dicult. Tongue%iting is common after insertion of the denture.%iting is common after insertion of the denture.

- +mall tongue does not provide ade"uate lingual- +mall tongue does not provide ade"uate lingualperipheral seal.peripheral seal.

%)%) 804T 4$ C88$94T9845804T 4$ C88$94T9845

- 9t is important to register a good peripheral- 9t is important to register a good peripheral

tracing.tracing. - :elps in maintaining the denture in the mouth- :elps in maintaining the denture in the mouth

during the function activities li1e speech,during the function activities li1e speech,deglutition and mastication.deglutition and mastication.

Diagnosti! !ast:Diagnosti! !ast:


96/160

Diagnosti! !ast:Diagnosti! !ast:

$iagnostic cast should %e accurate$iagnostic cast should %e accuratereproduction of the teeth and adHacentreproduction of the teeth and adHacenttissue.tissue.

Pur#ose of the diagnosti! !ast:-Pur#ose of the diagnosti! !ast:-

9t should permit dentist to plan ahead9t should permit dentist to plan aheadto avoid undesira%le compromises into avoid undesira%le compromises inthe treatment %eing given to a patient.the treatment %eing given to a patient.

Cast should %e surveyed !ith a cast surveyor toCast should %e surveyed !ith a cast surveyor to


97/160

determine the parallelism or lac1 of parallelismdetermine the parallelism or lac1 of parallelism

of tooth surfaces involved and to esta%lish theirof tooth surfaces involved and to esta%lish their

inuence on the design of partial denture and toinuence on the design of partial denture and todetermine the need for mouth preparation5-determine the need for mouth preparation5-

Proximal tooth surfaces, !hich can %e madeProximal tooth surfaces, !hich can %e made

parallel to serve as guiding plane.parallel to serve as guiding plane.

Retentive and non retentive areas of theRetentive and non retentive areas of the

a%utment teeth.a%utment teeth.

reas of interference to placement andreas of interference to placement andremoval.removal.

sthetics eBects of the selected path ofsthetics eBects of the selected path of

insertion.insertion.

9t should use to permit a logical and9t should use to permit a logical and


98/160

p gp g

comprehensive presentation to the patient ofcomprehensive presentation to the patient of

present and future restorative needs, as !ellpresent and future restorative needs, as !ell

as of the ha'ards of future neglect.as of the ha'ards of future neglect.

9t should point out5-9t should point out5-

vidence of tooth migration and the existingvidence of tooth migration and the existing

results of such migration.results of such migration. Bects of further tooth migration.Bects of further tooth migration.

*oss of occlusal support and its conse"uences.*oss of occlusal support and its conse"uences.

:a'ard of traumatic occlusal contacts.:a'ard of traumatic occlusal contacts.

Cariogenic and periodontal implications ofCariogenic and periodontal implications of

further neglect.further neglect.

9ndividual impression trays may %e9ndividual impression trays may %e


99/160

9ndividual impression trays may %e9ndividual impression trays may %e

fa%ricated on the diagnostic casts,fa%ricated on the diagnostic casts,

or the diagnostic cast may %e usedor the diagnostic cast may %e usedin selecting and 2tting a stoc1in selecting and 2tting a stoc1

impression tray for the 2nalimpression tray for the 2nal

impression.impression. $iagnostic cast may %e used as a$iagnostic cast may %e used as a

constant referenceconstant reference asas

the !or1 progresses.the !or1 progresses.


100/160

To determine the most suita%le path of insertion that To determine the most suita%le path of insertion that

!ill permit locating retainers and arti2cial teeth to!ill permit locating retainers and arti2cial teeth to

%est%est estheti!estheti! advantageadvantage..

To record the cast position in relation to the selected To record the cast position in relation to the selected

path of insertion for future references.path of insertion for future references.

100100


101/160

$iagnostic !ax-up5$iagnostic !ax-up5 9ndicates pro%lems !hich may %e encountered during treatment.9ndicates pro%lems !hich may %e encountered during treatment.

Provides a guide for toothProvides a guide for tooth

preparation.preparation.

De2nite e4aminationDe2nite e4amination is carried out at secondis carried out at second

appointment !hen patient, radiographs & articulatedappointment !hen patient, radiographs & articulatedstudy casts can %e %rought together for 2nal study &study casts can %e %rought together for 2nal study &

decision ma1ing.decision ma1ing.

treatment plan is formulated & presented to the patient treatment plan is formulated & presented to the patient

!ith the help of study casts.!ith the help of study casts.

101101

oentgenogra#hi!oentgenogra#hi!


102/160

oe ge og a# !g g #

inter#retation:inter#retation:lveolar %one is evaluated for thelveolar %one is evaluated for the

"uality and "uantity (height) ."uality and "uantity (height) .

Roentgenographic changes are notRoentgenographic changes are not

o%served until approximately @N ofo%served until approximately @N ofthe mineral content has %een depleted.the mineral content has %een depleted.

n increased thic1ness of then increased thic1ness of the

periodontal space around the tooth,periodontal space around the tooth,suggests varying degrees of mo%ility,suggests varying degrees of mo%ility,

!hich can %e evaluated clinically.!hich can %e evaluated clinically.

;nde4 areas:;nde4 areas:


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Reaction of %one adHacent to teeth thatReaction of %one adHacent to teeth that

have %een su%Hected to a%normal stresshave %een su%Hected to a%normal stressserves as indication of pro%a%leserves as indication of pro%a%le

reactions of that %one !hen such teethreactions of that %one !hen such teeth

are used as a%utments for 2xed orare used as a%utments for 2xed or

remova%le restorations. +uch areas areremova%le restorations. +uch areas are

called indexcalled index

areas.areas.


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Teeth that have %een su%Hected to Teeth that have %een su%Hected toa%normal loading %ecause of the lossa%normal loading %ecause of the loss

of adHacent teeth or that haveof adHacent teeth or that have

!ithstood tipping forces in addition to!ithstood tipping forces in addition toocclusalocclusal

loading may %e %etter ris1s asloading may %e %etter ris1s as

a%utment teeth than those that havea%utment teeth than those that havenot %een called on to carry an extranot %een called on to carry an extra

occlusal load.occlusal load.


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Al*eolar lamina dura:

9t is the thin layer of9t is the thin layer ofhard cortical %one thathard cortical %one that

normally lines thenormally lines the

soc1ets of all teeth.soc1ets of all teeth. 9t aBords attachment for9t aBords attachment for

the 2%ers of thethe 2%ers of the

periodontal mem%rane.periodontal mem%rane.

9ts function is to9ts function is to

!ithstand mechanical!ithstand mechanical

strain.strain.

9t is a radiopa"ue !hite line around9t is a radiopa"ue !hite line around


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9t is a radiopa"ue !hite line around9t is a radiopa"ue !hite line aroundthe radiolucent dar1 line thatthe radiolucent dar1 line that

represents therepresents the periodontal mem%rane.periodontal mem%rane.


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9t determines the a%ility of a%utment9t determines the a%ility of a%utment

teeth to resist additional rotationalteeth to resist additional rotational

forces that may %e placed on them.forces that may %e placed on them.

Teeth !ith multiple and divergent Teeth !ith multiple and divergent

roots !ill resist stresses %etter thanroots !ill resist stresses %etter than

teeth !ith fused and conical rootsteeth !ith fused and conical roots

<

Third molars:Third molars:


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Third molars:

#nerupted >rd molars should %e#nerupted >rd molars should %e

considered as prospective futureconsidered as prospective futurea%utments to eliminate the need of aa%utments to eliminate the need of a

distal extension remova%le partialdistal extension remova%le partial

denture.denture. 9t !ill help in increasing the sta%ility9t !ill help in increasing the sta%ility

of the denture.of the denture.

"arious lesions:"arious lesions:


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"arious lesions:"arious lesions: 9nitial carious lesion and recurrent9nitial carious lesion and recurrent

caries adHacent to existingcaries adHacent to existing

restorations should %e noted.restorations should %e noted.

$eep lesions or extensive$eep lesions or extensive

restorations in teeth that arerestorations in teeth that arepotential a%utments for prosthesespotential a%utments for prostheses

should receive special scrutiny.should receive special scrutiny.


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111111


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Phase ;;;Phase ;;;


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Phase ;;;Phase ;;; Pre-prosthetic surgical procedures.Pre-prosthetic surgical procedures.

$e2nitive endodontic procedures.$e2nitive endodontic procedures.

$e2nitive restoration of teeth.$e2nitive restoration of teeth. ixed partial denture construction.ixed partial denture construction.

Reinforcement of education and motivation of theReinforcement of education and motivation of the

patientpatient..

Phase ;Phase ;

Construction of prosthesis.Construction of prosthesis.Reinforcement of education and motivation of patientReinforcement of education and motivation of patient ..

Phase Phase Post-insertion care.Post-insertion care.

Periodic recallPeriodic recall

Reinforcement of education and motivation of patient.Reinforcement of education and motivation of patient.

113113

Pre#rostheti! surgery:Pre#rostheti! surgery:


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e# os e ! su ge y# g y


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protu%erances or undercuts.protu%erances or undercuts.:ave no sharp ridges.:ave no sharp ridges.

Provide ade"uate %uccal and lingualProvide ade"uate %uccal and lingualsulcisulci

:ave no peripheral scar %ends that:ave no peripheral scar %ends that

prevent seating of a denture prosthesis.prevent seating of a denture prosthesis.:ave no muscle 2%res or frena that:ave no muscle 2%res or frena that

mo%ili'e the prosthesis.mo%ili'e the prosthesis.Contain no soft tissue folds,Contain no soft tissue folds,

redundancies or hypertrophies on theredundancies or hypertrophies on theridges or in the sulci, andridges or in the sulci, and

Posses no neoplastic lesionsPosses no neoplastic lesions

N3N-+=G;"A6 /ET3D+N3N-+=G;"A6 /ET3D+


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N3N +=G;"A6 /ET3D+N3N +=G;"A6 /ET3D+

est for denture su##ortingest for denture su##ortingtissues:-tissues:-Removal of denture from the mouth for anRemoval of denture from the mouth for an

extended period of time (IM 6 Q@ hours).extended period of time (IM 6 Q@ hours).

#se of temporary soft reliners3tissue#se of temporary soft reliners3tissue

conditioners.conditioners.

Regular home care program5Regular home care program5

Rinsing of mouthRinsing of mouth

anaging the residual ridge areas, palateanaging the residual ridge areas, palate

and tongue !ith a soft tooth %rush.and tongue !ith a soft tooth %rush.


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3!!lusal !orre!tion of old3!!lusal !orre!tion of old

#rosthesis:-#rosthesis:-

n attempt should %e made to restoren attempt should %e made to restore

an optimal vertical dimension ofan optimal vertical dimension ofocclusion to the denture presently !ornocclusion to the denture presently !orn

%y the patient %y using an interim%y the patient %y using an interim

resilient lining material.resilient lining material.


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"onditioning of #atient1s"onditioning of #atient1s

mus!ulature:-mus!ulature:-

#se of Ha! exercises can permit#se of Ha! exercises can permit

relaxation of the muscles of masticationrelaxation of the muscles of masticationand strengthen their coordination.and strengthen their coordination.

This facilitates the registration of Ha! This facilitates the registration of Ha!

relation.relation.

+=G;"A6 /ET3D++=G;"A6 /ET3D+


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+=G;"A6 /ET3D++=G;"A6 /ET3D+

Certain conditions of denture %earingCertain conditions of denture %earing

tissues re"uires to %e surgicallytissues re"uires to %e surgically

treated.treated.

There should %e ade"uate healing There should %e ade"uate healing

time %efore the fa%rication of thetime %efore the fa%rication of the

prosthesis.prosthesis.

Common conditions !here surgicalCommon conditions !here surgical

intervention is indicated are5intervention is indicated are5

y#er#lasti!y#er#lasti!

tissue:tissue:-


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tissue:-tissue:-

-- 9t is seen in the9t is seen in the

form of 2%rousform of 2%rous

tu%erosities, softtu%erosities, soft

a%%y ridges, foldsa%%y ridges, foldsof redundantof redundant

tissue in thetissue in the

vesti%ule, on thevesti%ule, on theoor of the mouthoor of the mouth

and palataland palatal

papillomatosispapillomatosis.


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- ll these excess tissues should- ll these excess tissues shouldremoved to provide a 2rm %ase and aremoved to provide a 2rm %ase and a

more sta%le denture and reducedmore sta%le denture and reduced

stress and strain on the supportingstress and strain on the supportingteeth and tissues.teeth and tissues.

Pendulous 2brous ma4illaryPendulous 2brous ma4illary


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Pendulous 2brous ma4illaryPendulous 2brous ma4illary

tuberosities:-tuberosities:-

- 9t occurs unilaterally or %ilaterally and- 9t occurs unilaterally or %ilaterally and

interfere !ith denture construction.interfere !ith denture construction.

Enlargement of dentureEnlargement of denture

bearing areas:-bearing areas:-

- 0esti%uloplasty and ridge- 0esti%uloplasty and ridgeaugmentation varied out to improveaugmentation varied out to improve

denture retention function.denture retention function.

7 l d l7 l d l


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7renular and mus!le7renular and mus!le

atta!hment:-atta!hment:-

- $ue to loss of alveolar %one height,- $ue to loss of alveolar %one height,

muscle attachment may insert on ormuscle attachment may insert on ornear the alveolar crest.near the alveolar crest.

- axillary la%ial and mandi%ular- axillary la%ial and mandi%ular

lingual frenulas are fre"uent sourceslingual frenulas are fre"uent sourcesof interferences !ith denture design.of interferences !ith denture design.

Pressure onPressure on

mental foramen:-mental foramen:-


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mental foramen:-mental foramen:-

- Pressure from the- Pressure from the

denture against thedenture against themental nerves andmental nerves and

over the sharp %onyover the sharp %ony

edge !ill cause pain.edge !ill cause pain.

- This can %e dealt in @- This can %e dealt in @

!ays!ays

i.i. lter the dentallter the dental

design.design.ii.ii. Trim the %one and Trim the %one and

relieve mental nerverelieve mental nerve

from pressure.from pressure.


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Dis!re#an!ies in 8a$ si,e:-Dis!re#an!ies in 8a$ si,e:-- andi%ular osteotomy is done to- andi%ular osteotomy is done to

create optimal Ha! relations forcreate optimal Ha! relations for

prosthetic patients !ho haveprosthetic patients !ho havediscrepancies in Ha! si'e.discrepancies in Ha! si'e.

/outh #re#aration/outh #re#aration


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The preparation of the mouth is The preparation of the mouth isfundamental to a successfulfundamental to a successfulremova%le partial denture service.remova%le partial denture service.

9n general mouth preparation includes9n general mouth preparation includes

procedures in the categories5procedures in the categories5

?.?. 8ral surgical preparation8ral surgical preparation

@.@.

Periodontal preparationPeriodontal preparation>.>. 8rthodontic preparation8rthodontic preparation

I.I. Preparation of a%utment teethPreparation of a%utment teeth

3ral surgi!al3ral surgi!al


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g#re#aration:#re#aration: xtraction of teeth5xtraction of teeth5

- ach tooth must %e evaluated concerningach tooth must %e evaluated concerning

its strategic importance and its potentialits strategic importance and its potential

contri%ution to the success of RP$.contri%ution to the success of RP$.- xtraction of non-strategic teeth thatxtraction of non-strategic teeth that

!ould present complication or those!ould present complication or those

!hose presence may %e detrimental to!hose presence may %e detrimental tothe design of the partial denture, is athe design of the partial denture, is a

necessary part of the overall treatment.necessary part of the overall treatment.


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- Teeth !hich are hopelessly Teeth !hich are hopelessly

diseased or %adly destroyeddiseased or %adly destroyed

as to %e unsalva%le shouldas to %e unsalva%le should

%e removed.%e removed.

- ll impacted teeth should %ell impacted teeth should %e

considered for removal. s they mayconsidered for removal. s they may

contri%ute to the formation of thecontri%ute to the formation of theperiodontal poc1et and compromiseperiodontal poc1et and compromise

the periodontal condition.the periodontal condition.


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Removal of residual roots5Removal of residual roots5

- Residual roots adHacent to a%utment- Residual roots adHacent to a%utment

teeth may contri%ute to theteeth may contri%ute to theprognosis of periodontal poc1ets andprognosis of periodontal poc1ets and

compromise the results fromcompromise the results from

su%se"uent periodontal therapy.su%se"uent periodontal therapy.

PeriodontalPeriodontal


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#re#aration:#re#aration:8%Hectives of periodontal therapy58%Hectives of periodontal therapy5Removal of all etiologic factorsRemoval of all etiologic factors

contri%uting to periodontal disease.contri%uting to periodontal disease.

limination of all poc1et.limination of all poc1et.Creation of physiologic gingival andCreation of physiologic gingival and

osseous architecture.osseous architecture.

$evelopment of personali'ed pla"ue$evelopment of personali'ed pla"uecontrol program and de2nitivecontrol program and de2nitivemaintenance schedule.maintenance schedule.


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Periodontal treatment planning canPeriodontal treatment planning can%e divided in > phases5%e divided in > phases5

Phase 93 9nitial disease control therapyPhase 93 9nitial disease control therapyPhase 993 $e2nitive periodontal surgeryPhase 993 $e2nitive periodontal surgery

Phase 9993 Recall maintenancePhase 9993 Recall maintenance

Phase 95Phase 95


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This phase include5 This phase include58ral hygiene instruction5-8ral hygiene instruction5-

- otivate the use of disclosing agents,- otivate the use of disclosing agents,soft nylon tooth %rush and un!axedsoft nylon tooth %rush and un!axed

dental oss.dental oss.+caling and root planning5-+caling and root planning5-

- limination of all the calculus, pla"ue- limination of all the calculus, pla"ue

and necrotic cementum.and necrotic cementum.-


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- 8verhanging margins of restorations,- 8verhanging margins of restorations,

overhanging cro!n margins and openoverhanging cro!n margins and opencontacts leading to food impaction shouldcontacts leading to food impaction should%e corrected.%e corrected.

limination of gross occlusallimination of gross occlusalinterferences5interferences5

- Poor occlusal relationships contri%ute to- Poor occlusal relationships contri%ute to

more rapid loss of periodontalmore rapid loss of periodontalattachment.attachment.

- Traumatic cuspal interferences are- Traumatic cuspal interferences areremoved %y grinding procedures.removed %y grinding procedures.

Phase 995Phase 995


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9f poc1et !ith inammation and9f poc1et !ith inammation andosseous defects are still present, aosseous defects are still present, a

variety of periodontal surgicalvariety of periodontal surgical

techni"ues should %e considered totechni"ues should %e considered torestore periodontal health.restore periodontal health.

Procedures li1e gingivectomy,Procedures li1e gingivectomy,

periodontal ap surgery and otherperiodontal ap surgery and otherreconstructive surgical procedures,reconstructive surgical procedures,

etc. is carried out in this phase.etc. is carried out in this phase.

Phase 9995Phase 9995


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The fre"uency of recall appointments The fre"uency of recall appointmentsshould %e customi'ed for theshould %e customi'ed for the

patients depending on thepatients depending on the

suscepti%ility and severity ofsuscepti%ility and severity ofperiodontal disease.periodontal disease.

3rthodonti!3rthodonti!


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#re#aration:#re#aration:/inor tooth mo*ement:-/inor tooth mo*ement:-

nomalies in tooth position, !hichnomalies in tooth position, !hich

can interfere !ith the ideal design ofcan interfere !ith the ideal design of

a prosthesis.a prosthesis.

The mesially in!lined molar:The mesially in!lined molar:


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The mandi%ular molar that has tipped The mandi%ular molar that has tippedmesially can %e return to a more nearlymesially can %e return to a

diagnosis and treatment planning for partially edentulous patients11

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