Diagnosis of partially

edentulous patientsDr Mostafa Ibrahim Fayad

Lecture of Removable ProthodonticsAl-Azhar UniversityBritish University

Drmostafafayadgmailcom

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

bull A Edentulous areas too long for a fixed prosthesis bull B Need to restore soft and hard tissue contours bull C Absence of adequate periodontal support bull D Structurally or anatomically compromised abutment

teeth bull 1 Lack of clinical crown height bull 2 Lack of sound tooth structure bull 3 Unfavorable position contour or inclination

bull E Need for cross-arch stabilization bull F Restoration of an extension base bull G Anterior esthetics bull 1 Attitude and desires of patient

Diagnosis

bull It is the determination of the nature location and causes of diseases

To assemble all appropriate information about the patientrsquos 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 includesbull Patient Historybull Clinical examination ( Extraoral and

Intraoral) bull Radiographsbull Mounted Diagnostic Castsbull Occlusal plane analysisbull Surveying of the diagnostic castbull Pre-extraction record

Treatment plan

1 Patient history

ndash Personal and Social history

ndash Chief complaintsndash Medical historyndash Dental historyndash Mental attitudes

Personal and Social history

bull Name - Address - Tel N0

bull Age - Sex

bull Occupation and Socio-economic Class

bull Public speakers and singers

bull Wind instrument players

bull Psychological conditions

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Diagnosis

bull It is the determination of the nature location and causes of diseases

To assemble all appropriate information about the patientrsquos 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 includesbull Patient Historybull Clinical examination ( Extraoral and

Intraoral) bull Radiographsbull Mounted Diagnostic Castsbull Occlusal plane analysisbull Surveying of the diagnostic castbull Pre-extraction record

Treatment plan

1 Patient history

ndash Personal and Social history

ndash Chief complaintsndash Medical historyndash Dental historyndash Mental attitudes

Personal and Social history

bull Name - Address - Tel N0

bull Age - Sex

bull Occupation and Socio-economic Class

bull Public speakers and singers

bull Wind instrument players

bull Psychological conditions

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

To assemble all appropriate information about the patientrsquos 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 includesbull Patient Historybull Clinical examination ( Extraoral and

Intraoral) bull Radiographsbull Mounted Diagnostic Castsbull Occlusal plane analysisbull Surveying of the diagnostic castbull Pre-extraction record

Treatment plan

1 Patient history

ndash Personal and Social history

ndash Chief complaintsndash Medical historyndash Dental historyndash Mental attitudes

Personal and Social history

bull Name - Address - Tel N0

bull Age - Sex

bull Occupation and Socio-economic Class

bull Public speakers and singers

bull Wind instrument players

bull Psychological conditions

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Diagnosis of partially edentulous pt includesbull Patient Historybull Clinical examination ( Extraoral and

Intraoral) bull Radiographsbull Mounted Diagnostic Castsbull Occlusal plane analysisbull Surveying of the diagnostic castbull Pre-extraction record

Treatment plan

1 Patient history

ndash Personal and Social history

ndash Chief complaintsndash Medical historyndash Dental historyndash Mental attitudes

Personal and Social history

bull Name - Address - Tel N0

bull Age - Sex

bull Occupation and Socio-economic Class

bull Public speakers and singers

bull Wind instrument players

bull Psychological conditions

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

1 Patient history

ndash Personal and Social history

ndash Chief complaintsndash Medical historyndash Dental historyndash Mental attitudes

Personal and Social history

bull Name - Address - Tel N0

bull Age - Sex

bull Occupation and Socio-economic Class

bull Public speakers and singers

bull Wind instrument players

bull Psychological conditions

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Personal and Social history

bull Name - Address - Tel N0

bull Age - Sex

bull Occupation and Socio-economic Class

bull Public speakers and singers

bull Wind instrument players

bull Psychological conditions

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Chief complaints

bull Reason for attendance (Patients requests and desires)

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Medical history

bull 1048633 Diabetesbull 1048633 Arthritisbull 1048633 Pagetrsquos diseasebull 1048633 Acromegalybull 1048633 Parkinsonrsquos diseasebull 1048633 Pemphigus vulgarisbull 1048633 Epilepsybull 1048633 Cardiovascular diseasesbull 1048633 Cancerbull 1048633 Transmissible diseases

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

1 Smokinghas been known to be

associated with a variety of oral conditions including Periodontal disease

Bone amp tooth loss

Peri-implantitis Dental implant

failureThe effect of tobacoo is due to1 resistance to inflammation2 resistance to infection3 Impaired wound healing4 Calcium absorption

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Patients who are unable to sustain a high level of plaque control eg Parkinsonism

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Dental history

bull The cause of teeth lossbull Patient experience during and following

previous partial denture constructionbull Expectation of treatmentbull Chewing habits preferred side for chewing

This will determine the amount of support retention and bracing of the denture on each side

bull Para functional habits clinching and bruxism

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Mental attitudes

ndash Houses Classification Based on patientrsquos mental attitude

bull philosophical patients (Well adjusted and easygoing)

bull Exacting patients (Precise in everything they do)

bull Hysterical patients (Are emotionally unstable and convinced that they will never be able to wear a prosthesis)

bull Indifferent patients (are uncooperative)

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Clinical examination

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Clinical oral examination

What features should be considered in the

examination

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

bull PATIENT EVALUATION

bull EXTRAORAL EXAMINATION

bull INTRAORAL EXAMINATION

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

PATIENT EVALUATION

bull Gait

bull Complexion and Personality

bull Cosmetic Index

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

II-Clinical Examination

Extra oralExtra oral Intra-oralIntra-oral

Facial ExaminationFacial Examination

TMJ ExaminationTMJ Examination

Visual ExaminationVisual Examination

Digital ExaminationDigital Examination

Radiographic ExaminationRadiographic Examination

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Extra oral Examination

Front ViewFront View Profile ViewProfile View

Angle of the mentolabial SulcusAngle of the mentolabial Sulcus

Vertical dimension of old denture wearersVertical dimension of old denture wearers

Size - Form ndash Shape of the faceSize - Form ndash Shape of the face

Juvenile Appearance of the patientJuvenile Appearance of the patient

A- Facial Examination

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Extra oral Examination

Clinical InterpretationClinical Interpretation Radiographic InterpreRadiographic Interpre

DigitalExamDigitalExam

Clicking or Pop sounds on jaw OpeningClicking or Pop sounds on jaw Opening

Panoramic Panoramic

Corrected Cephalometric TomographyCorrected Cephalometric Tomography

B- TMJ Examination

Transcranial RadiographyTranscranial Radiography

Computerized TomographyComputerized TomographyMRIMRI

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

EXTRAORAL EXAMINATION

bull Facial examinationndash Facial Formndash Facial Features

bull Lip Examination

bull TMJ Examination

bull Neuromuscular Examination

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Intra oral exam

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Intra Oral Examination

For Partially Edent ptFor Partially Edent pt

Edentulous Area Edentulous Area

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Colour- Contour-Ridge

Relationship -Tongue Tori-

UndercutndashThroat form-

Saliva- Frena Att

Remainimg Natural TeethRemainimg Natural Teeth

A- Visual Examination

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

N0 - Form-Location-Caries- Existing Restoration-Periodontium-Positions- Occlusion

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Intra Oral Examination

Edentulous Area Edentulous Area

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Firmness -Irregularities-

Tongue- Tuberosities- Slope of

RetromPad- Mylohyoid Ridge-

Lingual Pouch-Painful Areas

Remainimg Natural TeethRemainimg Natural Teeth

B- Digital Examination

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

Vitality test- Percussion ndash

Mobility- pocket

Evaluation

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

The following should be examined

1-Oral Hygiene2-Carious lesions and existing

restorations3-Evaluation of the periodontium4-Tooth mobility5-Sensitivity to percussions6- vitality tests of individual teeth7- Atrition8- Occlusion9 Ridge Morphology10- Arch form 11- Interarch space12-Evaluation of the space for the

mandibular major connector

13 Maxillo-mandibular relationship

14-Para-functional habits15-Mouth opening16- Oral mucosa17- Hard tissue abnormalities18- Soft tissue abnormalities19- Occlusal relationships20- Temporomandibular joint

(TMJ) examination21- Quality and quantity of saliva22-Tounge size and mobility23- 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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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 Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Oral Hygienebull The patient must

have a high standard of plaque control

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

2-Carious lesions and existing restorations

bull Any caries should be restored prior to PD fabrication

bull Patient with caries index should have the abutment teeth crowned

bull 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 periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

3-Evaluation of the periodontiumExamination findings

that indicate the need for PL treatment includes

bull Gingivitisbull Pocket depth in excess

of 3 mmbull Calculous depositsbull Furcation involvementbull Marginal exudate

upon probing or application of digital pressure

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

4-Tooth mobility

Causesbull Trauma from occlusion (usually reversible)bull Inflammation in PL (usually reversible)bull Loss of osseous support (irreversible)

Whether to splint a mobile tooth with a strong one is

questionableSo 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 causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

5-Sensitivity to percussions

All remaining teeth should be tested for sensitivity to percussion

Possible causes1 Tooth in traumatic occlusion2 Periapical or pulpal abscess3 Periodontitis4 Cracked tooth

The cause must be identified and treated before partial

denture construction

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

6 -vitality tests of individual teeth

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

7-Attrition

Loss of teeth

drifting and migration

deflective occlusal contact

increased muscular response

bruxism and excessive tooth wear

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Types of wear1 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 patientrsquos 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 restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

A popular misconception about severely worn

dentition is that patients have lost their VDO and that

it must be restoredThe 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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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

2 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)

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

8- OcclusionA 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 formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

9 Ridge Morphology

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

10 Arch formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

10 Arch formbull It is either ovoid tapered or square

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

11-Interarch spacebull For fixed restorations 7

mm in the posterior region and 8-10 in the anterior region

bull For removable restoration at least 12 mm

bull 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 spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Management of inadequate interarch space

Excessive interarch spaceOnlay bone graft may be used before implant

placement to decrease the interarch space if fixed restoration is to be made

Decreased interarch spaceTreatment of the overerrupted opposing teethIf opposing teeth are adequate Osteoplasty

andor 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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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 relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

13 Maxillo-mandibular relationshipbull Arch relationship often concern implant

placement in the anterior regions of the mandible and maxilla

bull 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

bull This will require overcontouring of the final restoration to place the incisal 23 in an ideal position cantilever force on the implant

bull 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

bull In case of angle class II casesManaged by anterior cantilever on

implants in the mandibular arch but this requires

Increase number of implantsIncrease in the anteroposterior

distance between implants

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

14-Para-functional habitsbull Bruxusmbull Clenchingbull 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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

15-Mouth opening

Tongue Position

Normal tongue positions Retracted or awkward

tongue positions

23-Examination of old denture

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Tongue Position

Normal tongue positions Retracted or awkward

tongue positions

23-Examination of old denture

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

23-Examination of old denture

ndash a- the design and quality of construction should be noted

ndash Any associated problems in relation to gingival and mucosal inflammation or to decalcification of contacting tooth surfaces

ndash 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

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

4 Radiographic examination

1 Caires

Clinical findings must be correlated with radiographic examination to reveal

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

1 Caires

Clinical findings must be correlated with radiographic examination to reveal

bull Severity and extent of caires

bull 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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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 retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

3 -Root canal filling

An abutment tooth with inadequate root canal filling must be retreatedNot 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 durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

4-Locate areas if infection

5-Lamina durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

5-Lamina durabull Resorption of LD occurs where there is

pressure and apposition occurs when there is tension

bull Loss of lamina dura may be due to1 Systemic disorders as hyperparathyrodism

or Pagetrsquos disease2 Excessive pressure on the toothbull 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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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 CR ratio is 11 poor prognosis but still we can use it as an overdenture abutment

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

7-Bone index areas

bull Index areas are those areas of bone that disclose the reactions of bone to additional stresses

bull Bone may respond to abnormal stresses by increase in bone density bone condensation which is a favorable bone response

bull Although it is a favorable bone response the excessive stresses must be relieved because at any time if the patientrsquos resistance is decreased bone resorption may occur

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

bull 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

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

8-Periodontal ligament space

Thickness of lamina dura with widening of the periodontal ligament space indicates

MobilityOcclusal 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

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

9-Root length size and form

bull 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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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 molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

11-Third molarbull 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

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

5-Evalation of the mounted

diagnostic casts

The diagnostic casts should be mounted on a semiadjustable articulator with

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

The diagnostic casts should be mounted on a semiadjustable articulator with

bull Face bow transferbull Centric relation record

at the correct vertical dimension

bull Protrusive and lateral records

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

1-Interarch distancebull Loss of interarch space is

frequently caused by a large maxillary tuberosity

bull 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 determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

2 -Diagnostic surveying

To determine1 Parallelism or lack of parallelism

of tooth surface involved 2 Areas of interferences to path of

placement and removal3 Esthetic effects of the selected

path of insertion

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

3-0cclusal plane

Most partially Most partially edentulous pts have edentulous pts have occlusal interferences occlusal interferences due to due to driftingdrifting and and migrationmigration of natural of natural teeth which require teeth which require occlusal equilibrationocclusal equilibration

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Treatment of irregular occlusal planebull Treatment ranges from simple enameloplasty

to extraction of the toothbull If a single tooth is overerupted it may be

treated by1 Simple enameloplasty if overerruption is

within 2 mm2 Reduction and crowning if dentine will be

exposed3 RCT reduction and crowning4 RCT and reduction of the tooth to be used as

an overdenture abutment5 in severe overeruption it may be necessary to

remove the tooth and recontour the surrounding bone

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Treatment of malpositioned occlusal plane

bull 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 be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Tipped or malposed teeth

May occur if an edentulous space is present mesial to a posterior tooth it may be1 Orthodontically repositioned2 Adjusted with a crown3 Onlay rest

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

5Occlusal 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Occlusal interferences is manifested as follows

Clinically1 Wear facets2 Tooth mobility3 Muscle spasm pain and TMDRadiographically1 Widening in the periodontal

membrane space2 Periapical radiolucency3 Bone condensation4 Bone resorption5 Root resorption

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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

Areas of interferences are detected eitherManually 1 Ribbons2 Marking papers3 Waxes4 Pastes sprays and paint-on

materialsComputer assisted analysisEG T-scan

T-scan IIIThe 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 IIIThe 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

Diagnostic equilibriation

bullOcclusal 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 CO2 Absence of posterior teeth contact3 When all posterior teeth contact are

to be made by fixed restoration4 Few remaining posterior contacts5 Clinical symptoms of occlusal

trauma (TMJ disorder)

Examination of the articulated study casts

Importance of the study castsbull Evaluate several

prosthodontic criteria in the absence of the patient

bull Evaluate the current occlusion

bull The relationship of the edentulous area to the adjacent natural teeth and opposing arch

bull Position of the potential natural abutments parellelism and esthetic considerations

bull Number of missing teeth

bull Inter-arch space analysis

bull -Perform wax up and surgical template

bull -Perform the provisional prosthesis

bull -Ridge mappingbull -Future comparison

Treatment PlanTreatment PlanProper Diagnosis is the Key of Best Prognosis

bullAdjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support

-Tissue Conditioning -Nutritional CounselingbullProsthodontic Care

• Diagnosis of partially edentulous patients
• Slide 2
• Diagnosis
• Slide 4
• Diagnosis of partially edentulous pt includes
• Patient history
• Personal and Social history
• Chief complaints
• Medical history
• Slide 10
• Slide 11
• Dental history
• Mental attitudes
• Clinical examination
• Clinical oral examination
• Slide 16
• PATIENT EVALUATION
• II-Clinical Examination
• Extra oral Examination
• Slide 20
• EXTRAORAL EXAMINATION
• Intra oral exam
• Intra Oral Examination
• Slide 24
• The following should be examined
• 1-Oral hygiene of the patient
• 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-Attrition
• Types of wear
• A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
• Actually loss of VDO occurs in 2 situations
• 8- Occlusion
• 9 Ridge Morphology
• 10 Arch form
• 11-Interarch space
• Management of inadequate interarch space
• 12-Evaluation of the space for the mandibular major connector
• 13 Maxillo-mandibular relationship
• Slide 44
• Slide 45
• 14-Para-functional habits
• Slide 47
• 15-Mouth opening
• Slide 49
• Slide 50
• 4 Radiographic examination
• 1 Caires
• 2-Presence of root fragments
• 3- Root canal filling
• 4-Locate areas if infection
• 5-Lamina dura
• 6- The quality of alveolar support
• 7-Bone index areas
• Slide 59
• 8-Periodontal ligament space
• 9-Root length size and form
• 10-Proximity of roots
• 11-Third molar
• 5-Evalation of the mounted diagnostic casts
• Slide 65
• 1-Interarch distance
• 2- Diagnostic surveying
• 3-0cclusal plane
• Treatment of irregular occlusal plane
• Treatment of malpositioned occlusal plane
• Tipped or malposed teeth
• 5Occlusal equilibriation
• Slide 73
• Occlusal interferences is manifested as follows
• Areas of interferences are detected either
• T-scan III
• Diagnostic equilibriation
• Slide 78
• The following situations suggest that prosthesis should be constructed at centric relation
• Slide 80
• Importance of the study casts
• Slide 82

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 CO2 Absence of posterior teeth contact3 When all posterior teeth contact are

to be made by fixed restoration4 Few remaining posterior contacts5 Clinical symptoms of occlusal

trauma (TMJ disorder)

Examination of the articulated study casts

Importance of the study castsbull Evaluate several

prosthodontic criteria in the absence of the patient

bull Evaluate the current occlusion

bull The relationship of the edentulous area to the adjacent natural teeth and opposing arch

bull Position of the potential natural abutments parellelism and esthetic considerations

bull Number of missing teeth

bull Inter-arch space analysis

bull -Perform wax up and surgical template

bull -Perform the provisional prosthesis

bull -Ridge mappingbull -Future comparison

Treatment PlanTreatment PlanProper Diagnosis is the Key of Best Prognosis

bullAdjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support

-Tissue Conditioning -Nutritional CounselingbullProsthodontic Care

• Diagnosis of partially edentulous patients
• Slide 2
• Diagnosis
• Slide 4
• Diagnosis of partially edentulous pt includes
• Patient history
• Personal and Social history
• Chief complaints
• Medical history
• Slide 10
• Slide 11
• Dental history
• Mental attitudes
• Clinical examination
• Clinical oral examination
• Slide 16
• PATIENT EVALUATION
• II-Clinical Examination
• Extra oral Examination
• Slide 20
• EXTRAORAL EXAMINATION
• Intra oral exam
• Intra Oral Examination
• Slide 24
• The following should be examined
• 1-Oral hygiene of the patient
• 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-Attrition
• Types of wear
• A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
• Actually loss of VDO occurs in 2 situations
• 8- Occlusion
• 9 Ridge Morphology
• 10 Arch form
• 11-Interarch space
• Management of inadequate interarch space
• 12-Evaluation of the space for the mandibular major connector
• 13 Maxillo-mandibular relationship
• Slide 44
• Slide 45
• 14-Para-functional habits
• Slide 47
• 15-Mouth opening
• Slide 49
• Slide 50
• 4 Radiographic examination
• 1 Caires
• 2-Presence of root fragments
• 3- Root canal filling
• 4-Locate areas if infection
• 5-Lamina dura
• 6- The quality of alveolar support
• 7-Bone index areas
• Slide 59
• 8-Periodontal ligament space
• 9-Root length size and form
• 10-Proximity of roots
• 11-Third molar
• 5-Evalation of the mounted diagnostic casts
• Slide 65
• 1-Interarch distance
• 2- Diagnostic surveying
• 3-0cclusal plane
• Treatment of irregular occlusal plane
• Treatment of malpositioned occlusal plane
• Tipped or malposed teeth
• 5Occlusal equilibriation
• Slide 73
• Occlusal interferences is manifested as follows
• Areas of interferences are detected either
• T-scan III
• Diagnostic equilibriation
• Slide 78
• The following situations suggest that prosthesis should be constructed at centric relation
• Slide 80
• Importance of the study casts
• Slide 82

The following situations suggest that prosthesis should

be constructed at centric relation

1 Coincidence of CR and CO2 Absence of posterior teeth contact3 When all posterior teeth contact are

to be made by fixed restoration4 Few remaining posterior contacts5 Clinical symptoms of occlusal

trauma (TMJ disorder)

Examination of the articulated study casts

Importance of the study castsbull Evaluate several

prosthodontic criteria in the absence of the patient

bull Evaluate the current occlusion

bull The relationship of the edentulous area to the adjacent natural teeth and opposing arch

bull Position of the potential natural abutments parellelism and esthetic considerations

bull Number of missing teeth

bull Inter-arch space analysis

bull -Perform wax up and surgical template

bull -Perform the provisional prosthesis

bull -Ridge mappingbull -Future comparison

Treatment PlanTreatment PlanProper Diagnosis is the Key of Best Prognosis

bullAdjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support

-Tissue Conditioning -Nutritional CounselingbullProsthodontic Care

• Diagnosis of partially edentulous patients
• Slide 2
• Diagnosis
• Slide 4
• Diagnosis of partially edentulous pt includes
• Patient history
• Personal and Social history
• Chief complaints
• Medical history
• Slide 10
• Slide 11
• Dental history
• Mental attitudes
• Clinical examination
• Clinical oral examination
• Slide 16
• PATIENT EVALUATION
• II-Clinical Examination
• Extra oral Examination
• Slide 20
• EXTRAORAL EXAMINATION
• Intra oral exam
• Intra Oral Examination
• Slide 24
• The following should be examined
• 1-Oral hygiene of the patient
• 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-Attrition
• Types of wear
• A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
• Actually loss of VDO occurs in 2 situations
• 8- Occlusion
• 9 Ridge Morphology
• 10 Arch form
• 11-Interarch space
• Management of inadequate interarch space
• 12-Evaluation of the space for the mandibular major connector
• 13 Maxillo-mandibular relationship
• Slide 44
• Slide 45
• 14-Para-functional habits
• Slide 47
• 15-Mouth opening
• Slide 49
• Slide 50
• 4 Radiographic examination
• 1 Caires
• 2-Presence of root fragments
• 3- Root canal filling
• 4-Locate areas if infection
• 5-Lamina dura
• 6- The quality of alveolar support
• 7-Bone index areas
• Slide 59
• 8-Periodontal ligament space
• 9-Root length size and form
• 10-Proximity of roots
• 11-Third molar
• 5-Evalation of the mounted diagnostic casts
• Slide 65
• 1-Interarch distance
• 2- Diagnostic surveying
• 3-0cclusal plane
• Treatment of irregular occlusal plane
• Treatment of malpositioned occlusal plane
• Tipped or malposed teeth
• 5Occlusal equilibriation
• Slide 73
• Occlusal interferences is manifested as follows
• Areas of interferences are detected either
• T-scan III
• Diagnostic equilibriation
• Slide 78
• The following situations suggest that prosthesis should be constructed at centric relation
• Slide 80
• Importance of the study casts
• Slide 82

Examination of the articulated study casts

Importance of the study castsbull Evaluate several

prosthodontic criteria in the absence of the patient

bull Evaluate the current occlusion

bull The relationship of the edentulous area to the adjacent natural teeth and opposing arch

bull Position of the potential natural abutments parellelism and esthetic considerations

bull Number of missing teeth

bull Inter-arch space analysis

bull -Perform wax up and surgical template

bull -Perform the provisional prosthesis

bull -Ridge mappingbull -Future comparison

Treatment PlanTreatment PlanProper Diagnosis is the Key of Best Prognosis

bullAdjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support

-Tissue Conditioning -Nutritional CounselingbullProsthodontic Care

• Diagnosis of partially edentulous patients
• Slide 2
• Diagnosis
• Slide 4
• Diagnosis of partially edentulous pt includes
• Patient history
• Personal and Social history
• Chief complaints
• Medical history
• Slide 10
• Slide 11
• Dental history
• Mental attitudes
• Clinical examination
• Clinical oral examination
• Slide 16
• PATIENT EVALUATION
• II-Clinical Examination
• Extra oral Examination
• Slide 20
• EXTRAORAL EXAMINATION
• Intra oral exam
• Intra Oral Examination
• Slide 24
• The following should be examined
• 1-Oral hygiene of the patient
• 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-Attrition
• Types of wear
• A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
• Actually loss of VDO occurs in 2 situations
• 8- Occlusion
• 9 Ridge Morphology
• 10 Arch form
• 11-Interarch space
• Management of inadequate interarch space
• 12-Evaluation of the space for the mandibular major connector
• 13 Maxillo-mandibular relationship
• Slide 44
• Slide 45
• 14-Para-functional habits
• Slide 47
• 15-Mouth opening
• Slide 49
• Slide 50
• 4 Radiographic examination
• 1 Caires
• 2-Presence of root fragments
• 3- Root canal filling
• 4-Locate areas if infection
• 5-Lamina dura
• 6- The quality of alveolar support
• 7-Bone index areas
• Slide 59
• 8-Periodontal ligament space
• 9-Root length size and form
• 10-Proximity of roots
• 11-Third molar
• 5-Evalation of the mounted diagnostic casts
• Slide 65
• 1-Interarch distance
• 2- Diagnostic surveying
• 3-0cclusal plane
• Treatment of irregular occlusal plane
• Treatment of malpositioned occlusal plane
• Tipped or malposed teeth
• 5Occlusal equilibriation
• Slide 73
• Occlusal interferences is manifested as follows
• Areas of interferences are detected either
• T-scan III
• Diagnostic equilibriation
• Slide 78
• The following situations suggest that prosthesis should be constructed at centric relation
• Slide 80
• Importance of the study casts
• Slide 82

Importance of the study castsbull Evaluate several

prosthodontic criteria in the absence of the patient

bull Evaluate the current occlusion

bull The relationship of the edentulous area to the adjacent natural teeth and opposing arch

bull Position of the potential natural abutments parellelism and esthetic considerations

bull Number of missing teeth

bull Inter-arch space analysis

bull -Perform wax up and surgical template

bull -Perform the provisional prosthesis

bull -Ridge mappingbull -Future comparison

Treatment PlanTreatment PlanProper Diagnosis is the Key of Best Prognosis

bullAdjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support

-Tissue Conditioning -Nutritional CounselingbullProsthodontic Care

• Diagnosis of partially edentulous patients
• Slide 2
• Diagnosis
• Slide 4
• Diagnosis of partially edentulous pt includes
• Patient history
• Personal and Social history
• Chief complaints
• Medical history
• Slide 10
• Slide 11
• Dental history
• Mental attitudes
• Clinical examination
• Clinical oral examination
• Slide 16
• PATIENT EVALUATION
• II-Clinical Examination
• Extra oral Examination
• Slide 20
• EXTRAORAL EXAMINATION
• Intra oral exam
• Intra Oral Examination
• Slide 24
• The following should be examined
• 1-Oral hygiene of the patient
• 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-Attrition
• Types of wear
• A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
• Actually loss of VDO occurs in 2 situations
• 8- Occlusion
• 9 Ridge Morphology
• 10 Arch form
• 11-Interarch space
• Management of inadequate interarch space
• 12-Evaluation of the space for the mandibular major connector
• 13 Maxillo-mandibular relationship
• Slide 44
• Slide 45
• 14-Para-functional habits
• Slide 47
• 15-Mouth opening
• Slide 49
• Slide 50
• 4 Radiographic examination
• 1 Caires
• 2-Presence of root fragments
• 3- Root canal filling
• 4-Locate areas if infection
• 5-Lamina dura
• 6- The quality of alveolar support
• 7-Bone index areas
• Slide 59
• 8-Periodontal ligament space
• 9-Root length size and form
• 10-Proximity of roots
• 11-Third molar
• 5-Evalation of the mounted diagnostic casts
• Slide 65
• 1-Interarch distance
• 2- Diagnostic surveying
• 3-0cclusal plane
• Treatment of irregular occlusal plane
• Treatment of malpositioned occlusal plane
• Tipped or malposed teeth
• 5Occlusal equilibriation
• Slide 73
• Occlusal interferences is manifested as follows
• Areas of interferences are detected either
• T-scan III
• Diagnostic equilibriation
• Slide 78
• The following situations suggest that prosthesis should be constructed at centric relation
• Slide 80
• Importance of the study casts
• Slide 82

Treatment PlanTreatment PlanProper Diagnosis is the Key of Best Prognosis

bullAdjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support

-Tissue Conditioning -Nutritional CounselingbullProsthodontic Care

• Diagnosis of partially edentulous patients
• Slide 2
• Diagnosis
• Slide 4
• Diagnosis of partially edentulous pt includes
• Patient history
• Personal and Social history
• Chief complaints
• Medical history
• Slide 10
• Slide 11
• Dental history
• Mental attitudes
• Clinical examination
• Clinical oral examination
• Slide 16
• PATIENT EVALUATION
• II-Clinical Examination
• Extra oral Examination
• Slide 20
• EXTRAORAL EXAMINATION
• Intra oral exam
• Intra Oral Examination
• Slide 24
• The following should be examined
• 1-Oral hygiene of the patient
• 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-Attrition
• Types of wear
• A popular misconception about severely worn dentition is that patients have lost their VDO and that it must be restored
• Actually loss of VDO occurs in 2 situations
• 8- Occlusion
• 9 Ridge Morphology
• 10 Arch form
• 11-Interarch space
• Management of inadequate interarch space
• 12-Evaluation of the space for the mandibular major connector
• 13 Maxillo-mandibular relationship
• Slide 44
• Slide 45
• 14-Para-functional habits
• Slide 47
• 15-Mouth opening
• Slide 49
• Slide 50
• 4 Radiographic examination
• 1 Caires
• 2-Presence of root fragments
• 3- Root canal filling
• 4-Locate areas if infection
• 5-Lamina dura
• 6- The quality of alveolar support
• 7-Bone index areas
• Slide 59
• 8-Periodontal ligament space
• 9-Root length size and form
• 10-Proximity of roots
• 11-Third molar
• 5-Evalation of the mounted diagnostic casts
• Slide 65
• 1-Interarch distance
• 2- Diagnostic surveying
• 3-0cclusal plane
• Treatment of irregular occlusal plane
• Treatment of malpositioned occlusal plane
• Tipped or malposed teeth
• 5Occlusal equilibriation
• Slide 73
• Occlusal interferences is manifested as follows
• Areas of interferences are detected either
• T-scan III
• Diagnostic equilibriation
• Slide 78
• The following situations suggest that prosthesis should be constructed at centric relation
• Slide 80
• Importance of the study casts
• Slide 82