Transcript Diagnosis and Treatment Planning for Partially Edentulous

EXAMINATION AND EVALUATION OF DIAGNOSTIC DATA: THE
SECOND DIAGNOSTIC APPOINTMENT
GOOD MORNING
Presented by:
Dr. Kamleshwar Singh
BDS, MDS, ICMR-IF(Japan)
Assistant Professor
Department of Prosthodontics
King George’s Medical University, Lucknow
Second appointment
The second diagnostic appointment is used to complete the
gathering and the evaluation of the diagnostic data.
Diagnostic mounting:
a) supplement examination of oral cavity.
b) analysis of occlusion
c) patient education
d) provide a record of patients condition before treatment
Procedure:
 Facebow transfer
 Centric relation registration
 Mounting casts
 Protrusive record, setting condylar elements
Face bow transfer:

Preparation of bite fork
 Orientation of face bow
to bite fork and
reference points
 Orientation of face bow
to articulator
 Attachment of maxillary
cast to articulator
Centric relation record
Recommended method

Backrest at 60 degrees.

Deprogram oral musculature.

Slight backward and downward
pressure on patient mandible

Then CR record made.
Centric relation record:
Using wax

We can also use elastomeric registration
materials (wax tends to change dimension over
time and can become brittle)
Centric relation record:
Using Record bases

If patient does not
have enough teeth to
mount lower cast to
upper (i.e. no
posterior teeth),
fabricate record
bases.
 Wax-up, take
relation in centric
relation.
Setting condylar elements

Protrusive record: with either wax or
elastomeric material.
 Patient instructed to protrude mandible by 56mm, then close into recording material.
Setting condylar elements
Too steep
The condylar setting is…
Correct
inclination
Too shallow
Extra-0ral examination:

Facial form and symmetry, jaw opening and
closing movements, palpation of TMJ and
muscles of mastication.
Definitive Oral Examination:
Caries and existing restorations

Carious lesions:
surface restorations
cast restorations
crowns
 Margins of cast
restorations.
 Possible extractions.
Definitive Oral Examination:
pulpal tissues

Possible pulp testing should be used to
determine the vitality of the teeth.

Selection of endodontically treated tooth
as abutments is NOT contraindicated.
Better prognosis with full crown coverage
restoration.
Definitive Oral Examination:
sensitivity to percussion

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Unstable occlusion
Tooth in traumatic
occlusion
PA abscess
Acute pulpitis
Cracked tooth
syndrome
Definitive Oral Examination:
Periodontium

Trauma of occlusion
 Inflammation of
periodontium
 Colour, contour ,
form and stippling of
gingiva
 Loss of bone support
Not useful as an abutment
for a partial denture
Useful for an abutment for
an over denture
Definitive Oral Examination:
Tooth mobility

-
Degree of mobility
(Grant, Stern & Everett 1972)
NP mobility – 0.05 -0.1 mm
Viscoelastic property of pdl
(Carranza)
Class1: More than normal physiologic mobility but less
than 1mm of movement in any direction.
Class 2: A tooth moves 1 mm from normal position in any
direction
Class 3: A tooth moves more than 2 mm in any direction,
including rotation or depression.
Definitive Oral Examination:
Periodontium:
Need for periodontal treatment:
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Pocket depth>3mm
Furcation involvement
Gingivitis, ginigival cleft,
festooning
 Marginal exudate
 Proposed abutment teeth
exhibiting < 2mm attached
gingiva width
Definitive Oral Examination:
Oral mucosa:

Uicers, inflammation, rough
teeth, existing prosthesis

Pathologic lesions

Papillary hyperplasia
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Epulis fissuratum

Denture stomatitis
(Candida infectn)
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Soft tissue
displacement- tissue support
Biopsy, m washes, nutritional
deficiencies & nystatin
Definitive Oral Examination:
Denture bearing residual ridge
Ideal denture bearing residual ridge (ATWOOD, 1973)
Wide, Smooth, Rounded and Covered With tough, firmly
attached, keratinized mucosa
Definitive Oral Examination:
Hard tissues
abnormalities:

Torus palatinus &
mandibularis
 Exostoses &
 undercuts.
Definitive Oral Examination:
Soft tissues abnormalities:

Labial frenum

Unsupported and hypermobile
gingiva
Space for mandibular major
connector: 8mm space for
lingual bar
Definitive Oral Examination:
Radiographic evaluation of
prospective abutments:

Root length, size and form
 Crown-root ratio
 Lamina dura
 Periodontal ligament space
Evaluation of mounted diagnostic
casts

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Interarch distance
Ridge relationship
Tissue contours
Occlusal plane
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Irregular occlusal
plane
Malpositioned
occlusal plane
Selective grinding,
crown, endo Rx,
Extraction
Evaluation of mounted diagnostic
casts

Tipped or malposed
teeth
 Occlusion
Role of occlusal
equilibration
Interferences need to be corrected
Evaluation of mounted diagnostic
casts

Occlusal indicator wax, articulating paper or tape, and thin
metal foil may be helpful in assessment of occlusion.
treatment at centric relation ….

To observe the contacts of the teeth in the centric
relation, the dentist should ask the patient to touch the
teeth together slowly and lightly until the first contact is
felt and then to “ close all the way”.

Demonstration of a “slide” between the initial contact
and the position of maximum intercuspation indicates
a discrepancy in jaw closure between centric relation
and centric occlusion positions.
treatment at centric relation.....

The recontouring or restoration of the teeth to make
the centric relation and centric occlusion positions of
the jaw coincide is not always required.

Certainly, premature contacts in normal closure and
deflective occlusal contacts that causes the mandible
to slide protrusively or laterally must be corrected.
treatment at centric relation ….

According to Renner, following conditions should be
met:
1.
The jaw closes smoothly and consistently into the centric
occlusion position.
2.
Multiple, simultaneous, stable occlusal contacts in the centric
occlusion position.
3.
No evidence of a slide following the initial occlusal contact.
4.
No symptoms of dysfunction.
Finally….
Diagnostic wax-up

Provides a great
deal of information
regarding tooth
preparation,
placement and
occlusion.
Development of Treatment plan
How do I
develop a
Treatment
Plan????
Developing a sequenced treatment
plan
 Phase
I:
 Evaluation
of diagnostic data
 Immediate Rx – pain, discomfort, infection
control
 diagnostic mounting, wax-up, partial
design,
 referral to other specialties (endo, ortho,
oral surgery etc.),
 patient education (OHI, etc).
Developing a sequenced treatment
plan
 Phase
II:
 Removal
of caries,
 extractions,
 periodontal treatment –plaque control
measures,
 occlusal equilibration- deflective and
premature contacts elimination,
 placement of temporary restorations
(temporary crowns, etc).
Developing a sequenced treatment
plan

Phase III (continuation of Phase II):
Pre-prosthetic surgeries,
 root canal therapies,
 definitive restoration of teeth,
 RPD mouth preparation.
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Phase IV:


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Placement of RPD,
Instruction for patient and written consent.
Phase V: Periodic recall, reinforcement of
education and motivation of the patient .
Typical problem.....
Changes caused by a mandibular Rpd opposing maxillary CD
Ellisworth Kelly -1972
Five changes may constitute
combination syndrome, as they are
quite characteristic. These changes are
loss of bone from the anterior part of
the maxillary ridge,
overgrowth of the tuberosities,
papillary hyperplasia in the hard
palate,
extrusion of the lower anterior teeth,
and
the loss of bone under the partial
denture bases.
CONCLUSION......
In no other phase of dentistry is the need for
knowledgeable planning and forethought so vital to a
successful outcome as it is in the practice of
removable partial prosthodontics.
The multitude of procedural and clinical details that
must be coordinated into an orderly sequence makes
it imperative that all factors bearing on the treatment
be carefully evaluated so that each phase of therapy
can be coordinated with the overall plan.
Bibliography:
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Removable partial denture prosthetics- STEWART,
3rd edition.
Removable partial dentures – Robert Renner &
Louis Boucher
McCracken's Removable partial prosthodonticsMcGivney
Essentials of removable partial denture prostheticsOLIVER C APPLEGATE.
A colour atlas of removable partial denturesDAVENPORT, BASKER.
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Partial dentures- OSBORNE & LAMMIE, 5th edition.

Dental implant prosthetics- CARL E MISCH

JPD, Vol. 11, No. 3, 2002:pp 181-93
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JPD, 16, 1966: 533-39
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DCNA- Vol.34. No.4,1990:607-09
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JPD, october,1973: 526-32
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Removable partial prosthodontics- SYBILLE K
LECHNER.
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Removable partial prosthodontics- Miller & Grasso
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JPD, December, 1974: 639-45

JPD, July, 1953: 506-16

JPD, July, 1953: 517-24
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Q1. The first step in the diagnostic mounting
procedure is the mounting of the maxillary
cast on a
a) Fully
adjustable articulator
b) Semi-adjustable articulator
c) Denar
articulator
d)Free plane articulator

Q2. Face bow which requires styli to be
placed on selected points on the face is
a) Whip
mix
b) Hanau
spring bow
c) Hanau
SM
d)Hanau H2

Q3. Beyron’s point is located _ mm anterior
to the posterior margin of the tragus of the
ear on a line to the outer canthus of the eye
a) 11
b) 12
c) 13
d)14

Q4. While adjusting the articulator, the
following setting are followed for condylar
guidance, Bennett guide and incisal table
respectively
a) 30,
b) 0,
15, 0
30, 15
c) 15,
30, 0
d) 30,
0, 15

Q5. Ramfjord and Ash (1971) have stated
that three factors must be controlled in order
to succeed in determining centric jaw
relation. Which one is not among them?
a) Psychologic
b) Pain
stress
in temporomandibular joints
c) Muscle
memory
d) Systemic
illness

Q6. In which method of recording jaw
relation does the operator place all four
fingers of his hand on the lower border of the
mandible and thumbs over the symphysis?
a) Bilateral
manipulation of the mandible
b) Alternate
c) Both
d) Use
protrusion and retrusion
a and b
of an occlusal splint

Q7. Frequently the lateral pterygoid muscle prevents
relaxation and free rotation of the mandible. This method
attempts to fatigue this muscle sufficiently so that it will
reduce its contraction and allow retrusion of the mandible
a)
Bilateral manipulation of the mandible
b)
Alternate protrusion and retrusion
c)
Both a and b
d)
Use of an occlusal splint

Q8. Which of the following is not used to
record centric jaw relation
a) Acrylic
b) ZoE
paste
c) Dental
d) All
resin
stone
of the above are used

Q9. Wax is the most commonly used recording medium
while making jaw relations. Which is not true about it?
a)
It is most unreliable and unpredictable
b)
Can distort when the records are made, when the records are
stored and when the cast is mounted
c)
Exhibits “memory”
d)
The hard wax, Alu-wax, contains aluminium or bronze for
filler

Q10. While using metal impregnated wax,
water bath temperature kept is
a) 40°C
b) 43°C
c) 45°C
d) 37°C