Diagnosis of RPD patients

Presented by;
dr; Hamada Mahross
Ass. Prof. of prosth

1
 objectives
- The aims of the lectures are educating the students theoretic and practical
diagnostic step.

- Different systemic disease which implicated during treatment of partially

edentulous patients.

- Diagnostic aids and their importance.

- Treatment planning of partial edentulous cases.

2
 Contents
- Terms for diagnosis.
- Diagnostic procedures.
- Diagnostic aids Treatment planning of partial edentulous cases.

3
 Terms

Diagnosis; It is a general term denoting a scientific evaluation of existing condition (GPT6).

It include history taking, examination, treatment plane and prognosis.

Examination: it is the procedures performed by the practitioner to help treatment of the

patient.

Treatment plane: The sequence of procedures planned for the treatment of a patient
following diagnosis (GPT6).

Prognosis: it is the suspicion or prediction of end result for all treatment protocol as success
or not. Described as excellent, good, fair, or poor.

4
 Diagnostic Procedures
• History taking:

• Examinations:

1- clinical exam.: a- Extra-oral b- Intra-oral

2- diagnostic aids ( laboratory investigation, radiographic evaluation and diagnostic cast

analysis).

• treatment plane,

• prognosis.

5
6
a- personal data (social history);
- name, age, sex, race, occupation, address, Tel.
Number, alcoholic drinkers and previous dentist.

b- medical history;
- diabetic, cardiovascular, bone, skin, neurological,
cancer, transmissible, renal diseases or drugs.

c- chief complaint ;
( patient Owen wards).

7
 d- dental history.
- history of teeth loss.
- The Patient's Attitude to Dentures.
- history with edentulous period.

e- psychological evaluation.
- level of motivation
- psychological disorder.
- House (1978) classification( personality classification).

8
 Medical History
There are many systemic diseases can be causing difficulty during treatment
with RPD:

- Systemic disturbances that can have a significant effect on the treatment of the
patient include:

Diabetes , Vitamin deficiency , Cancer , Blood disease , hepatitis and

tuberculosis, arthritis, parkinsonism, epileptic…

9
 1- Diabetes:
uncontrolled diabetic patients suffering from;

- multiple small abscesses, Liability for

infection, poor tissue tone, reduce tissue
healing and gingival recession.

• Prosthodontic difficulty:
- reduced salivary output (Xerostomia), which reduce the ability to wear
denture with comfort, reduce retention and increases caries potential.
- Increased residual ridge resorption.
10
 2- Vitamin deficiency
• cause

- inflamed and bleeding gingiva and fissures in the corners of the mouth
(angularchilitis ….. Vitamin B12 deficiency).

11
3- Cancer:
complications arising from radiation and chemotherapy for malignancies are
mucosal irritation, Xerostomia and bacterial and fungal infections, radiation
caries ( cervical) , osteo-radionecrosis of bone.

12
4-Blood disease
e.g. anemia; patients have pale mucosa, sore and red
tongue and gingival bleeding.

5- Transmissible diseases;
e. g. hepatitis and tuberculosis;

Infection for the dentist, patients and dental

auxiliaries.

13
6- Epilepsy: (phenytoin ttt)
- The denture is contraindicated if severe sudden attack with
little or no warning.

- If treated with prosthesis must select a material has

radio-opaqe properties.

- if treated with phenytoin the problem of gingival

hyperplasia occur.

14
7- cardiovascular disorder,
hypertension, hypotension, artificial valve,
angina….,

special protocol submitted to

- adjust patient position,

- make a short visit,

- patient may be subjected to syncope or

comatized.

- so select the time of visit and the prescribed drugs bring with the
15 patient.
8- rheumatoid Arthritis,

difficulty in adjust patient position and recording jaw

relation.

9- parkinsonism,

improper neuromuscular coordination and difficulty

during procedure.

10- facial paralysis,

asymmetric face cause unbalance and difficulty in

jaw relation.
16
11- Current Medication;

 Insulin *

 Anticoagulants : bleeding occur with traumatic procedures.

 Antihypertensive: dryness & postural hypotension.

 Corticosteroids: dryness, confusion & behavioral changes.

 Antiparkinson agents like Norflex and Akineton: dryness, confusion & behavioral changes.

17
 Dental History

- The cause of teeth loss…> ( caries, periodontal, traumatic, surgical…)

- Patient experience…..> ( have a denture or not)

- Expectation of treatment……> ( as if a palatal coverage need..

- Chewing habits….. > (preferred side for chewing.

- Para functional habits ……….> as clinching and Bruxism has adverse effect on the denture
supporting structures.
18
 The patient's attitudes towards dentures
• DeVan stated that, "We should meet the mind of the patient before we meet the
mouth of the patient."

• psychological status of the patient have considerable influence on the success of the
treatment, the patient according to House (1978) classification can be classified into;

1- Philosophical patients 2- The exacting patients

3- The hysterical patient 4- Indifferent patients

5- skeptical.

19
 House (1978) classification

1- Philosophical patients are the easiest to treat, adjust to any prosthesis that is well designed and
constructed.

2- The exacting patients are satisfied only by perfection. These patients should not be promised that
they will be able to wear a prosthesis without inconvenience or discomfort.

20
3- The hysterical patient are emotionally unstable
and tend to complaint without valid reasons.
4- Indifferent patients are characterized by lack of
motivation about their oral health. They are
uncooperative in treatment and tend to ignore
instruction.
5- Skeptical patients are whose have a bad
experience with old doctor.

21
22
 Clinical examination

Extra oral Intra-oral

Facial Examination
TMJ Examination
• Visual, digital and auscultation.
- examination of teeth and surrounding
tissues,
- Pocket depth
- Vitality tests of critical teeth
- Residual ridge

23
 Visual and Digital Oral
Examination

- The teeth and periodontium, The

alveolar ridge , The oral mucosa ,
Hard tissue abnormalities , Soft
tissue abnormalities

24
- Quantity and quality of saliva

- Oral hygiene

- Caries susceptibility

- Evaluation of space for mandibular

Major connector

- Examination of old denture

25
 Occlusal relationships

- Relation between opposing (natural or

artificial teeth) in centric occlusion.
- Over jet and overbite,
- if heavy close bite or open.

26
 Occlusal relationships

- Available interocclusal space.

- Occlusal wear causing change vertical
dimension.
- Occlusal plane orientation.

27
• Abutment evaluation;
- Alignment

- Number

- Periodontium, pocket depth

- Restoration; filling and crowning

- Mobility

- Isolated abutment (pier abutment

“alone standing abutment”).

28
 I- Radiographs
II- Mounted Diagnostic casts
(Diagnostic cast analysis)
29
 I- Radiographs:
- Radiolucent and radiopaque areas,
which may indicate a pathological
conditions

- Carious lesions and existing

restorations

- Root fragments and other foreign

bodies

- Unerupted third molars

- Root canal fillings

30
 Radiographs The abutment teeth

- Crown / root ratio.

- Bone changes around the abutment teeth

include;

loss of lamina durra, loss of bone height, widening

of the periodontal ligament space and apical or
furcation radiolucency.

31
 Radiographs The abutment
teeth

- Root length, size, number, form, carious and furcation involvement.

Root no. & morphology

32
 Radiographs The abutment
teeth
• Bone factor :
Reaction of the bone to extra load (index area); determined by the amount of bone
resorption or degree of radiolucency and radio-opacity of bone.

33 -ve bone response +ve bone response

 II- Mounted Diagnostic casts
(Diagnostic cast analysis)
Indications;

1- Evaluation of occlusion and space

available.

2- Topographic surveying of the dental arch:

3- Comprehensive presentation to the patient

about the ttt .

4- Construction of special trays.

5- Constant reference as work progress.

6- permanent record for the patient before ttt.

34
 II- Mounted Diagnostic casts
It helps in analysis of : (Diagnostic cast analysis)
1- Inter-arch distance:

A common finding is lack of sufficient inter-arch distance for the placement of artificial
teeth caused by a too large maxillary tuberosities and the opposing teeth over
eruption.

35
 II- Mounted Diagnostic casts
(Diagnostic cast analysis)
2- Lack of Centric Stops

36
 3- occlusal plane :

The occlusal plane may be irregular because one or more are unopposed teeth extruded or
malposed.

37
 II- Mounted Diagnostic casts
(Diagnostic cast analysis)

4- Permitting lingual view.

38
 II- Mounted Diagnostic casts
(Diagnostic cast analysis)

5- OCCLUSAL RELATION and intercuspal

relation

39
 II- Mounted Diagnostic casts
(Diagnostic cast analysis)

6- Topographic surveying of the dental arch:

- Parallel proximal teeth surfaces

- Retentive areas & non retentive,

- Areas of Interferences.

40
 II- Mounted Diagnostic casts
(Diagnostic cast analysis)

7- construction of special tray;

41
 Treatment Planning for The Partially
Dentate Patients

42
 If space exist?

Leave it
Restore it
When?

Fixed prosthesis Removable prosthesis Implants

Acrylic partial dentures Cobalt Chrome partial dentures

43
 When we leave space !?

• The concept of the shortened dental arch ( SDA) → remember

this when deciding whether or not to restore a free-end saddle.

44
 SDA Principle
“The SDA concept is that adequate oral function can be
maintained with a reduced dentition, consisting of 9 or 10
occluding pairs of teeth”

45
 SDA CONCEPT

• Provision of satisfactory oral function

without the use of removable partial
dentures.

• Priority is to maintain anterior and

premolar dentition in both jaws.

46
• Indications of SDA;

- Patient is able to function comfortably.

- Patient is able to chew food without pain.

- 10 occluding pairs with good prognosis.

- No evidence of trauma from occlusal contact .

- Patient is not motivated to pursue a complex treatment plan.

47
 If space exist?

Leave it
Restore it
When? When?

Fixed prosthesis Removable prosthesis Implants

Acrylic partial dentures Cobalt Chrome partial dentures

48
Fixed or
Removable?
1. Saddle → If bounded → Think fixed.

2. If free-end saddle → Think removable.

3. Length of span→
- If one tooth or two teeth missing → Think
fixed
- If many teeth missing →
Think removable

49
 Fixed or Removable?

4. Tilting of abutment →

If tilted → Think removable.

If parallel → Think fixed.

5. Clinical crown height of abutment teeth. ( crown/ root

ratio)

6. Condition of abutment teeth →

If heavily restored → Think fixed

If sound → Think removable

if attrition …..> think fixed.

50
7- Bone loss → If significant → Think removable.
8-The patient’s needs and requests.

51
 If Removable partial dentures
- Acrylic or Cobalt Chrome?
1- Number of missing teeth →

If only few teeth remaining → Think acrylic.

2- Age of patient →

If teeth are still developing → Think acrylic.

3- Aim of providing dentures →

If temporary, immediate or transitional → Think acrylic.

If Permanent → Think Cobalt Chrome.

4- Patient’s needs and requests.

If patient is allergic to metal → Think acrylic.

5- if patient uncontrolled diabetic or loss of teeth due to periodontal

diseases …….>Think acrylic for suspicion of future relining
needed.

52
 Quizzes

What's the
treatment
plane for
case “a”
53
 References
• McCracken’s Removable Partial Prosthodontics 12 th
edition, Mosby Co. 2011 pgs: 150-184

54
 Thank You
55