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Oral diagnosis and treatment IN BRIEF

Highlights that, in general, fixed


planning: part 7. Treatment rather than removable prostheses are

PRACTICE
increasingly preferred by patients.
Stresses that in all instances a panoramic

planning for missing teeth radiograph is required, which may reveal


retained roots and other conditions likely
to cause dental treatment problems.
Determines that where no compelling
F. McCord1 and R. Smales2 reason can be found, no replacement of the
missing teeth is the preferred treatment
option, particularly in older adults.
VERIFIABLE CPD PAPER

Although more people are retaining increasing numbers of their natural teeth into older ages, approximately 3040% of
persons over the age of 75years in Western countries are edentulous. The causes and significance of tooth loss vary widely
among individuals and cultures, and missing teeth may be replaced by a variety of means for functional, social and psycho
logical reasons, rather than for significant physical health benefits. Therefore, it is essential to determine what the loss of
teeth means to patients and what their expectations are for the outcomes following tooth replacement by various methods.

When there are compelling reasons for often required before a definitive prosthesis of teeth and the replacement of missing
tooth replacement, and when there are is fabricated for the clinical option chosen teeth results in an increased need for pre
no financial or other constraints, then in consultation with the patient. The suc ventive, periodontal and restorative dental
fixed rather than removable prostheses cessful outcome of complete dentures in services, which may not be available to, or
are increasingly preferred by patients. particular is determined by many patient, affordable by, many disadvantaged per
For both partially dentate and edentulous dentist and dental technician factors. sons. Providing dental care for the elderly
patients, either initial restorative or other Successive national oral health sur is more complex than providing dental
pre-prosthetic preparatory treatments are veys from several Western countries care for younger patients. Deleterious
show an increasing number of natural cumulative effects from dental diseases
teeth retained in their increasingly elderly and previous dental treatments, combined
ORAL DIAGNOSIS populations. However, the average num with increasing physical and mental health
AND TREATMENT PLANNING* ber of teeth present decreases with age, in problems (and associated polypharmacy-
Part 1. Introduction to oral diagnosis particular after the age of approximately induced problems) that may be associ
and treatment planning 5565 years, when around 810 perma ated with ageing, are challenging factors
Part 2. Dental caries and assessment of risk nent teeth (usually posterior) are missing. for satisfactory treatment planning and
Part 3. Periodontal disease and assessment
Although fewer persons are now edentu patient management. In addition, the
of risk
Part 4. Non-carious tooth surface loss lous, the prevalence increases markedly in increased demands and expectations
and assessment of risk those aged 75years or older to approxi of many older patients for various aes
Part 5. Preventive and treatment mately 3040%. Though only approxi thetic restorative treatments that have
planning for dental caries
mately 15% of persons wear dentures, been promoted by media sources are not
Part 6. Preventive and treatment
planning for periodontal disease the prevalence also increases markedly in always realistic.
Part 7. Treatment planning for those aged 75 years or older to around
missing teeth 60%. In addition, many of these elderly CAUSES AND SIGNIFICANCE
Part 8. Reviews and maintenance persons require either new, or repairs to
OF MISSING TEETH
of restorations
existing, removable complete and partial The reasons for the teeth being missing
*This series represents chapters 1, 7, 8, 9, 14, 15, 16 and 19 from
the BDJ book A Clinical Guide to Oral Diagnosis and Treatment dentures. For many reasons, some 20% should be determined as part of the pre
Planning, edited by Roger Smales and Kevin Yip. All other
chapters are published in the complete clinical guide available of all dentures are not usually worn by vious dental history. Usually, teeth are
from the BDJ Books online shop.
patients. The future need for prosthodon missing because of extractions caused by
tic services will increase substantially in previous dental caries and advanced peri
tandem with ageing populations. odontal disease. Unfortunately, in many
1
12 Harlyn Avenue, Bramhall, Stockport, Cheshire, SK7 Despite improvements in oral health, as instances the remaining teeth and poten
2HN; 2* Visiting Research Fellow, School of Dentistry,
Faculty of Health Sciences, The University of Adelaide, shown by various surveys, there are large tial tooth abutments for prostheses are
Adelaide, South Australia 5005, Australia differences in the levels of oral disease compromised by the same dental diseases.
*Correspondence to: Roger J. Smales
Email: roger.smales@adelaide.edu.au present among populations from differ Some teeth may not be present following
ent socioeconomic groups, and between acute trauma, or because they are either
Accepted 7 June 2012
DOI: 10.1038/sj.bdj.2012.889 institutionalised and non-institutional unerupted or impacted. In other instances,
British Dental Journal 2013; 213: 341-351 ised populations. The increased retention teeth may not be present in the mouth

BRITISH DENTAL JOURNAL VOLUME 213 NO. 7 OCT 13 2012 341


2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

because they are congenitally absent. In Individuals also place a differing empha medical, dental and social/family histo
all instances, a panoramic radiograph is sis on the relative importance of mastica ries, followed by a thorough extraoral and
required, which may reveal retained roots tory function, phonetics and appearance. intraoral clinical examination. Before a
and other conditions likely to cause dental For example, bilateral mandibular free-end treatment decision is made to replace miss
treatment problems. saddle (denture base) removable partial ing teeth, the reasons usually stated for
Increasingly, tooth loss from dental dentures may be worn only to improve such a decision should be examined. All
caries is associated with hyposalivation appearance, and be removed to allow bet too often, it is automatically assumed that
caused by many prescription and non- ter and more comfortable chewing. Many all missing teeth have to be replaced, often
prescription drugs, and by salivary gland patients are more concerned about the for ill-defined and unconfirmed reasons.
damage. Apart from increased dental car adverse effect on their appearance caused Do tooth extractions lead to occlusal
ies that typically involves the cervical and by a single missing maxillary anterior instability and the worsening of the peri
cusp tip/incisal edge regions and exposed tooth than about any possible adverse odontal health of adjacent teeth? Though
roots of the teeth, severe hyposalivation effects caused by many missing posterior no substantial evidence base is available,
also may result in: teeth. Following the loss of (usually molar) clinical experience indicates the tooth loss
Dry, reddened painful oral mucosa and teeth in younger patients, concerns may in middle-aged and older persons does not
cracked lips, angular cheilitis, atrophy occasionally be expressed about subse lead to significant tooth migration and
of the tongues filiform papillae and quent problems caused by the migration tipping of posterior teeth adjacent to the
gingivitis and tipping of teeth adjacent to the extrac extraction sites, or to significant supra-
Candidosis, oesophagitis, heartburn tion sites, and by the supra-eruption of eruption of posterior teeth opposite the
and oral malodour (halitosis) unopposed teeth. extraction sites. In most instances, long-
Impaired speech, chewing, swallowing, Moderate loss of posterior teeth may or term tooth movements in one study were
taste and smell may not result in a significant decrease 1.0 mm, and largely stable after two
Impaired denture wearing and denture- in maximum bite force. There is a very years. Occlusal instability following tooth
induced stomatitis. large overlapping range of maximum bite extraction is more likely following perma
forces between persons with reduced num nent molar extractions in adolescents and
Affected persons may aggravate their bers of posterior teeth and those with com young adults. Clinical advantage may even
existing poor oral and general health by plete natural dentitions. The gender and be taken of the rapid mesial migration of
resorting to cariogenic and acidic foods, frailty of persons is probably of greater erupting permanent molar teeth in chil
beverages, chewing gums and confec significance for maximum bite force than dren. When the extractions of first or sec
tionary. Their quality of life may be very merely the possession of a certain num ond permanent molar teeth are required,
poor, leading to chronic depression with ber of natural teeth. Maximum bite forces then these extractions may be timed to
potential increased suppression of saliva should not be equated with chewing effi allow tooth replacement (repositioning)
production. ciency, because chewing occurs at much by the rapid mesial migration of erupting
The significance of loss of teeth var lower forces. Chewing efficiency is related second or third molar teeth, respectively.
ies greatly among individuals. A sin to the number and types of natural teeth How many pairs of occluding teeth are
gle missing second molar tooth may be present, and artificial teeth and prostheses needed for adequate function and appear
a significant concern for one person, present, as well as to the types of food ance? A full complement of 32 or even
while another person may regard being consumed and amount of saliva produced. 28permanent teeth is not required for the
edentulous as inevitable and merely an Importantly, the significance of the miss masticatory system to function adequately.
inconvenience. Others believe that all of ing teeth to the patient, and to the dental The concept of the shortened dental arch
their dental problems will be resolved health of the patient, must be determined is well established. In older persons,
most effectively by the extraction of all before tooth replacement is undertaken. In tenpairs of occluding anterior and premo
of their teeth. In years past, it was not most instances, in most patients, not all lar teeth meet the functional and aesthetic
unusual for young adults to have all their missing teeth require replacement either demands of most patients, with two pairs
teeth extracted before marriage or before to avoid adverse social, professional, psy of molars required for the improved chew
commencing employment in some occu chological and dental health problems, or ing of very hard foods. Six to eightpairs
pations. In some instances, the removal to allow adequate mastication, phonetics only of occluding anterior and premolar
of a previously sound maxillary central and appearance. It is debatable whether, teeth may possibly lead to occlusal insta
incisor tooth is evidence of adult initia apart from quality-of-life concerns, that bility, but the evidence is weak.
tion and acceptance into a specific popu the replacement of congenitally absent or Do fixed and removable partial dentures
lations culture, and the missing tooth is extracted teeth significantly benefits patients lead to better oral health and improved
not replaced. However, the absence or loss from a physical medical health perspective. survival of the remaining teeth? Adjacent
of teeth in some persons may have severe tooth survivals after tenyears were high
social and professional ramifications, and THE PARTIALLY DENTATE PATIENT and not significantly different for either
be strongly associated psychologically Treatment options for missing teeth should untreated extraction spaces or tooth
with the loss of self-esteem and even the be preceded by a systematic gathering replacements by fixed prostheses. However,
adverse consequences of ageing. of information concerning the patients the long-term survivals of teeth adjacent

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PRACTICE

Table 1 Relative advantages and disadvantages of fixed and removable partial dentures

Fixed partial dentures Removable partial dentures

Advantages: Advantages:

More natural appearing tooth substitutes Generally less expensive

Feel more natural Minimal tooth preparation

Superior stability with chewing hard foods Longer edentulous spans can be restored
Fig. 1 The mesiodistal space between the
Minimal soft tissue coverage Replacement of missing alveolar ridge tissues is possible
missing central incisor and the first premolar
is larger than the contralateral lateral incisor Not easily removed Can be removed for cleaning and adjustments or repairs
width, the loss of labial alveolar bone has
attened the arch contour, and rotation of Disadvantages: Disadvantages:
the first premolar has created additional
More expensive Clasps may be unattractive
aesthetic problems
More suitable for short spans Designs may be bulky, complicated and plaque-retentive

Extensive tooth preparation is usual May cause gagging


Abutments must be in good alignment
Retention and stability may be problematic
and functionally adequate

older adults, no replacement of the missing ridge between, or distal to, the
teeth is the preferred treatment option. The abutment teeth is adequate in quantity
advantages of not replacing every missing and quality
tooth include, less: The soft tissue of the edentulous ridge
Complex and costly dental treatments is satisfactory in quantity and quality.
Fig. 2 The very deep anterior overbite has
required
created insufficient vertical space for the
fabrication of the cast frame for a removable Iatrogenic tissue damage and resulting An assessment also needs to be made of
partial denture problems the space available for the prosthesis, after
Protracted treatments, treatment stress mounting diagnostic casts on a semi-adjust
and discomfort able articulator. Mesio-distal spaces between
Subsequent dental disease and the abutment teeth may be too small or too
problems with less-than-ideal large for the artificial tooth pontic(s)/dental
abutment teeth implant(s) relative to the sizes and positions
Maintenance and replacement of of the natural teeth (Fig.1).
defective prostheses In some instances, orthodontic tooth
Risk of litigation from failed repositioning and/or judicious contouring
treatments and dissatisfied patients. of natural tooth crowns using resin com
posite may be indicated. Isolated pier abut
Fig. 3 A removable Dahl anterior bite-raising When natural teeth are being considered ment teeth and their prosthodontic retainers
appliance incorporating artificial central as potential abutments for either fixed or are prone to failures caused by functional
and lateral incisors will allow the remaining removable prostheses to replace missing overloading. Fixed partial dentures should
posterior teeth to erupt passively into
occlusal contact over a period of 36 months, teeth, several factors need to be considered. have a semi-rigid connector placed at the
thus providing increased anterior inter- Investigations include radiographic, pulp, distal surface of the central pier abutment
occlusal space dental hard tissue and periodontal tissue retainer. When planning for removable
health, and occlusal evaluations. Ideally: partial dentures, consideration should be
to extraction spaces were significantly The teeth are structurally sound, with given to elective endodontic therapy and
lower where removable partial dentures satisfactory appearance and crown forms de-coronation of the pier tooth, using the
were used. Failed teeth had more restora The teeth are in good alignment and root to support the denture.
tive, endodontic and periodontal treat position, requiring neither orthodontic Insufficient inter-occlusal vertical space
ments than surviving teeth. Many studies therapy nor complex designs for the may require an increase in the occlusal
have demonstrated the adverse effects of prostheses vertical dimension. This may be achieved
removable partial dentures on the abut The previous restorations and by placing a Dahl bite-raising appliance
ment teeth in particular. Adverse effects endodontic treatments are satisfactory that only occludes with selected teeth, thus
on the oral soft tissues and alveolar bone The abutment tooth roots and allowing the separated non-occluding teeth
also may be present. supporting alveolar bone are to erupt further passively (Figs2 and 3).
In all instances where no compelling functionally adequate Instead of first using a Dahl appliance, per
reason can be found, and particularly in The alveolar bone of the edentulous manent restorations (usually either resin

BRITISH DENTAL JOURNAL VOLUME 213 NO. 7 OCT 13 2012 343


2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

composite build-ups, artificial crowns or


cast onlays), employing the same principle
may be placed immediately. Alternatively,
a cast alloy removable onlay denture may
be fabricated. Often, the abutment teeth,
or proposed dental implants, may be over-
tilted facio-lingually. This usually involves Fig. 8 To reduce the stresses arising from
the lingual tilting of mandibular molar occlusal forces, the partial denture in the patient
and premolar teeth, and the facial tilting in Fig. 7 incorporated a semi-rigid connector
Fig. 4 After the fabrication of a conventional housed within the first premolar pontic
of maxillary dental implants that are con
cantilever fixed partial denture to replace the
strained by the form of the alveolar ridge. missing premolar, the patient decided that she
no longer required a removable partial denture
FIXED PARTIAL DENTURES for improved chewing and appearance
(BRIDGES)
Despite their higher costs, fixed prostheses,
including dental implant superstructures,
are perceived by patients to be preferable
to removable partial dentures for replac
ing missing teeth. Many removable par
tial dentures are not worn, in particular Fig. 9 Maxillary occlusal view of multiple
mandibular posterior free-end saddle missing teeth and a long edentulous span
appliances and those that do not improve anteriorly. The right second premolar is a pier
abutment tooth
the appearance of patients. The fit, reten
tion, support and stability of acrylic resin Fig. 5 A resin-bonded fixed partial denture
was cantilevered from the maxillary left
removable partial dentures are often central incisor to replace the missing right
unsatisfactory. Relative advantages and central incisor
disadvantages for fixed and removable
partial dentures are given in Table 1. Often,
a short-span fixed prosthesis or a dental
implant can be used to replace a single
missing anterior or premolar tooth, and
a removable partial denture of simplified
design can then be used to replace multiple Fig. 10 Mandibular occlusal view of multiple
missing teeth from the same patient in Fig.
missing posterior teeth in the same patient. 9. The retained left first premolar root was
Frequently, however, following the place Fig. 6 The palatal view shows a resin-bonded extracted
ment of the fixed prosthesis, the patient fixed partial denture cantilevered from the
decides that the additional removable maxillary right central incisor to replace the
missing left central incisor, in a younger patient
prosthesis is not really necessary (Fig.4).
There have been several reports of
numerous designs proposed by different
practitioners for both fixed and remova
ble prostheses to replace the same missing
teeth. Increasingly, with the outsourcing
of laboratory work and the reduction in
undergraduate prosthodontic clinical expe
rience, designs and materials for prostheses Fig. 7 The maxillary second molar and canine Fig. 11 The upper removable partial denture
are no longer being prescribed by dentists. have been prepared to fabricate a long- designed for the dentition shown in Fig. 9.
span fixed-movable partial denture that will The pier abutment tooth does not provide any
There have also been differing opinions
oppose the natural dentition support or retention for the metal frame
on using either dental implants, or fixed
and removable prostheses to replace sin biological hard and soft tissue costs to the cantilevered fixed prostheses of all
gle missing teeth. The choice is obviously patient. Simplified designs for the pros designs had a reported ten-year survival
inuenced by numerous patient-related theses are required to minimise damage to of 82%. This figure would undoubtedly
and dentist-related factors. Although there teeth and soft tissues. be higher for short-span conventional
is no perfect design for a prosthesis, some Missing single anterior and premolar mesially-cantilevered prostheses placed in
designs are more appropriate than others teeth may be replaced effectively using low-stress situations.
for patients. Whatever treatment mode is short-span cantilevered fixed prosthe Resin-bonded single tooth replace
selected, it should minimise the long-term ses. From meta-analysis, conventional ments using cantilevered metal or winged

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PRACTICE

ceramic retainers have reported fiveyear REMOVABLE PARTIAL DENTURES


survivals from 8392%. These percentages These are usually considered when mul
were much higher than those for resin- tiple missing teeth, long edentulous
bonded fixed-fixed designs using the spans, unsuitable abutment teeth that
same two retainer materials (Figs 5 and also may include sound abutment teeth
6). The earlier metal framework designs in young patients, alveolar ridge deficien
for resinbonded prostheses resulted in cies (because socket preservation grafting
unacceptable failure rates. Since then, was not carried out at the time of tooth
the importance of both improved reten extraction), and financial costs preclude
Fig. 12 The lower removable partial denture tive and resistant tooth preparation and alternative fixed prostheses. However,
designed for the dentition shown in Fig. 10.
Long cast clasps achieve adequate exibility framework designs has been realised. missing tooth spaces with a single central
to prevent their permanent deformation and Resin-bonded cantilevered anterior sin pier abutment tooth result in more com
fatigue fracture gle-tooth replacements require two diag plex metal framework designs and high
onally opposite axial retention grooves stresses on the pier abutment (Figs9 to 12).
placed in the abutment tooth, while sim Tooth-supported removable partial
ilar posterior single-tooth replacements dentures are generally preferable to those
require that the two diagonally opposite that are soft tissue-borne or mucosal-
axial grooves in the abutment tooth be supported, and removable partial den
joined occlusally by a Dshaped strut. tures with cast alloy frameworks are
Cantilevered designs include the advan generally preferable to acrylic resin-based
tages of simpler single-tooth preparations partial dentures. The latter are usually
and easier insertion of prostheses, and entirely mucosal-borne resulting, in the
Fig. 13 Gingivally-approaching long Ibar being less expensive than conventional mandible in particular, in excessive alve
cast clasps maintain adequate exibility while
minimising their conspicuousness
fixed-fixed prostheses. olar bone resorption and gingival reces
Conventional fixed-fixed and fixed- sion affecting adjacent teeth. Cast alloy
movable partial denture designs and, in frames using base-metal alloys require
selected situations, resin-bonded fixed- long cast clasp arms (~14 mm) engag
movable partial denture designs may be ing small retentive undercuts (~0.25mm)
suitable for longer-span edentulous ante to prevent their permanent deformation
rior and posterior sites (Figs 7 and 8). and fatigue fracture caused by constant
The retainer designs should allow for the exure when placing and removing the
later possible loss of abutment teeth hav partial denture. Therefore, long gingivally-
ing a questionable long-term prognosis, approaching Ibar clasps are required for
and for the possibility of the patient later canine and premolar abutment teeth, espe
Fig. 14 Stone cast of the resorbed edentulous requiring dental implants or a remov cially when using stiff cobalt-chromium
mandibular alveolar ridge. The 60-year old
patient was unable to wear several previous able partial denture. In this latter situa alloys (Fig.13).
sets of removable complete dentures tion, the appropriate fixed partial denture Wrought stainless steel wire clasps,
crown retainer should include an occlusal which have greater exibility, may be
rest seat, a lingual guide plane, and have indicated for short clasp arms engaging
the facial surface contoured to allow for larger undercuts. Simplified biologically
future adequate denture clasp retention, if friendly removable partial denture designs
so required. are preferred, which attempt to minimise
The survival rates of vital abutment plaque retention and contact of the partial
teeth are usually higher than those for denture with tooth and gingival tissues.
non-vital endodontically treated abut Removable partial dentures require
Fig. 15 Panoramic radiograph of implant-
ment teeth, for long-span fixed prosthe regular patient recalls and high main
retained fixed lower complete denture, from
the patient in Fig. 14 ses in particular. The survival rates of tenance, with the need for adjustments
long-span fixed partial dentures also are and the repair of denture fractures and
usually lower than those for short-span of tooth abutments a common occur
prostheses. A meta-analysis of six stud rence. Problems may include tooth and/or
ies of fixed partial dentures inserted on mucosal pain or discomfort, looseness, dif
teeth with severely reduced but healthy ficulties in seating, problems with chewing
periodontal tissue support yielded surviv and speech, and poor appearance of the
als of 93% after ten years, which com denture. Despite the use of simple remov
Fig. 16 Frontal view of removable upper pared favourably with similar prostheses able partial denture designs and regular
complete denture and fixed lower complete placed on non-periodontally compromised recalls, their survival rate in one large
denture, from the patient in Fig. 14
tooth abutments. study was only 50% after tenyears.

BRITISH DENTAL JOURNAL VOLUME 213 NO. 7 OCT 13 2012 345


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PRACTICE

OSSEOINTEGRATED problems and costs associated with and local anatomical and other oral fac
DENTAL IMPLANTS implant superstructures in particular. tors, is required for successful dental
The use of dental implants, in particu The clinical success rates of implants are implant-supported prostheses. There are
lar single-tooth implants, continues to usually not reported, but are lower than many biophysical differences between a
increase. Some 25% of practitioners now the actual high survival (retention) rates natural tooth and an endosseous dental
provide this treatment in developed coun reported, which often pertain to relatively implant, requiring careful assessments
tries. An extensive literature has docu small long-term sample sizes. In addition, of occlusal loading of implants and the
mented the high long-term clinical survival implant failures before functional load design of the prosthetic superstructures.
rates of osseointegrated dental implants ing may be excluded from the survival During the childhood period of rapid
supporting single-tooth crowns, fixed analyses. Thus, excellent results may be jaw development, apart from the ante
partial and fixed complete dentures, and recorded despite such occasional failures, rior mandibular region, the placement of
implant-supported removable complete the presence of soft tissue complications dental implants in the jaws is not advis
overdentures in selected patients. When and high marginal bone losses around able because the implants behave as
they are indicated, dental implants offer the implants, and technical complications ankylosed teeth. As part of the treatment
increased comfort, retention and stabil requiring treatment. planning process, sophisticated three-
ity for mandibular complete dentures and Unfortunately, there is a lack of long- dimensional radiographic imaging and
overdentures in particular (Figs14 to 16). term controlled clinical trials to determine associated treatment planning software
However, implant-supported fixed par the relative cost-effectiveness of replacing are promoted to achieve the optimum
tial dentures do not appear to provide a even single missing teeth. Such trials are intraosseous placement of various sizes
significant functional improvement com required to establish the relative cost-effec and forms of dental implants. Cone beam
pared to tooth-supported removable partial tiveness of the single implant-supported computed tomography is rapidly becom
dentures. Considerable ingenuity has been crown, the cantilevered twounit fixed par ing the required diagnostic and treatment
used to overcome the problems caused for tial denture (both conventional and resin- planning method.
implant placement from inadequate bone bonded), and the endodontically treated and
support and the anatomical structures pre restored tooth. The single implant option is INITIAL AND DEFINITIVE
sent at some sites. But, several of the surgi possibly the least cost-effective long-term
TREATMENTS
cal procedures required are both traumatic treatment choice, though there may be lit Extensive and expensive comprehensive
and expensive, and are not accepted or tle short-term cost difference between the definitive treatments to replace missing
afforded by many patients. single-tooth implant and the more exten teeth should be deferred until the initial
Though the long-term survival (reten sive conventional threeunit fixed partial emergency, active disease control, pre
tion) of dental implants is very high, denture in some practices. Financial costs ventive and restorative dental treatments
the long-term survival of the prosthetic should be balanced against biological required are completed and the results
superstructures is somewhat lower. A costs, as the use of dental implants avoids evaluated. Teeth are often missing because
meta-analysis of survival studies reported the problems of dental caries, tooth ero of untreated previous dental diseases aris
93% for implants and 87% for superstruc sion and the preparation of abutments in ing from dental neglect. In many instances,
tures after ten years. However, 39% of sound tooth structure, as well as exces the remaining teeth show evidence of
patients had superstructure complica sive alveolar ridge resorption following similar untreated dental diseases such as
tions, usually minor, and 9% had peri- tooth extractions. dental caries and periodontal disease, and
implantitis and soft tissue complications The unattractive display of clasps on untreated conditions such as tooth surface
needing treatments after only fiveyears. removable partial dentures and of metal loss, and unsatisfactory restorations and
Another study of single-tooth implant retainers in resin-bonded fixed partial root canal therapy. Decisions have to be
survivals found 97% for implants and dentures may be avoided. Dental implants made as to which teeth are likely to have
83% for superstructures after fouryears. may also act as substitutes for unsatisfac a poor long-term prognosis, which teeth
At this time, approximately 20% of tory tooth abutments, and may be prefer are non-restorable, and which teeth are
patients had mechanical superstruc able when there are long edentulous spans critical to maintain as possible abutments
ture complications needing some form present (Fig. 17). Although there are no for prostheses.
of treatment. In edentulous jaws, over significant differences in survival between Unfortunately, consistency in treat
five years, superstructure repairs were restored endodontically treated teeth and ment decisions by individual practitioners
found to be high when implant-supported single-tooth implants, there is some anec is lacking, and there also is ample evi
prostheses were opposed by fixed pros dotal evidence to suggest that increasing dence of the inability of different practi
theses of similar design, but low where numbers of endodontically questionable tioners to agree on the most appropriate
the implant-supported prostheses were teeth are being extracted unnecessar treatment plan for a particular patient.
opposed by removable complete den ily, and being replaced by costly dental However, although there are few clinical
tures. High maintenance has also been implants to then preserve the remaining prosthodontic guidelines that are strongly
reported for implant-supported removable alveolar bone. evidence-based, the practitioner should
complete overdentures. These studies all Careful treatment planning involving have an established template on which to
point to frequent long-term maintenance physical and psychological health factors, base short-term and possible long-term

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PRACTICE

Treatment stratergy options

No operative treatment

Monitor Operative treatment

Fig. 17 Three dental implants have been


placed in the long edentulous span distal to
Ever Adapt and maintain a
the restored maxillary first premolar
preventative programme

treatment plans that are appropriate for Basic treatment eg OHI,


simple cons/perio/exodontia
each patient (Fig.18).
First, the information obtained from
the histories and clinical examination Restore with a prosthesis
should broadly determine, after careful (fixed and/or removable)
reection on the risk-benefits of each
strategy, whether therapeutic treatment Render edentulous (or de-coronate) in one or both jaws, provide complete
is required or not. And, if treatment is dentures (or overdentures), eith immediate or definitive
required, whether the remaining dentition
should either be restored or the patient Fig. 18 Initial broad treatment strategy options (adapted from McCord JF, Grant AA, Youngson
rendered essentially edentulous in one or CC, Watson RM, Davis DM. Missing reeth a guide to treatment options. pp 12, Fig. 2.
Edinburgh: Churchill Livingstone, 2003. Copyright Elsevier 2008, adapted with permission)
both jaws. (Transitional therapy involv
ing a training denture may be consid
ered when, in the reasonably near future, younger than in older persons. The larger Monitoring of oral health
becoming edentulous is inevitable). Next, pulp chambers present in younger persons and treatments
the clinical options for replacing missing may preclude the provision of anterior all- Monitoring of oral health and the con
teeth by using dental implants, traditional ceramic crowns. dition of prostheses, together with the
fixed and removable partial or complete maintenance of a preventive programme
dentures (and combinations thereof) are Dentist and technician factors is required for all patients. Monitoring
determined by many patient-related and Of critical importance are the abilities is a proactive recorded process, which
dentist-related factors. Many of these gen of the dental practitioner and laboratory should not be confused with doing noth
eral considerations or factors have been technician competently to provide the ing over long periods, as with instances of
mentioned previously (parts one and six). treatment and prostheses required, and to active periodontal disease and tooth ero
However, several additional factors are maintain and repair the prostheses. Good sion. Basic dental treatments are usually
pertinent to the replacement of missing teamwork, involving good communica required before the subsequent provision
teeth in the partially dentate patient. tion and planning, is important to avoid of a prosthesis. In many instances, ini
problems in the fabrication of prostheses tial preparatory treatments may be quite
Patient factors and the ordering of parts and laboratory extensive and require a period of moni
Numerous periodontal pockets, restora analogues. Detailed laboratory instructions toring after their completion before any
tions, endodontic therapies and extensive should accompany the disinfected high- prosthesis is fabricated.
tooth surface loss affecting the remaining quality clinical records. Semi-adjustable Frequently, the so-called ideal treat
teeth of young adults are more clinically articulators should be stipulated as being ment plan is replaced by the most practical
significant than similar conditions present routine for fabricating most prostheses. or realistic optimal treatment plan. Most
in older persons. Smoking is a significant Appropriate magnification is essential for dental problems have more than one treat
factor for adversely affecting periodon most operative and laboratory procedures. ment option or solution, and each solution
tal health and osseointegration of dental A careful analysis of the occlusion and has its own treatment planning implica
implants. Occasionally, minor occlusal careful surveying of mounted diagnostic tions with associated advantages and dis
adjustments are required before tooth casts are required as part of the treatment advantages, including the time taken and
preparation, and minor orthodontic tooth planning for all fixed and removable financial costs. A comprehensive definitive
repositioning may improve the periodontal partial dentures, and dental implants. A treatment plan may only evolve after a
health and the spacing and alignment of diagnostic wax-up of the proposed restor protracted period of initial priority treat
abutment teeth or teeth adjacent to pro ative changes, and intraoral photographs, ments and consultations during which
posed dental implant sites. Orthodontic should form part of the treatment planning time the oral health condition and attitude
tooth repositioning is generally faster in and patient discussion processes. of the patient are monitored and evaluated.

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2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

Because comprehensive dental treatments


are seldom final, being subject to con
tinued wear and tear, with the need for
ongoing reviews and maintenance, these
latter requirements must form part of the
dental treatment aims or goals agreed to
by the patient.

THE EDENTULOUS PATIENT


The acceptance by patients of complete Fig. 19 Candidosis associated with denture-
induced stomatitis was present beneath the
dentures largely depends on their being Fig. 21 The presence of undercuts also may
upper complete denture in this patient. The
able to make the necessary functional, cause problems in providing satisfactory
condition resolved after oral and denture
complete dentures
social and psychological adaptations hygiene instruction and antifungal treatment
required for successful denture wearing.
Otherwise, even the highest clinical and
technical skills employed in the provision
of the dentures may result in disappoint
ment. Therefore, it is essential to determine
whether the patients expectations of den
ture wearing are realistic or not. The patient
who brings a collection of unsatisfactory
complete dentures to their first appoint
ment is a real challenge for any practi
tioner. Most people in developed countries Fig. 20 The presence of the torus palatinus,
canine exostosis and enlarged bilateral
now lose all of their teeth at much older maxillary tuberosities will cause difficulties in Fig. 22 A painful traumatic ulcer has been
ages than previously, and consequently providing satisfactory complete dentures caused by an over-extended denture ange
they often have concomitant medical and
other problems. For these reasons, the Dental implant-supported fixed complete neuromuscular control for the successful
information required for adequate diag dentures may be an alternative treatment management of new dentures. These per
nosis and treatment of edentulous patients option, where the psychological benefits sons also may have problems with their
is somewhat different from that pertaining may equal the functional benefits. It is also eyesight and hearing, and have difficul
to younger dentate patients. important to find out how the patient has ties in getting into and out of the dental
managed with any previous dentures that chair, and even in physically accessing the
Chief complaint may have been made. A history of wearing dental practice.
or reason for attendance dentures that were previously satisfactory
This should be recorded in the patients is likely to result in fewer problems than a Family and social history
own words, but may require clarification. history of several unsuccessful attempts at Consideration should be given to the social
A denture that does not fit may be loose, wearing dentures. If the previous dentures and environmental aspects of patients.
oversized, or have very worn artificial were successful, then they should be used Some patients may attend with a relative
teeth. It is essential to establish a rapport as a template for replacement. or friend for support and to offer an opin
with the patient at this time by demon ion at the trial denture stage before final
strating, both verbally and by using appro Previous medical history fabrication. Some prosthodontic norms
priate body language, genuine concern Many of the elderly patients requiring might produce dentures that restore facial
and interest in the patients problem(s). complete dentures will be under medical contours, but these may result in social
treatment and taking prescribed drugs and embarrassment owing to relatives of older
Previous dental history other medications for numerous physical patients being accustomed to the appear
This should determine when and why and psychological conditions, some being ance of the patient wearing worn dentures.
the natural teeth were lost, and how the serious illnesses requiring consultation Again, some patients perceive that their
patient feels about this loss. Teeth lost with the patients physician. Various medi partners are unaware of their denture-
because of advanced periodontal disease cations and illnesses may result in a dry wearing status and are thus disinclined to
in older persons or from dental caries at mouth which, together with psychological have radical changes to their appearance.
a young age may result in poor residual problems such as depression, and problems This may be counterbalanced with the
alveolar ridge form. Patients who regret associated with mental impairment and patient requesting that replacement den
having had all of their teeth extracted, reduced neuromuscular coordination, will tures eliminate post-extraction and ageing
and who find this loss very difficult to adversely affect successful denture wear changes. Old photographs are frequently
accept, may prove difficult to treat suc ing. The elderly and frail in particular may presented with the request to duplicate the
cessfully with conventional dentures. have a reduced tolerance, adaptability and appearance of the natural teeth in the new

348 BRITISH DENTAL JOURNAL VOLUME 213 NO. 7 OCT 13 2012


2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

dentures. In all cases, the clinician should mobility and size of the tongue that may may require a resilient denture base
endeavour to produce an agreed appear enlarge following the loss of teeth, the in these areas or, in extreme cases,
ance that will not cause social embarrass size and form of the edentulous ridges, surgical reduction to provide sufficient
ment. Patients also may have unrealistic the relationship of the maxillary and inter-arch clearance provided that
expectations of the types of foods that they mandibular residual alveolar ridges to the maxillary antra are not encroached
can manage with complete dentures, such each other, and the quantity and qual on (Fig.20)
as biting hard apples. Softer foods and ity of the saliva. The soft tissues should Undercuts, which may dictate and
small portions of harder foods comprising be inspected carefully for any suspicious limit denture extension or the path
an adequate and balanced nutritional diet lesions, including those that may be poten of insertion, or require a resilient
should be able to be eaten satisfactorily. tially malignant, and palpated gently for denture base in these areas (Fig.21)
regions of tenderness. Appropriate con Areas of the mouth that are tender
Extraoral examination sultations are required when suspicious to palpation, such as over the
Apart from an initial assessment of the lesions are detected. The mucosa may show superficial inferior dental and mental
general physical condition and dentofacial evidence of damage from the existing den nerves, which may require relief on the
form of each patient, specific features of tures, such as denture-induced stomatitis/ master cast
the edentulous patient should be evalu papillary hyperplasia (denture sore mouth), Severe alveolar ridge resorption and
ated. These include: and mucosal ulceration/hyperplasia from atrophic mucosal covering, which
Whether or not an obvious skeletal over-extended anges and cheek biting. A may make it difficult or impossible
malrelationship is present between the panoramic radiograph may be indicated as to prescribe satisfactory complete
maxillary and mandibular jaws that part of the clinical examination, as it may dentures. A thin body of the mandible
may inuence the positioning of teeth reveal the presence of unerupted teeth and is also prone to fracture from even
or denture stability retained root fragments. minor trauma in the elderly
Whether the vertical facial dimension It is usually assumed that the support, Displaceable tissue such as fibrous
indicates either overclosure (a reduced retention and stability of complete den (abby) ridges, and denture ange
occlusal vertical dimension) or an tures are related directly to the potential ulcers and/or irritation hyperplasias,
excessive occlusal vertical dimension denture-bearing areas, although many which may require surgical removal
associated with the existing dentures studies have failed to show a clear rela or the use of an appropriate selective
Bruising of the bridge of the nose tionship between denture-bearing ana pressure impression technique (Fig.22)
associated with the wearing of tomical features and patient satisfaction Frenae or muscle attachments close
spectacles, which may suggest with their dentures. However, the provi to the crest of the edentulous alveolar
impaired tissue fragility sion of pain-free and comfortably fit ridge, which may interfere with the
The presence of angular cheilitis, which ting, well-functioning dentures with a peripheral extension of the complete
may indicate a maxillary denture- socially acceptable appearance contrib denture and lead to denture instability.
induced stomatitis associated with utes much to the satisfaction of patients. Midline denture fractures are more
poor denture hygiene and candidosis. The following conditions may adversely probable when the upper denture
Occasionally, there may be poorly affect the support, retention and sta with a deep frenal notch opposes
controlled diabetes or an associated bility of both removable partial and natural teeth, because of the higher
anaemia and nutritional deficiency complete dentures: occlusal forces that are possible.
Reduced tonus of the facial tissues Deficiencies in the quantity and Where the upper complete denture
and masticatory muscles, and whether quality of saliva, which may be opposes remaining natural mandibular
a normal range of pain-free, smooth associated with poor denture anterior teeth only, focused occlusal
excursive movements of the mandible retention, traumatic micro-abrasions, forces may result in the occurrence
can be made. Patients may request difficulties in eating and speaking, of a abby anterior maxillary ridge
that their new dentures incorporate altered taste perception, candidosis replacing alveolar bone lost from
additional bulk to plump out the soft and denture-induced stomatitis, and chronic trauma, this being the
tissues of their lips and cheeks burning mouth syndrome (Fig.19). principal component of the so-called
Uncontrolled muscular activity, for The latter, when affecting the palatal combination syndrome.
example, Parkinsonial dyskinaesia. mucosa, is significantly associated
with wearing complete upper dentures ASSESSMENT OF
Difficulties in pronouncing certain and a dry mouth
EXISTING DENTURES
words and letters, and lisping, or postur Retained roots and partially erupted Though research has largely failed to dem
ing of the mandible and tongue or lips teeth, which require assessment and onstrate, conclusively, that denture qual
during speaking. possibly their removal ity affects patient satisfaction, and hence
Bony lumps and prominences denture success, support remains for the
Intraoral examination (exostoses and tori), which may require important contribution that clinical and
A thorough examination is required to relief on the master casts (Fig.20) technical factors make towards successful
assess the health of the oral mucosa, the Enlarged maxillary tuberosities, which treatment outcomes. Therefore, there are

BRITISH DENTAL JOURNAL VOLUME 213 NO. 7 OCT 13 2012 349


2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

good reasons to examine carefully, exist the overall appearance of the patient. facial height (RFH) and the facial
ing and previous dentures both inside and Generally, the pattern of maxillary height with the teeth in occlusion
outside the mouth. residual ridge resorption dictates the occlusal vertical dimension
that to restore support for the facial (OVD). The FWS=RFHOVD, being
Intraoral assessment tissues, the artificial teeth should be approximately 35mm when the
The complete dentures should be exam set labial to the residual alveolar ridge, patient is sitting upright and looking
ined for: although the obvious exception is straight ahead. The RFH is also known
Support (the property of the when immediate complete dentures as the resting vertical dimension
denture-bearing tissues that resists are being provided. And, to enhance (RVD). For older patients in particular
displacement of the denture towards lower denture stability it is generally with poor residual alveolar ridges then
these tissues). This involves maximum held that the central fossae of the for comfort, close the bite
peripheral extension of the denture artificial lower posterior teeth, along Appearance. This is very subjective
relative to anatomical landmarks such with the necks of the lower anterior but, at a basic level, the pattern of
as the sulci, the junction of the hard teeth, should lie over the crest of the maxillary residual alveolar ridge
and soft palates, the retromolar pads mandibular residual alveolar ridge resorption dictates that to restore
and the retromylohyoid fossae Occlusal contact relationships. These support for the facial tissues, artificial
Retention (the property of the denture- also have a bearing on denture teeth should be set labial to the
bearing and peri-denture tissues that stability and patient comfort. residual ridge. The obvious exception
resists displacement of the denture Simultaneous bilateral occlusal tooth is when immediate complete dentures
away from these tissues). Adequate contacts should occur at the retruded are provided.
retention depends mainly on close contact position of the jaws. The lower
adaptation of the denture base to the denture should be held in place by the Extraoral assessment
tissues and a good peripheral border dentist while the patient is performing The dentures should be rinsed, dried and
seal, in the presence of mucus secreted this manoeuvre. In some patients, examined under good lighting:
by palatal salivary glands for the upper the manoeuvre may be facilitated by Denture hygiene should be assessed
denture. Continuous wearing of upper asking the patient to curl his or her and, if necessary, reinforced to the
dentures damages the palatal glands tongue so that the tip contacts the patient by dye disclosure of plaque
resulting in less mucus. Retention of posterior border of the upper denture, deposits. Poor cleaning may result
the lower denture is usually low, and while at the same time elevating the in denture-induced stomatitis, oral
may be assessed by placing a probe mandible. Preferably, the patient is malodour (halitosis) and angular
into the embrasure between the central positioned semi-supine in the dental chelitis. All patients should receive
incisors and attempting to lift the chair with the dentist seated behind advice regarding how best to clean and
denture vertically the patients head. It is important to maintain their acrylic resin complete
Stability (the property of the ridges, observe the first point of occlusal dentures, such as placing them in
peri-dental musculature and the contact as the mandible may deviate dilute bleach for 20minutes then
occlusal form of the dentures into a position of convenienceone storing in water overnight
that resists displacement of the that may not be reproducible, and Signs of excessive wear of the
denture). Assessment requires careful which may contribute to skewing artificial teeth and denture bases
observation of the denture while and instability of the lower denture may indicate dietary habits such as
the examiner gently manipulates in particular. The result may be confections containing peppermint
the lips and cheeks, or while the pressure sore spots and mucosal oil, and/or parafunctional and other
patient slowly opens his or her ulcers. Also assess whether smooth habits such as pipe smoking. Any one
mouth. Displacement of the denture articulatory movements are possible of these factors will also affect the
while these movements are being without causing the dentures to be replacement dentures
performed indicates overextension of displaced. Although many patients Tooth size, shape, colour and
the denture base and/or impingement manage to chew effectively without arrangement should be noted,
onto muscle attachments. Equally their dentures having a balanced particularly regarding any comments
important is to determine whether the articulation, for some patients this the patient may make concerning these
denture peripheries are short of the may be a necessary requirement The fitting or impression surfaces
sulcular reection, thereby indicating Interocclusal distance. Clinical of the denture bases should be
underextension experience suggests that an carefully examined for any signs of
Positioning of the artificial teeth appropriate amount of interocclusal relief provided, as this may indicate
relative to the levels and orientations distance or freeway space (FWS) problems previously encountered with
of the occlusal and incisal planes, and is needed for patients to speak the supporting tissues
tooth arrangement. These factors have clearly and to chew effectively and Materials used in denture construction
implications for denture stability and comfortably with their dentures. It is should be discussed, as there may
patient comfort, and contribute to determined by measuring the resting be patient preferences such as

350 BRITISH DENTAL JOURNAL VOLUME 213 NO. 7 OCT 13 2012


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PRACTICE

characterisation, or problems that Treatment should only commence after a Hakestam U, Sderfeldt B, Rydn O, Glantz E, Glantz
PO. Dimensions of satisfaction among prosthodontic
previously required the use of resilient thorough assessment and analysis of each patients. Eur J Prosthodont Restor Dent 1997; 5: 111117.
denture base materials. patient has been made. Diagnosis should Iqbal MK, KimS. A review of factors inuencing treat
aim to elicit those factors that are thought ment planning decisions of single-tooth implants versus
preserving natural teeth with nonsurgical endodontic
ENHANCING COMPLETE to contribute to the successful wear therapy. J Endod 2008; 34: 519529.
DENTURE FUNCTION ing of complete dentures. Only then can Jivraj J, Chee W. Treatment planning in implant dentistry.
AND COMFORT London: British Dental Association, 2007.
the patient be advised of their treatment
Kayser AF. Limited treatment goals - shortened dental
The following suggestions are made: choices and thus be in a position to give arches. Periodontol 2000 1994; 4: 714.
Construct close-fitting, border- informed consent to treatment. Equally, Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations
in implant therapy: clinical guidelines with biochemical
moulded (muscle-trimmed) dentures should a practitioner be unsure about rationale. Clin Oral Implants Res 2005; 16: 2635.
of optimum extension, having whether the expectations of the patient can McCord JF, Grant AA. A clinical guide to complete denture
narrow cusped or cuspless posterior be met, the appropriate course of action prosthodontics. London: British Dental Association, 2000.
McCord JF, Grant AA, Youngson CC, Watson RM,
teeth placed in the neutral zone. The would be to withdraw from treatment and Davis DM. Missing teeth - a guide to treatment options.
maxillary second molars or second refer the patient to another, presumably Edinburgh: Churchill Livingstone, 2003.
premolars may be omitted more experienced, clinician. Oruc S, Eraslan O, Tukay A, Atay A. Stress analysis of
effects of nonrigid connectors on fixed partial dentures
Avoid opening the bite too much with pier abutments. J Prosthet Dent 2008; 99: 185192.
Adjust the occlusion, then the denture FURTHER READING Pjetursson BE, Tan K, Lang NP, Brgger U, Egger M,
Zwahlen M. A systematic review of the survival and
bases when pressure spots are present Aquilino SA, Shugars DA, Bader JD, White BA. Ten-year complication rates of fixed partial dentures (FPDs) after
Consider 3mm thick acrylic resin survival rates of teeth adjacent to treated and untreated an observation period of at least fiveyears. Clin Oral
posterior bounded edentulous spaces. J Prosthet Dent Implants Res 2004; 15: 667676.
long-term soft liners for lower 2001; 85: 455460.
Rich B, Goldstein GR. New paradigms in prosthodontics
dentures Atwood DA. Some clinical factors related to rate of treatment planning: a literature review. J Prosthet Dent
resorption of residual ridges. J Prosthet Dent 2001; 2002; 88: 208214.
Maintain hydration and saliva 86: 119125.
Sarita PT, Witter DJ, Kreulen CM, Vant Hof MA,
production and stimulation Berkey DB, Berg RG, Ettinger RL, Mersel A, Mann J. The Creugers NH. Chewing ability of subjects with shortened
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cream (upper denture) or moistened
Botelho M. Design principles for cantilevered resin- Torabinejad M, Goodacre CJ. Endodontic or dental
powder (lower denture) denture bonded fixed partial dentures. Quintessence Int 2000; implant therapy. The factors affecting treatment plan
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Creugers NH, Kreulen CM, Snoek PA, de Kanter RJ. A van Dalen A, Feilzer AJ, Kleverlaan CJ. A literature
Keep the dentures clean and store them systematic review of single-tooth restorations supported review of two-unit cantilevered FPDs. Int J Prosthodont
in water overnight by implants. J Dent 2000; 28: 209217. 2004; 17: 281284.
Brush the edentulous ridges and the Fenlon MR, Sherriff M, Walter JD. Comparison of Vermeulen AH, Keltjens HM, Vant Hof MA, Kayser
patients appreciation of 500 complete dentures and AF. Ten-year evaluation of removable partial dentures:
dorsum of the tongue clinical assessment of quality. Eur J Prosthodont Restor survival rates based on retreatment, not wearing and
Consider implant-supported Dent 1999; 7: 1114. replacement. J Prosthet Dent 1996; 76: 267272.
Gragg KL, Shugars DA, Bader JD, Elter JR, White BA. Wstmann B, Budtz-Jrgensen E, Jepson N etal.
fixed dentures and removable Movement of teeth adjacent to posterior bounded eden Indications for removable partial dentures: a literature
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