Fundamentals of Treatment Planning

FUNDAMENTALS OF TREATMENT PLANNING
Calvani_Frontmatter.indd 1 3/10/20 9:28 AM

FUNDAMENTALS OF
TREATMENT PLANNING
Guidelines on how to develop,
plan, write and deliver a
prosthodontic care project
Lino Calvani
Lino Calvani, MD, DDS, CDT, MSc, PhD
Adjunct Associate Professor
Department of Prosthodontics and Operative Dentistry
Faculty of Prosthodontics
Tufts University School of Dental Medicine
Boston, Massachusetts, USA
Fellow of the:
American College of Prosthodontists
Academy of Prosthodontists
Greater New York Academy of Prosthodontists
International College of Prosthodontists
International College of Dentists
III

Library of Congress Cataloging-in-Publication Data
Names: Calvani, Lino, author.

Title: Fundamentals of treatment planning : guidelines on how to develop,
plan, write and deliver a prosthodontics care project / Lino Calvani.
Description: Chicago : Quintessence Publishing Co, Inc, 2020. | Includes
bibliographical references and index. | Summary: “This book helps
dentists, prosthodontists, and students form and organize their thinking
and formulate correct diagnoses and therapies that start with
appropriate treatment planning”-- Provided by publisher.
Identifiers: LCCN 2020010451 (print) | LCCN 2020010452 (ebook) | ISBN
9780867157925 (hardcover) | ISBN 9781647240332 (ebook)
Subjects: MESH: Dental Prosthesis | Patient Care Planning |
Prosthodontics--methods
Classification: LCC RK651 (print) | LCC RK651 (ebook) | NLM WU 500 | DDC
617.6/92--dc23
LC record available at https://lccn.loc.gov/2020010451
LC ebook record available at https://lccn.loc.gov/2020010452
©2020 Quintessence Publishing Co, Inc
Quintessence Publishing Co, Inc

411 N Raddant Road
Batavia, IL 60510
www.quintpub.com
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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or
otherwise, without prior written permission of the publisher.
Editing: Quintessence Publishing Co Ltd, London, UK

Layout and Production: Quintessenz Verlags-GmbH, Berlin, Germany
Cover illustration: Lino Calvani
Printed in Korea

“Tristo Discipulo Qui Magister Non Superavit!”
“Bad is the student who won’t do better than his
teacher!”
University La Sapienza, Rome, Italy (founded in 1303)
“Great spirits have always encountered violent

opposition from mediocre minds. Imagination is
more important than knowledge. Knowledge is
limited; imagination encircles the world. Any fool
can know, but the point is to understand.
I didn’t arrive at my understanding of the fun-
damental laws of the universe through my rational
mind. I have no special talent; I am only passion-
ately curious.
Time is relative and its unique value is given by
what we do as it passes.
Only a life lived for others is a life worthwhile.”
Albert Einstein (1879–1955)

Dedication
As science teaches, the concepts

expressed in this book were not
written as a point of arrival of
learning, but rather as a continuous
progression of learning. This book is
dedicated to all my beloved teachers
who inspired me and who still enrich
my life as I remind my students that
knowledge always follows when you
have passion and commitment.
Lino Calvani
VI

Table of Contents
Foreword XIII Prosthodontists: Who we are and what we

Acknowledgments XV do XIX
Organization of the book and how to use it XVI Literature XX
Chapter one
Past, present, and future of treatment planning _________________________________________ 1
The distant past 2 ‘Hyper-science’ and the future 4

20th century to the present 3 References 7
Chapter two
Treatment planning management ___________________________________________________________ 9
Some definitions and basic premises 10 || Costs in the face of disease 14

Professionalism: four human factors 11 || Transparency and politeness 14
|| 1. Proper communication and dialogue with the Informed consent 15
patient 11 || Consent 15
|| 2. Motivating patients 11 || Informed consent 15
|| 3. Patient management 12 || We are not obliged to treat all patients 15
|| 4. Positive professional characteristics 12 || In case of emergency 16
Priorities 12 || The use of the informed consent 16
The ideal treatment plan 12 || Essential aspects of the informed consent
Compromise 13 document 16
Prosthodontic economics and patient treatment || Digital technology and informed consent
costs 14 documents 17
|| Affordability of the treatment plan 14 References 18
|| The patient’s occupation 14
Chapter three
Prosthodontic tools for treatment planning ______________________________________________ 21
How prosthodontists can help their patients 22 Removable overdentures 24

Aims and requirements of all prostheses 22 Full-arch implant-retained fixed prostheses 25
Current main prosthodontic tools 22 Bioinformatics and the digital prosthodontics
Fixed restorations 22 paradigm shift 25
Removable partial dentures 23 Computerized chairside and laboratory
Complete dentures 23 technologies 25
VII

Table of Contents
|| Digital software treatment revolution 25 || 3D virtual articulators 26

|| In the clinic 26 || Facially driven dentistry 26
|| Digital treatment planning 26 || Computerized laboratory technologies 27
|| Cloud dentistry 26 Holographic prosthodontics 27
|| Computer-guided implant-positioning software The day after tomorrow 27
and hardware 26 References 28
Chapter four
Data, findings, and dental semiotics ________________________________________________________ 33
Data 34 || Simultaneous symptoms and signs 36

Findings 34 || Main symptoms and signs in dental medicine 37
|| Symptoms 34 Semiotics and dental semiotics 43
|| Signs 36 References 45
Chapter five
The first visit – diagnostics ___________________________________________________________________ 49
Approaching and meeting the patient 50 || Emergency examination 53

|| Professionalism 51 || Screening examination 53
|| Attitude 51 || Comprehensive examination 54
|| Kindness 51 The first professional appraisal 54
|| Empathy 52 The important basic information 54
Where we meet our patients for the first visit 52 Chief complaint 55
How to communicate with patients during the || The histories 56
first visit 52 Clinical examinations 60
Professional office techniques to gather || Radiographic examinations 60
information 53 References 64
Chapter six
Diagnosis and prognosis ______________________________________________________________________ 69
Diagnosis 70 || New predictive technologies 71

|| Differential diagnosis 70 || Prosthodontic prognoses 71
Prognosis 71 References 79
Chapter seven
Physical examination – Part I: extraoral examination ___________________________________ 85
Clinician qualities 86 || Prepare the environment 87

Steps of the physical examination 86 || Make the patient feel at ease 87
VIII

Table of Contents
|| Check the evaluation questionnaire with the Nerves 97

patient 88 || Neurologic examination 97
Physical examination checklist 88 || Trigeminal nerve (sensory component of the
Physical inspection of the body, auscultation, and nerve) 98
odor examination 89 || Facial nerve (sensory and motor components of the
|| General appearance 89 nerve) 99
|| Body posture 89 Muscles 100
|| Movements and muscle coordination 89 || Masticatory muscles 102
|| Nails, skin, and hair 89 || Muscles of facial expression 103
|| Breathing patterns 90 Temporomandibular joints 104
|| Odors 90 || Neurological examination 104
|| Speaking ability 90 Lymphatic system 106
|| Speech peculiarities 91 || The lymph nodes and their importance 106
|| Understanding ability 92 Salivary glands 114
|| Vital statistics 92 || How to palpate the salivary glands 114
Head and neck inspection – examination 92 Thyroid gland 116
|| Face 92 || Shape 116
|| Eyes 92 || Inspection 116
|| Ears 95 || Palpation 117
|| Nose 95 || Health status 118
|| Mouth 95 || Function 118
Head and neck inspection – palpation || Clinical relevance 118
examination 96 || Absence 118
|| Static and dynamic possibilities 96 References 119
|| Palpation techniques 96
Chapter eight
Physical examination – Part II: intraoral examination ___________________________________ 121
Intraoral examination procedure 122 || Anatomy 132

Intraoral examination checklist 122 || Examination of the tongue 133
Vestibular area 123 Floor of the mouth 135
|| Lips 123 Salivary glands 137
Vestibules 126 || Submandibular salivary glands 137
|| Cheeks 126 || Sublingual salivary glands 137
|| Parotid (salivary) glands 126 || Minor mucous salivary glands 138
|| Floor of the vestibules 128 || Von Ebner’s glands 139
Oral cavity 128 || Clinical conditions of salivary glands 139
|| Palate 128 Alveolar arches and teeth 140
Oropharynx and isthmus of fauces 129 Occlusion 140
|| Pharyngeal tonsils 131 || Radiographic examination 141
Tongue 132 References 149
IX

Table of Contents
Chapter nine
Main clinical examination assessment questions ________________________________________ 153
Clinical extraoral examination 154 || Case assessment occlusal evaluation 158

Clinical intraoral examination 156 || Clinical oral and tooth assessment questions 159
|| Oral mucosa evaluation 156 References 161
Chapter ten
The type and structure of prosthodontic treatments ____________________________________ 163
Prosthodontic treatment algorithms 164 Classification of prosthodontic treatments 168

Treatment planning and predictable results 164 || Class I: Prosthodontic treatments – full
|| Clinical priorities 164 reconstructive rehabilitations 168
|| Presence of an infectious disease and its healing || Class II: Prosthodontic treatments –
time 165 interdisciplinary improving rehabilitations 169
|| Need for additional clinical collaborators 165 || Class III: Prosthodontic treatments –
|| Consequentiality of procedures 165 interdisciplinary healing rehabilitations 169
Treatment planning of complex cases 165 Prosthodontic treatment phases and their
|| Concept of the ‘initial phase’ 166 algorithms 169
|| Concept of customization 166 Predictability, sequence of work, and consent 171
|| Expectations: a danger zone 166 || Predictability 171
|| ‘Not enough time’ 167 || ‘Red line’ concept 171
|| Balance of time commitment 167 || Emergencies and priorities 172
|| Posttreatment care commitment 167 References 172
|| The clinical result should not be equal to or worse
than the problem itself 167
Chapter eleven
Treatment planning analysis of complex rehabilitations
Phase I: Diagnostics, consultations, and emergencies ___________________________________ 173
Some preliminary remarks 174 || Diagnostic digital dental technology 180

|| Treatment variations and alterations 174 Emergencies 181
|| Time for communication and || Preprosthetic emergencies, priority treatments, and
explanations 174 initial disease control 181
Diagnostics 175 || Preferential route medical priorities 181
|| Initial diagnostic screening questionnaire 175 || Oral cancer control 182
|| Second updating questionnaire 175 || Maxillofacial emergencies 183
|| Initial interview and first visit 176 || Periodontal emergencies 183
Consultations with other specialists 178 || Endodontic emergencies 184
|| Dental specialties and other areas of || Tooth extraction emergencies 184
consultation 179 || Caries emergencies 184

Table of Contents
|| Professional oral hygiene emergencies 184 References 185

|| Relining and rebasing of complete and partial
dentures 185
Chapter twelve
Phase II: Prosthetic and restorative treatment ___________________________________________ 189
Some preliminary remarks 190 || Long-term fixed provisionals 195

|| General factors that may affect the planned || Analog or digital provisionals? 195
treatment sequence 190 Implant placement 195
|| Complications that may affect the planned || Implants are a sensitive rehabilitation to plan 197
treatment sequence 191 || Implant postsurgery instructions for patients 198
Orthodontic therapy 191 Maxillomandibular registration 199
Periodontal and oral surgery therapies 192 Final impressions 199
Endodontic therapies 192 Final prosthesis try-in and delivery 200
Mutilated roots and teeth 193 || Relining and rebasing of RPDs and CDs 200
Post and cores 193 Bite guards 201
Provisional restorations 194 References 206
|| Planning the lifespan of provisionals 194
Chapter thirteen
Phase III: Posttreatment care and recalls __________________________________________________ 211
Planning for Phase III 212 || Educating patients about personal oral

|| Periodic recalls for maintenance 213 hygiene 216
|| Patient compliance and special maintenance Treatment planning fluoride 219
holding programs 213 Treatment planning prophylactic therapies 220
Basic prosthodontic maintenance checklists 214 Treatment planning the improvement of the
|| Fixed prosthesis maintenance checklist 214 patient’s diet 221
|| Removable partial denture (RPD) maintenance Making patients more aware of dangerous
checklist 214 habits 222
|| Complete denture (CD) maintenance checklist 215 References 223
Reinforcing oral hygiene at recall visits 216
Chapter fourteen
Treatment planning for the elderly and those with challenging health
conditions _______________________________________________________________________________________ 227
Some medical statistics 228 Prosthodontic treatment planning for elderly and

Patient awareness and communication 229 geriatric patients 230
XI

Table of Contents
|| Some basic statistics 230 || Sedatives, anxiolytics, and antidepressants 235

|| Treating elderly people 231 || Marijuana 236
Prosthodontic treatment planning for patients || Cocaine 236
who are addicted to drugs 232 || MDMA and ecstasy 236
Signs and symptoms of the most common || Methamphetamines 236
drugs 235 || Heroin 237
|| Prescription analgesics 235 References 237
Chapter fifteen
How to write a prosthodontic treatment plan ____________________________________________ 241
I. How to write a prosthodontic treatment plan for || Phase I diagnostics – case narrative 255
your patient 242 Case 4 Perioprosthetic treatment 259
II. How to write a prosthodontic treatment plan || Phase I diagnostics – case narrative 259
for a professional case presentation 243 Case 5 Perioprosthetic treatment 263
III. Main text and writing guidelines 243 || Phase I diagnostics – case narrative 263
IV. Prosthodontic case presentation Case 6 Maxillary complete dentures and
narratives 247 mandibular fixed/removable partial denture 266
|| Examples and scenarios 247 || Completed case narrative 1 266
Case 1 Perioprosthetic treatment 248 Case 7 Rehabilitation of complete dentures 277
|| Phase I diagnostics – case narrative 248 || Completed case narrative 277
Case 2 Perioprosthetic treatment 252 Case 8 Fixed and removable combined
|| Phase I diagnostics – case narrative 252 rehabilitation 282
Case 3 Perioprosthetic treatment 255 || Completed case narrative 282
XII

Foreword
What we know and do today creates the premises to rationalize and select the fundamentals. It was
of our tomorrow. a challenge to avoid dipping too deeply into the
A scientific book is like a mosaic, a complex of various more philosophical ideas and notions that
many chapters or tiles, each one with its color and comprise this complex field, although some of these
meaning and specific position in the whole. How- are touched upon in the text when necessary. How-
ever, when you look at a single tile you only see that ever, analysis and description are the backbones of
particular color, whereas if you look at all the tiles the book, and treatment planning is the basic scaf-
you see the overall final composition. This book it- folding on which I have constructed the text. Treat-
self is a humble tile that is part of a much larger ment planning is the investigative and diagnostic
mosaic – medical care. phase where the clinician plans a well-structured,
The specialty of prosthodontics was born almost rational sequence of care steps in order to best treat
two centuries ago in the United States of America, each individual patient. And this aspect naturally
where it still evolves at a pace and level of complex- expands in the book into defining and discussing
ity that is unknown anywhere else. Prosthodon- many other aspects of prosthodontic work as well
tic science is not an easy matter to deal with. It is as possible collaboration with other related dental
probably the field of dental medicine that deals with medical specialties that contribute to the rehabil
the largest amount of medical, dental, clinical, and itation of patients such as periodontics, orthodon-
laboratory data. But even though it is complex, it is tics, endodontics, maxillofacial surgery, and other
beautiful and requires humble passion and commit- specialties.
ment to know it well. Recent discoveries and tech- Although the book primarily addresses pros
nological advances have increased the amount and thodontic specialists, it also explains basic mat-
quality of new treatment modalities. This may some- ters relevant to all medical fields. Therefore, grad-
times be misinterpreted as ‘heavier’ procedures, but uate and postgraduate students as well as general
in fact it is not. While the increasing wealth of in- practitioners and specialists in other fields besides
formation may appear to be overwhelming or very prosthodontics will hopefully find useful explana-
complex, it is really only a matter of putting in the tions and outlines that will make them aware of
constant effort of learning how to handle it. For- the various aspects and possibilities of medical and
tunately, there are many new digital technologies prosthetic treatment planning as it exists today. Af-
available today that are helping us to achieve this. ter all, medical and dental medical treatment plans
The entire preliminary before-treatment assessment have the same basic origin and structure.
that professionals in all fields of medicine and den- I strongly believe that treatment planning should
tal medicine have to commit to before they begin to be elevated to the same level as other scientific medical
care for a patient can be summarized in two simple fields such as anatomy and physiology and afforded
words: treatment planning. the same respect and dignity. It should be taught and
I wrote this book because while lecturing on the evaluated as a subject in its own right. Furthermore,
topic of prosthodontic treatment planning over the in the study, discussion, and formulation of a treat-
years I was asked to organize my notes and make ment plan, practitioners should never place their
them easily accessible to all students. The complex- own professional pride or economic interest be-
ity of the topic and the enormous body of existing fore the best interests of the patient, whose health
literature engaged me in a great effort of synthesis should always be the paramount issue. The needs of
XIII

Foreword
every patient should be treated with respect. Every we are in detecting their condition/s and realizing
case deserves to be rehabilitated in full agreement how other physical ailments may be manifesting as
with the patient. dental problems. It is for this reason that we need
Winston Churchill is credited with saying: “He to know our patients better from a broader med-
who fails to plan is planning to fail.” This refers to the ical perspective. A deeper understanding of how
logical premise that planning is essential in order to to conduct a physical examination of the head and
achieve success in human endeavor. Knowledge and neck area may be helpful and improve the way we
organization are the main keys to success and make work. The eyes, ears, nose, hands, and brain of the
all the difference between professionalism and in- dental medical professional can not only help peo-
competence. For this reason, success in prosthodon- ple to chew, speak, and look better, but also to live
tics (as in most other human activity) depends on better, safer, and longer lives; in some cases, they
the amount and quality of our knowledge and how may even save lives. As professionals we have to
we plan to carry out the work we face – the detail of be conscious and aware of this because we work in
the where, when, and how of it – in order to predict the same medical field as physicians and surgeons,
and then achieve the best possible results. and we should all be able to perform a careful phys-
The topic of this book is deeply rooted in medical ical examination of the head and neck. The more we
ethics. As a board-certified physician, dentist, dental know and practice, the better able we are to take
technician, and prosthodontist, over time I have care of our patients.
become convinced that our professional duties go I respectfully bring this book to the attention of
way beyond the limits of the teeth and the oral all my young colleagues, both national and inter-
cavity. national, who may find the text helpful in order to
Who we are is expressed by what we know and form and organize their thinking and to formulate
what we do, which is largely a matter of conscious- correct diagnoses and therapies that start with ap-
ness and awareness. The physical health of our pa- propriate treatment planning. I will derive a little
tients is our primary goal; it is for this reason they satisfaction if, with my effort, I am able to help cli-
seek our help. Apart from how patients take care of nicians and patients to improve their work and live
themselves, once they are in our offices their phys- better lives.
ical health largely depends on how well we perform
our examinations, and how attentive and clever Lino Calvani, 2020
XIV

Acknowledgments
Thank you to my parents, Mario and Jole, beloved helpful sensitivity and brainstorming capabilities.
knowledgeable pediatrician and dentist. Your Thank you, dearest Francesca, for your love. I hope
superb example and loving memories are always you will forgive me for all the private time I took
with me. You taught me to commit my profession to from your lives. Thank you dear Avril, unique editor
the exclusive interest of the patient and of science. and friend, you are always able to teach me a lot.
Thank you to my daughter, Ludovica, ortho- Thank you to my endless list of teachers who
dontist, for your invaluable contribution, and to have been beacons for me. I will always be your
my son, Gianluigi, actor and playwright, for your humble student.
XV

Organization of the book and how to use it
The book is divided into 15 chapters that describe to be considered; the importance of clearly under-
different aspects of prosthodontic treatment plan- standing the chief complaint/s that lead to patients
ning, from the first meeting with the patient to the seeking help; patients’ understanding of their actual
delivery of the final prosthodontic treatment plan. condition/s; the possibility of achieving an ideal
As you will see, each chapter describes a specific treatment plan; the sometimes inevitable compro-
topic. Due to the complexity of the subject mat- mises that need to be clearly explained to patients
ter, many topics appear in more than one chapter. to gain their understanding, awareness, and final
The reader is therefore provided with an index at approval; and the importance and possible limita-
the back of the book as well as cross-referencing tions of the informed consent, which is the neces-
throughout in order to reinforce the understanding sary final step before treatment begins.
of treatment planning.
Progressive explanations lead the reader to the Chapter three: Prosthodontic tools for
last chapter, which contains a number of examples treatment planning
of how to write and describe a treatment plan. This chapter describes the main restorative treatment
The structure of the book is learner-friendly and options that exist in prosthodontics, which can be
will hopefully help readers to understand and memo- used as care tools to plan any type of rehabilitation.
rize both the concepts and their functional rationale. The chapter also includes a discussion of the rapid
The following paragraphs present a short de- development of digital technologies and the impact
scription of what you can expect from each chapter. of this on the field of prosthodontics, including the
way in which our work has to be continually updated.
Chapter one: Past, present, and future of
treatment planning Chapter four: Data, findings, and dental
This introductory chapter, born from a curiosity to semiotics
better understand how medical treatment planning The topic of data and findings is discussed in the
came to be conceived, highlights the scientific as- next chapter, including how, when, and why to col-
pects related to the development of treatment plan- lect and interpret their meaning. Signs and symp-
ning. Only the information that seems to have an toms such as pain, fever, and hyperthermia are also
obvious connection to the topic is discussed. The defined and their diagnostic importance described.
data show the clear growth trend of treatment plan- The semiotic clinical analysis is explained with re-
ning in the western world. Possible future perspec- gard to investigating the clinical signs that lead to a
tives to date and in the foreseeable future are also more complete diagnosis.
touched upon. Due to the obvious restraints of the
size and nature of this publication, much informa- Chapter five: The first visit – diagnostics
tion has had to be omitted. The aims and significance of the first visit are elab-
orated upon in this chapter. A description is given
Chapter two: Treatment planning of the different types of practical techniques that
management are used to gather information about patients. Also
The purpose and aims of any treatment plan are ex- delineated is the diagnostic information that needs
plained and discussed in this chapter. Also discussed to be gathered and assessed during the first visit
are the basis of respect for all patients; the priorities such as the patient’s chief complaint/s; personal,
XVI

Organization of the book
medical, dental, and prosthodontic history; and psy- treatment types according to the three main possi-
chologic profile. The development of the initial part ble clinical variables: pure prosthodontic rehabilita-
of the treatment plan, the management of emergen- tions, those in collaboration with other specialists,
cies, and the restorative planning are also described. and the presence of disease.
Chapter six: Diagnosis and prognosis Chapters eleven, twelve, and thirteen:
The meaning of the diagnosis, the differential diag- Treatment planning analysis of complex
nosis, and the prognosis are detailed in this chapter rehabilitations
as well as their importance to the positive outcome The timing and organization of the different
of the prosthodontic treatment. The pretreatment phases comprising a prosthodontic treatment
and posttreatment prognoses are analyzed, and the plan are described and analyzed in these three
periodontal, prosthodontic, and orthodontic eti- chapters. Each of the three phases is explained
ology and risk factors that may impact the timing with a view to understanding the priorities and
of the prognoses are also described. to better organize the sequence of the phases in
order to simplify the analysis and narrative de-
Chapters seven and eight: Physical scription of a treatment plan. Also explained is
examinations the importance of integrating the radiographic
These two chapters on the medical examination and cone beam computed tomography (CBCT)
present a step-by-step description of the basic pro- diagnostic examinations to better define the final
cedures and methods that need to be applied when diagnosis.
examining patients, starting from the first moment
of engagement with the patient and following with Chapter fourteen: Treatment planning
the chairside examination at the first visit. Useful for the elderly and those with challenging
descriptions of all the most important extraoral and health conditions
intraoral anatomical features are provided, together This chapter deals with the topic of treatment plan-
with their clinical and prosthodontic relevance and ning for elderly patients and those with drug addic-
importance. The semiotic possibilities of these ex- tions. Included are observations on how the body
aminations are also evaluated. and oral cavity age, and how medicines and drugs
influence and affect patients and, in turn, the effect
Chapter nine: Main clinical examination this has on medical or dental treatment plans. Also
assessment questions shown is how the changes of aging can significantly
This chapter continues the topic of examinations. It affect a prosthodontic treatment, so that alternative
details the clinical intraoral and extraoral examina- solutions need to be planned according to the pa-
tions and their importance in evaluating and assess- tient’s needs. Discussed too is how transitory or
ing patients’ health status and possible past and ongo- chronic major conditions may modify a patient’s
ing conditions. This can be considered an important capability to withstand an oral rehabilitation. A
juncture in the clinician–patient relationship, which description and analysis are given of the most im-
can decide whether we gain patients’ trust or lose portant drugs and how they may cause addiction as
them as patients; the procedures and suggestions in well as how they affect and influence oral treatment
this chapter are therefore crucial. choices.
Chapter ten: The type and structure of Chapter fifteen: How to write a
prosthodontic treatments prosthodontic treatment plan
This chapter describes, analyzes, and proposes a The final chapter describes why and how treatment
new and original classification for prosthodontic plans can be presented for in-office purposes or for
XVII

Organization of the book
PowerPoint or Keynote presentations. A number

of useful clinical case narratives are presented as
practical treatment planning examples that could
be used for the purposes of university case pres-
entations and examinations, meetings, congress
presentations or lectures. The ‘narrative frame-
works’ of all the narrative reports explain the ra-
tionale behind why certain decisions have been
made while other choices have been avoided, and
how this rationale can be explained to patients, to
other professionals or to students during seminars.
XVIII

Prosthodontists: Who we are and what we do
“The world moves in front of them who know comprehensive treatment of clinical cases for miss-
where to go and what to do.” ing or deficient teeth and oral and maxillofacial tis-
Lino Calvani sue in order to competently find solutions and cures
using biocompatible substitutes. The focus is on the
I approached this profession and specialty with in- following areas:
finite humbleness, respect, curiosity, and commit-
ment, and this is what still pushes me forward with 1. Patient assessment (both medical and dental
passion. Prosthodontics is a beautiful, complex, and history).
very demanding specialty in terms of knowledge 2. Extraoral and intraoral examination.
and commitment. I have been moved to see in the 3. Radiologic assessment and occlusal analysis.
literature how many have dedicated so much of their 4. Temporomandibular joint (TMJ) assessment.
lives to its development and success. The list of lit- 5. Systemic, infectious, and neoplastic disease
erature that follows (in alphabetical order) is a small screening (education for prevention).
but highly representative sample of the significant 6. Diagnosis.
writings dedicated to the growth and development 7. Risk assessment and prognosis.
of prosthodontics. The amazing professionals who 8. Treatment planning.
have written these articles, papers, and books, and 9. Comprehensive treatment.
the many others who are not included in this list for 10. Outcomes assessment and delivery.
reasons of space, have set a standard of passion and 11. Follow-up and maintenance.
professionalism that is difficult to match.
The specialty of prosthodontics was originally As professionals, we ‘profess’ to believe in who we
recognized in 1948 by the Commission of Dental are and what we do. As the Mission Statement of the
Accreditation (CODA), an independent agency of American College of Prosthodontics states: “Prost-
the American Dental Association (ADA), which hodontists are specialists in the restoration and re-
is an independent organization recognized by the placement of missing teeth and oral/facial structures
United States Department of Education. with natural, esthetic, and functional replacements.
The ADA defines prosthodontics as: “the den- This includes surgical implant placement, the simple
tal specialty pertaining to the diagnosis, treatment to most complex implant-supported restorations, lab-
planning, rehabilitation, and maintenance of oral oratory and clinical training in esthetics/cosmetics,
function, comfort, appearance, and health of patients crowns, bridges, veneers, inlays, removable complete
with clinical conditions associated with missing or and partial dentures, dental implants, TMD-jaw joint
deficient teeth and/or oral and maxillofacial tissues issues, traumatic injuries to the mouth’s structures,
using biocompatible substitutes.” congenital or birth anomalies and/or teeth, snoring
During the three years of training in all United and sleep disorders, as well as oral cancer, prosthetic
States postgraduate prosthodontics specialty pro- reconstruction, and continuing care. Prosthodontists
grams, students must become knowledgeable in the are experts in treatment planning.”
XIX

Literature
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and examination requirements of the American Board of 1979;41:576–578.
Prosthodontics. J Prosthet Dent 1984;52:281–287. 20. Laney WR. History of the American Board of Prostho-
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Summit, 2006:11–12. thet Dent 1975;34:675–693.
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2018. dontics. J Prosthet Dent 1976;35:57–61.
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5. Atwood DA. Practice of prosthodontics: past, present, 24. Lytle RB. Criteria for evaluating candidates or the
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prosthodontics in the United States. J Prosthet Dent 25. Mann WR. What dentistry expect of the prosthodontist.
1966;16:873–879. J Prosthet Dent 1965;15:949–955.
7. Boucher LJ. The role of research in prosthodontics. 26. Morse PK, Boucher LJ. How 274 prosthodontists ranked
J Prosthet Dent 1965:15;962–966. four methods of advanced education in prosthodontics.
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1969;21:433–442. J Prosthet Dent 1969;21:409–416.
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XX

CHAPTER ONE
Past, present, and future of

treatment planning
Calvani_Ch_1.indd 1 12.02.20 12:04

1 Past, present, and future of treatment planning
“Those who do not learn from history are dental medicine, was more difficult because those
doomed to repeat it.” bright-minded individuals who became involved
George Santayana (1863–1952) had to face not only the extreme complexity and
difficulty of the subject matter of the human body
“The past should be read with the eyes of present and mind, but also the limitations imposed by the
time.” endless short-sighted and ignorant doctrines of the
Charles Darwin (1809–1882) time.11-13 The intelligent nature of humans means
that we need to trust in order to understand; trusting
“The past is never dead. It’s not even past.” in science means that in time science will explain
William Faulkner (1897–1962) everything, whereas trusting in a religious sense
(having faith) means believing that God will take
care of everything. Historically, the development of
medical treatment planning has been strongly in-
The distant past fluenced by this.14,15 Nevertheless, over the last two
The author believes it is important to understand centuries, science finally gained its autonomy from
history not so much as a chronicle of events but religion, and today the two areas of human endeavor
in terms of the value we attach to and derive from are separate, to the obvious advantage of medicine.
these events. In this way, we arrive at the signifi- An important aspect of the renaissance of med-
cance of the events. When we look back, we under- ical science was the contribution scientists made to
stand that for long millennia our civilization was laying the anatomical foundations for the under-
not able to conceive or understand much about sci- standing of the cause-and-effect relationship that
ence, as we know it today. Certainly, in the distant exists in the human body, and how the various parts
past, people had absolutely no idea what they were of the body function and malfunction in relation to
doing when treating physical disease and illness.1-4 each other. This had profound implications for the
But once in a while, a gifted individual with a ‘beau- development of clinical and surgical therapies. This
tiful mind’ sensed something new, and in this way cause-and-effect relationship can be seen as the
our knowledge was carried a step or two forward. initial basis for the current treatment planning ra-
Slowly there developed the understanding and ac- tionale. Nevertheless, despite all efforts, ignorance
knowledgment that the causes of illness and disease about medicine among the general public was rife
were not so much ‘divine’ as they were natural or because society was disconnected and disorganized,
human-made, and this understanding was the route and it was difficult and often impossible to teach
to healing them. Of course, the first medical treat- and impart new medical knowledge and trends. At
ments were simple natural herbal remedies, primi- that time, medical treatment planning was largely
tive bandages and cream prototypes, coupled with unknown, and to the extent that it did exist, it was
attempts of a philosophical or religious nature to very primitive and poorly understood. Therefore,
explain and justify all incomprehensible events by due to almost no true medical understanding, epi
relating them to the will of a moody God.5-7 demics, traumas, infections, and cancers indiscrim-
In more recent history, after the ‘static’ middle inately killed hundreds of millions of people. It
ages (from a medical point of view), an increasing took other two centuries before anatomy, physio
awareness of scientific evidence over the past five logy, and pathology became actual sciences, and the
centuries has allowed for a better understanding of word ‘treatment’ became a medical term.
the mechanics of our nature and of the ‘innate con- So, regardless of all the clever minds, poor trans-
sciousness’ and ‘self-awareness’ that distinguishes port and communication meant that people were
us as a species.8-10 However, compared with other isolated and led an insular way of life. Medicine it-
sciences, the development of medicine, including self was still largely based on old, inaccurate, and
Calvani_Ch_1.indd 2 12.02.20 12:04

20th century to the present
often imaginary notions. Medical practitioners were the developed world, for example, the Baltimore
on the whole pompously dressed, incapable igno- College of Dental Surgery was founded in 1840,
ramuses, trying to describe nonexistent diseases the Philadelphia College of Dental Surgery in 1842,
with useless Latin words. Original paintings of this Tufts Dental School in 1852, Harvard Dental School
medical class show images of fantastic methods and in 1867, and the University of Michigan in 1875.
therapies full of enemas, leeches, ointments, and Passionate researchers and clinicians started to cre-
draught potions that were invented and concocted ate the basis of actual medical and dental medical
to ‘cure’ all ailments and diseases.4,16 scientific treatments.19 So, by the turn of the 20th
Only during the 17th and 18th centuries did century, official medical and dental medical sci-
physicists and chemists boost the curiosity of many ence was starting to be oriented toward what we
people, so that people started to believe that they know today as ‘assessed methodology.’ The study
could follow in the footsteps of these scientists in all of anatomy was acknowledged as the basis for un-
scientific matters, driven by their then brand-new derstanding medicine, and investigations into the
practice of scientific research methods and the pur- body’s functions and malfunctions started to drive
suit of evidence of reality theories. This indirectly more organized and critical laboratory research and
contributed to the speeding up of the understand- clinical practice.18,20 Scientists’ curiosity and eager-
ing of medical science and treatment planning. In- ness for clarification drove them to begin to look
deed, probably without realizing it, physicists and for ‘evidence’ as the starting point. The worst of the
chemists at that time were changing the way people religious influence on medicine was part of the past.
thought about medical science.
It can therefore be said that medical treatment
planning has its origins in scientists attempting
to prove that formulas could explain all scientific
20th century to the present
elements and, indeed, the world. Over time, it be- While the 20th century gifted us with geniuses such
came clear that signs and symptoms were useful as Albert Einstein (1879–1955), it also plagued us
and necessary to make a correct diagnosis of illness with two devastating world wars, which had a sig-
and disease. In fact, medical treatment planning is nificant influence on the development of treatment
entirely based on scientific methodology and evi- planning in the west. About 20 million lives were
dence. However, while physics, astronomy, math- lost in the First World War (1914–1918), and about
ematics, and biology were progressing at a rapid 68 million in the Second World War (1939–1945).
pace, scarce technologies and immature methods Apart from the death toll, war means all kinds of
limited people’s knowledge of the human body, no terrible injuries, physical and psychologic, created
matter how curious they were. Also, the slow pace by all types of weapons. It means traumas, wounds,
of life and very limited social contact meant that it burns, disfigurements, and epidemics.
was difficult to spread news, which created many The world wars profoundly changed the lives of
problems.4,16,17 our grandparents and parents, and forced medical
During the 19th century, medical scientists science to find surgical, clinical, and pharmacologi
looking for scientific evidence and using the new cal solutions to address the sudden, terrible, and ur-
scientific instruments of the time discovered more gent traumas they caused. The wide range of inju-
ways to heal and cure, which were perfected with ries and infections, many of them never seen before,
time and passion, although many essential notions meant that the understanding about how to plan
were lacking, and there was still no precise under- the treatment of patients accelerated, both during
standing of treatment planning.13,18 Universities emergencies on the battlefields and in the clinic.
and medical and dental medical schools began to In addition, the 1918 influenza epidemic (known
open and flourish in the USA and in other parts of as the Spanish Flu), largely brought on by the un-
Calvani_Ch_1.indd 3 12.02.20 12:04

hygienic conditions of the First World War, left easily do, and thanks largely to the internet, their
roughly 50 million dead worldwide. Therefore, the contributions to science are easily and quickly
total death toll in the almost 50-year period span- spread throughout the world. Just a century ago,
ning both world wars was about 125 million peo- only a few physicians knew what an antibiotic was,
ple, not to mention the millions more who were and thousands of people died of bacterial infections.
seriously injured in these wars and who died pre- Today, most people know about antibiotics and mil-
maturely later on. On top of this, other local wars lions of people take them, often autonomously and
and epidemics followed, bringing the death toll to without careful prescription (which has unfortu-
some 13% to 14% of the entire world population at nately also resulted in an alarming and increasing
that time.21,22-24 physiologic resistance to them).
Due to these events, and thanks to the increased This ties in with another important factor in the
number of dedicated medical scientists and facili- understanding of the development of treatment
ties, improved communication and media, and the planning, which is communication and the media,
growing body of scientific and medical knowledge particularly the internet and smart phones.17,35-37
that had been slowly accumulating over centuries, Since the two world wars (and therefore in less
medical science made a great leap forward in the than a century), information about medical sci-
first part of the 20th century. The level of aware- ence has rapidly increased, and has been shared
ness and consciousness regarding medical treat- among millions of medical and dental profession-
ment and its planning increased rapidly during als. This means that the panorama of clinical plan-
that time, bringing a deeper understanding of the ning and treatment is continually changing and
importance of knowledge about medical proce evolving.
dures and being well organized in the planning of
treatment (this includes dental medicine and pros-
thodontic treatment planning, even though the lat-
ter is not always that well defined).25-27
‘Hyper-science’ and the future
Population growth is another important factor When the famous physicist Niels Bohr (1885–1962)
in the development of treatment planning. Over was asked to make predictions about the future, he
the last three millennia, the human population has said humorously: “Predictions are very difficult, es-
increased from about 50 million to 7.5 billion peo- pecially about the future.” Every small scientific step
ple. Parallel to this is the increase in the number forward changes our understanding of how to plan
of scientists and thinkers who have dedicated their and treat medical conditions. However, despite how
lives to solving medical problems, which has esca- technology today allows for easy online access for
lated the number of possibilities for furthering med- most people to medical research, data, literature,
ical and dental medical science.28,29 Inventions and and information, human endeavor remains crucial
discoveries that make possible the forward move- and necessary.
ment of science and medicine are not made so much Currently, data acquisition and processing
by specific individuals as by the collective know- speeds seem to depend on a number of disruptive
ledge and awareness that accumulates over time.30- ‘innovation platforms’ that cut across sectors and
34 This is known as ‘collective intelligence,’ which markets and converge on each other on the medical
expands exponentially all the time, thereby increas- stage, such as:
ing the possibility of more and more discoveries that 1. 5G and 6G internet connections.
lead to better medical understanding. For instance, 2. Micro and macro energy storage for industry,
about a century ago there would have been few, if farming, transportation, cities, etc.
any, physicists who properly understood Einstein’s 3. Plasma and quantum computers; liquid, nano-
theories. Today, hundreds of thousands of students magnetic, and graphene transistors.
Calvani_Ch_1.indd 4 12.02.20 12:04

‘Hyper-science’ and the future
4. Artificial intelligence (AI), artificial narrow injectable chemotherapeutical nanorobots and na-
intelligence (ANI), artificial general intelli- nocarriers. They will be much faster and, in many
gence (AGI), deep-learning software (DLS), and ways, more capable than humans to do the job of
self-learning software (SLS). medical care providers.25,41,55-58 We will refer to
5. Collaborative robotics and humanoids. them with trust when we are ill or wounded.
6. Computer-aided design/computer-aided manu- Knowledge, consciousness, and indeed our entire
facturing (CAD/CAM) and 3D printing. way of living and working are being revolutionized.
7. DNA sequencing and CRISPR therapeutic One only has to attend medical and dental medical
genome editing. meetings, conferences, and expos all over the world
8. Nanotechnologies. to see where the market is now and where it is
heading, and how much money is involved. Human
‘Hyper-science’ (author’s own word) seems an ap- history has always demonstrated that whatever we
propriate composite word for these revolutionary are capable of imagining, we are capable of achiev-
technologies and the current rapid growth of sci- ing. Digital science has come a long way, being
entific knowledge. As never before, the progress of completely free today of any religious constraints
science is accelerating, and capabilities and possibil- that might prevent it from progressing.
ities are increasingly opening up. Which is why the Currently, there is much hyper-scientific intel-
medical progress indicators predict that medical and ligent curiosity and imagination at work.59 An ex-
dental schools will structurally change in the near citing example is the newest IBM Watson Machine
future under the pressure of digital innovations.38-44 Learning, which harnesses machine learning and
A clear example of the above is the new, cheaper deep learning in a way that enables the manage-
DNA sequencing and CRISPR genome editing that ment of an infinite amount of data. It gives flexible
is enabling scientists to develop new types of diag- answers, insights, and possible solutions in many
nostic screens, tests, and therapies. Computational different fields of human endeavor, and is already
techniques are changing our schools and educa- useful to medical professionals in various fields of
tional programs constantly, with the three-dimen- health care. For treatment planning, for instance, it
sional resources of virtual reality (VR) and aug- can be used for collecting and reading scientific lit-
mented reality (AR) changing the way students erature published in many languages. When asked
and faculty interact, including the interaction with about a specific disease or illness, it can promptly
robots.45-54 Nanotechnology is increasingly being give one or more answers, propose a fitting diag-
used to treat patients. Predictions made on solid sci- nosis, and suggest various treatment options ac-
entific bases foresee that, two or three decades from cording to clinical facts, scientific evidence, and sta-
now, well-programmed super-intelligent ANI, and tistics. It can also design program interventions.60
well-instructed human-dependent or independent However, despite all future AI digital capabilities
AGI machines as well as AGI humanoid robotized and skills, the logic of treatment planning, with its
digital doctors and caregivers will clinically treat basic and complex algorithms, will always consti-
patients suffering from an increasing variety of dis- tute the common scientific foundation of medical,
eases and will also feature in the laboratory. These dental medical, and prosthodontic treatment and its
machines will be able to handle programmable and planning.
Calvani_Ch_1.indd 5 12.02.20 12:04

2000–present
AI, ANI, AGI,
and beyond ...
b. 1800–2000
Skoda, von Hebra, von
Helmholtz, Pasteur, Osler,
Bourdet, Kemperer, Muller,
Frugoni, Müller, Valdoni
b. 1600–1700
Sydenham, Locke, Lancisi,
460–359 Hippocratic Corpus 1163 – Edict of Tours Boerhaave, Fauchard,
428–347 Plato 1225–1274 Saint Thomas Morgagni, Bounon
384–322 Aristotle Aquinas
b. 1700–1800
129–216 Galen of b. 1300–1600 Auenbrugger, Pinel, Pfaff,
Pergamon Chauliac, Da Vigo, Bichat, Corvisart, Laennec,
354–430 Saint Augustine Da Vinci, Paracelsus, Andral, Welsley
3600–1000 BC AD Paré, Vesalius, Harvey
ANCIENT AGE of GODS MIDDLE AGE of GOD MODERN AGE SCIENCE AGE DIGITAL AGE
Fig 1-1 The birth and growth of medical examination, diagnosis, and treatment planning in western civilization.
The first real scientific impulse occurred in 1500, with curiosity for the unknown and for medicine following
until the end of 1700, when scientific evidence changed the schools and universities and gave birth to empirical
knowledge and scientific research.
Calvani_Ch_1.indd 6 12.02.20 12:04

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CHAPTER TWO
Treatment planning
management
Calvani_Ch_2.indd 9 12.02.20 12:04

2 Treatment planning management
We often take our knowledge for granted, which of education, knowledge, understanding, expertise,
in the medical field is a dangerous thing. While experience, observational capabilities, reasoning,
good sense and innate wisdom drive the profession, dexterity, skills, ethical awareness, responsibility,
things are changing so quickly in our technological communication, and critical thinking are distilled
age that we need to constantly keep ourselves in into one focus. From this focal point, treatment
formed about new terms, concepts, rationales, pro plans are conceived and presented to the patient.
cedures, and ideas in order to offer our patients the At this moment, professional values such as clarity,
best treatments possible. The science is not static but precision, and accuracy are key.
must be constantly learned, understood, reviewed, What follows are some basic concepts, defini
and remembered. Only then are we in a position to tions, and suggestions related to this aspect of the
formulate the best treatment plan. topic. Some may feel that their professional experi
So, what is the goal of a prosthodontic treatment ence means they will not benefit from this level of
plan? In most cases, patients come to us because basic analysis. But for those who humbly approach
they have an esthetic and/or functional problem in this subject with an open mind, these basic concepts
their oral cavity. It is understandable that they are will hopefully be useful to tune in, so to speak, to the
not concerned about the physiology of the entire matter of prosthodontic thought in order to enhance
oral system and how all aspects of it are interrelated. their knowledge and understanding. It should also
What is not so understandable is how many dental be borne in mind that, unfortunately, the speciality
medical professionals think it is sufficient to treat of prosthodontics still does not exist institutionally
the teeth only, ignoring the overall context in which in many parts of the world outside of the USA.
the masticatory system works. Considering the part
as inseparable from the whole is the basis of the ho
listic approach to medical and dental practice.
Prosthodontists need to solve problems in the
Some definitions and basic
oral cavity, but that is not just a matter of teeth. premises
Indeed, they need to find the best possible way of The three cornerstone definitions are:
healing the oral cavity and its potential clinical ● Treatment: According to the Cambridge
problems, taking into account all the structural and Dictionary, the word ‘treatment’ is defined as
biomechanical issues. They then need to rehabili “the way in which somebody behaves towards
tate the patient’s oral health in its entirety, focusing or deals with somebody or something.” 1 In
on the dentition and its compromised or lost func the sense of medical treatment, it refers to the
tions, while also taking into account the patient’s care given to a patient in response to an illness
needs, wishes, and expectations. Prosthodontists or injury, and in the case of dental medical
are called upon to improve the function of the den treatment, in response to an issue or issues
tition as well as the patient’s comfort and quality concerning the oral cavity.
of life so that both physical and psychologic health ● Plan: A plan has been defined as “an indivi
are restored. dual or collaborative enterprise that is carefully
Prosthodontists should be equipped to manage planned to achieve a particular aim.” 2 Indeed, a
treatment planing with understanding, expertise, plan is what results after:
and professionalism. This entails a sound know ● all the appropriate data have been acquired;
ledge of patient management, organization, and ● the situation has been carefully studied;
what is available in terms of clinical therapies that ● all the details are understood;
can be suggested to the patient. ● appropriate conclusions have been drawn;
Therefore, after the diagnosis, treatment plan ● one or more solutions necessary to solve the
ning is the moment where all the various aspects problem/s have been formulated.
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Professionalism: four human factors
● Purpose: The purpose of treatment planning main desirable qualities and skills necessary for us
in prosthodontic and restorative dental medi to succeed in clinical practice:
cine has been analyzed by many authors.
1. Proper communication and
According to Rosenstiel et al,3 the purpose is to for
dialogue with the patient
mulate “a logical sequence of treatment designed to
repair existing damage and restore the patient’s den The ability to communicate clearly is a primary skill.
tition to good and maintainable health, with optimal Clear, open communication leads to trust, which is
function and appearance.” not a given but is something that is earned. Trust is
the key to successful patient management and treat
A treatment plan will only be successful and effec ment. However, it is not always possible to achieve
tive if it is: trust during the first appointment, unless we are
● Organized: This important concept may seem able to immediately tune into our patient’s state
obvious but often it is not, so it is emphasized of mind. Trust often results when we successfully
here again that any treatment plan must be transfer to the patient through optimal communi
well organized and clear, first in the prostho cation skills a positive sense of our ability and pro
dontist’s mind and then transferred as such to fessionalism from the outset. This entails the ability
the patient. Only then can the plan be properly to clearly explain each step of the procedure and
understood by the patient. to motivate patients to trust us, to recognize our
● Explicable: During treatment planning, we professionalism and capability, and to feel confident
have the chance to understand the prosthodon that we are able to solve their problems.
tic rehabilitative course in detail and foresee its
possible final results. We then need to organize
2. Motivating patients
our conversation with the patient. Indeed, the
treatment plan that is well understood and Often, patients must be motivated to be cured. Natu
then accepted by the patient is the tipping rally, a patient’s personality, character, previous ex
point after which the clinical treatment may periences, expectations, and other factors may influ
begin. ence this process (this important aspect is discussed
● Predictable: Predictability of the clinical results later in the book). Clinical experience shows that a
is the highest aim of treatment planning. In number of impediments to communication can be
deed, during the planning, prosthodontists need identified when approaching patients such as:
to consider all possible variables in order to reduce 1. Lack of trust or agreement.
the likelihood of surprises or pitfalls during the 2. Stress due to patients’ personal problems.
clinical treatment and after the delivery of the 3. Lack of communication and understanding.
prostheses. 4. Lack of constancy to care.
5. An exacting, fussy, and/or controlling patient.
6. Special physical issues or needs patients may
have.
Professionalism: four human 7. Demanding patients, and special psychologic
factors attention they may require.
There are a number of positive characteristics that
the prosthodontist (or any clinician) should ideally However, no matter what past experience or per
cultivate and develop in order to grow as a profes sonal problems patients may have that could result
sional. These characteristics are further described in in a negative attitude on their part, we need to know,
Chapter 7. What follows is a brief description of the understand, and remember to behave professionally
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at all times in order to inspire trust in our patients 4. Positive professional

and communicate effectively with them. characteristics
Patient management is not an easy task to perform.
3. Patient management
To achieve success, we should always behave in an
This is one of the most important skills we need impeccable and appropriate professional manner –
to develop for success in the clinic. Patient man from the moment we first meet our patients, through
agement depends mainly on us, and according to the first dataset acquisition and case assessment, the
psychology is based on two personal qualities of explanation of the diagnosis and prognosis, the de
the clinician that should be carefully nurtured and livery and discussion of the proposed treatment plan,
developed: the ability to take responsibility and our and finally throughout the entire clinical treatment
freedom of choice (free will). and follow-up process. Professionalism in our ap
Some patients have demanding personalities or pearance, our manner of speaking and listening, our
suffer from complex psychologic problems. These body language (non-verbal communication), and our
factors could affect our ability to manage their general attitude and demeanor is essential to the pro
cases.4 For this reason, when we are dealing with fessional and respectful relationship we build with
difficult patients, we need to pay even more careful our patients. Every action has a reaction or conse
attention to our interpersonal management skills quence. Actions we take as professional caregivers
because problems with these challenging patients are directly related to how our patients perceive us
may arise at any time. from the beginning and will have an impact on how
Psychologic studies suggest that we should be much respect and trust they have in us – and ulti
professionally confident and capable and should mately in the success of the treatment. We need to
take responsibility for everything we say and do. listen carefully, be flexible in our approach, be adapt
The more we transfer positive feelings to our pa able to our patients’ needs, and respond with respect
tients, the more they will trust us and the easier it and empathy to their questions, requests, and concerns.
will be for them to accept the treatment we offer
them. A number of psychologists have studied pa
tient–clinician behavior and the kind of relations
that should be established from the first visit. It has
Priorities
been noted that if we succeed in our intentions, our Simply put, when patients seek our help, they do
self-esteem increases, which in turn increases the so according to their own personal priorities. These
positive attitude of our patients and the mutual abil priorities will differ for each patient. For some, the
ity to communicate and collaborate.4 priority will be pain relief, which can be seen as an
Psychologic studies also highlight the impor emergency. For others, it may be relief from discom
tance of knowing how to evaluate patient feedback fort, or perhaps unhappiness with the appearance
when we start to create a bond with our patients.4 of their smile or teeth. Our role is to assess these
According to the Oxford English Dictionary defi priorities and solve the case in such a way that the
nition, feedback is “the information about the result patient’s priorities are respected.
of a process or action that can be used to modify or
control a process or system.” It is therefore important
to learn how to listen to our patients so that we are
better able to help them. That is patient manage
The ideal treatment plan
ment in a nutshell. Is there an ideal treatment for all patients? First
and foremost, the Latin phrase ‘primum non nocere’
(above all, do no harm) – included in the Hippo
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Compromise
cratic Oath – should be the medical principle that minded and knowledgeable enough to treat our pa
guides our minds and hands. In this respect, the tients using a range of possible treatments and pros
ideal treatment plan is one that achieves the best thetic tools. Moreover, there is not one treatment plan
possible long-term prognosis with the minimum of for each patient, but possibly many. This depends on
necessary intervention, and which addresses all the variables such as evidence, clinical factors, pros
patient’s concerns and problems.5-7 thetic limitations, and patient preference. It also
Can this ideal treatment plan be achieved with depends on what is objectively possible and what
every patient? There are many answers to this ques we can imagine and plan within the context of the
tion, and this book explores them in some detail. A specific case.
guiding principle could be the KISS rule. KISS is an Also, despite the number of treatment options
acronym for ‘keep it simple, stupid’ or ‘keep it simple that we devise and customize for each patient, there
stupid,’ which was a design principle of the US Navy is usually one treatment plan that we particularly
in 1960. The KISS principle states that most systems prefer for that patient. And then it sometimes hap
work best if they are kept simple rather than made pens that for a number of reasons the patient prefers
complicated; therefore, simplicity should be a key a treatment other than the one we prefer.
goal in design, and unnecessary complexity should Indeed, to restore and rehabilitate a patient’s
be avoided. Basing a treatment plan on this princi mouth we usually have to agree to one or more
ple means that we seek out a simplified course of compromises that we hopefully have foreseen. We
action and solution to avoid the complications that then need to inform our patients of the final treat
may arise when things become more complex, both ment plan in such a way that they properly under
during the treatment and in the long term. How stand it, agree to it as the best treatment for them,
ever, it is not as simple as this. Due to today’s dig and willingly approve it.18-30
ital technological environment and more sophisti Therefore, we need to search for the best com
cated prosthetic rehabilitation options, simple may promise that will achieve the ideal outcome for that
not always be the best option. Perhaps KISS should particular patient, always taking into account the
therefore be amended to ‘keep it simple, sometimes.’ following four patient realities:
Therefore, while the rule of simplicity when con
ceiving a treatment plan is a sound notion, it is not 1. Chief complaint.
always entirely possible, nor is it always necessarily 2. Health status.
the best option. Again, flexibility is required in our 3. Motivation/will.
thinking. We also need to bear in mind that with in 4. Financial situation.
creasing complexity comes increasing compromise.8-19
Prosthodontic treatments are never easy and are
usually time consuming, both clinically and tech
nically. Therefore, considering the high expecta
Compromise tions of most patients, we would do well to heed
Perfection should be the ultimate goal in treatment Bolender’s advice: “Communication to avoid frus
planning, although it is seldom possible to achieve. tration!” 31,32 The right compromise can be reached
Despite our best intentions, we are usually forced to only if both parties, the clinician and the patient,
compromise. Experience tells us that even when the clearly communicate and agree. That is why it is
outcome is clear from the start, we need to propose so important for us to carefully pay attention and
more than one possible solution. listen closely to our patients. It is also crucial to
Furthermore, we should remember that there clearly and carefully explain to our patients what
is no ideal treatment plan that fits all cases. Each we can do for them (possibly in front of witnesses
patient is unique. We therefore need to be open- in cases where it is considered necessary) so that
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they clearly understand the limitations in terms of This is a responsible course of action that would be
the clinical and technical realities. In this way, their acceptable to the majority of patients. To do this,
expectations will not exceed what is feasible and we need to politely ask our patients what their pro
possible in the circumstances and in terms of our fession, job or occupation entails. Indeed, this in
professional capabilities.13,16,20-25,29,33,34-36 formation should be recorded as part of the initial
examination. This is not the same as asking outright
about a patient’s income, which can be construed as
rude even if we ask in a kind and confidential man
Prosthodontic economics and ner. Moreover, what we know about the occupation
patient treatment costs of our patients will throw light on their level of ed
Prosthodontic treatments are usually expensive due ucation, which has a bearing on how well they are
to the: able to understand the theoretical and practical in
● costly and ongoing dental office expenses; formation we need to transfer. However, we should
● duration of the treatment; always carefully explain why some treatment plans
● cost of dental materials; are more technical, time consuming, and/or expen
● laboratory fees; sive than others. It is our duty to help our patients
● services of other collaborating specialists, if to understand, and it ought to be a pleasure for us
any; to take all the time necessary to do this in the best
● clinical and prosthodontic complications that possible way. At the same time, we need to treat this
sometimes occur despite our professional ex issue with sensitivity because some patients may be
perience and capability to foresee them; embarrassed if certain prosthodontic solutions are
● treatment follow-up; too expensive for them to afford.37-39
● any relevant taxes that need to be paid.
Costs in the face of disease
Affordability of the treatment plan
If an infectious disease exists in the oral cavity, we
The financial resources available for treatment will have the duty as dental medical professionals to assess
differ for each patient, who will only be able to af it and to find the best way to explain the gravity of
ford a certain type of treatment. This is potentially the situation to the patient, together with the related
a serious limiting factor in treatment planning and treatment costs. Disease is a priority that needs to
selection. We therefore need to know the financial be resolved before any prosthodontic solution can
situation of our patients before we begin planning be performed, especially if sensitivity, discomfort,
an appropriate course of treatment for them. In and/or pain exist.37-39
many cases, we need to propose multiple solutions
for the same restorative problem in order to provide
Transparency and politeness
as many available options as possible for successful
treatment and rehabilitation.37-39 It is crucial to plan the treatment costs as comprehen
sively as possible and to be honest about them with
the patient in the interests of a good clinician–pa
The patient’s occupation
tient relationship. This will avoid surprises later on. If
From the start, it is wise to gently investigate to we anticipate additional service costs, we need to let
what extent patients are able to cope with the costs the patient know about them from the outset. Treat
of the restorative care we may propose (including ment planning is not an easy task, and explaining a
the follow-up maintenance costs) so that we com demanding prosthodontic plan is not like selling a
pletely understand their unique financial situation. product; we need to be truthful and transparent as we
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Informed consent
explain and advise about the solution/s that are in vised over the years. What is established with in
our patients’ best interests. At the heart of this aspect formed consent is that a clinician can only treat a
is having and showing respect for the patient.37-39 patient if and when the clinician is sure that the
In the same vein, we need to be kind and polite patient is fully aware of and understands the type
and treat our patients with empathy and gentleness of treatment being proposed to solve the problem.
in order for them to view us as concerned profes Apart from the more ethical aspects outlined above,
sionals with integrity, as opposed to being only in an informed consent is a necessary document for us to
terested in the money we will make from treating obtain to ensure control of our risk management and
them. We need to bear in mind that the decision to try to avoid legal problems that may arise later on
regarding which treatment to choose lies with both with some patients.
the patient and the clinician, and not with the clin The House classification (see Chapter 5) was a
ician alone. In some instances, patients are happy practical, organized attempt to define the personal
to allow us to make the decision, and may request ity of the edentulous patient. It may also be helpful
us to do so on their behalf. The rule of thumb is to for other patients (ie, those who are not edentulous),
be polite and respectful at all times, an attitude that and may indeed be useful to give us some idea of the
will reward us and our dental office with the trust complexity of patients and their idiosyncrasies. This
and respect of our patients. This has a bearing on allows us to be better equipped to avoid unpleasant
our business too, because every patient could po surprises later on during the treatment.
tentially refer family and friends to our office. Therefore, the treatment planning discussion or
initial diagnostic phase is the first ‘filter’ that as
sists us to get to know a new patient, and it is the
point from which all further decisions are taken.
Informed consent This sensitive phase is therefore very useful to our
The basic difference between the terms ‘consent’ and understanding of the personality and psychology of
‘informed consent’ is the degree of patient know a patient. It colors the type of treatment plan we de
ledge behind the consent decision. The amount of vise that is most likely to be accepted by the patient;
information required to make consent informed in some rare cases, we may even see no chance to
may vary depending on the complexity and risks of treat a particular patient at all.25,27,40,41
treatment as well as the patient’s wishes. In terms
of our professional responsibilities and liabilities,
We are not obliged to treat all
it is important to understand the exact meaning of
patients
these terms.
There will be instances where, already at the first
treatment plan discussion (initial diagnostic phase),
Consent
we realize that we are not in a position to treat a
Except in rare cases where we need to help patients given patient in a manner that is agreeable to us.
immediately such as in an urgent clinical emer In these cases, we may feel that, for a number of
gency or in the case of symptoms of severe pain, reasons, it is better not to start any treatment at all.
a patient’s consent to be treated is always required Some of these reasons may be immediately evident,
before the start of treatment. but unfortunately others may not. Obviously, it is al
ways our duty to try to help, but if the situation does
not feel right, or we are in serious doubt about whether
Informed consent
we should commit to treating a particular patient for
Informed consent refers to a doctrine that was es whatever reason, we need to heed that warning voice.
tablished in the 1950s and has been continually re If we conclude that we will not be able to help a
15
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atient properly, we have the right and the duty

p The use of the informed consent
to suggest without prejudice from the outset – as
kindly as possible and with the appropriate humil The informed consent document needs to be very
ity and politeness – that there may be more capable accurate and even customized in some cases. 6,27,41-
professionals who will be better able to help. It is 50 There are various examples of informed consent
therefore much better to spend more time initially forms and formats to be found on the internet.
with new patients, speaking clearly to them and However, as every patient is an individual whose
carefully analyzing them and their situation. data will differ from the next patient, you will find
Prosthodontics is often a matter of invasive and in later chapters many suggestions about what to
extremely complex treatments that go on for a long remember to include in the informed consent doc
time, treatments that may dramatically change the ument. Please bear in mind that these suggestions
esthetics and functionality of a patient’s mouth, are made from the vantage point of many years of
teeth, and face. Therefore, we need to be sure that experience.
we will be able to work with the patient’s full com Another thing to bear in mind is that dentistry
pliance and understanding about the often difficult and prosthodontics do not deal with an immediate
challenges that may lie ahead in the course of the threat to life. Therefore, patients can take all the time
treatment.15 The longer the treatment, the greater they need to listen to our proposals for solutions to
the need for clinician–patient understanding and their problems. They can then ask all the necessary
trust. If during the first visit or during the treat questions in order to understand exactly what we
ment plan discussion we cannot communicate are suggesting. They will then hopefully agree to a
properly, or if patients are unable or unwilling treatment plan and sign the informed consent form
to communicate properly with us, this may indi that we submit to them.17,30,34,51-55,57
cate the possibility that we will end up working
under great stress or tension, with the possibility
Essential aspects of the informed
of misunderstandings. This, in turn, could result
consent document
in the failure of the treatment, with further deep
frustration as well as possible legal problems and All informed consent documents pertaining to a
consequences.16 specific treatment plan should contain at least the
following elements:
1. The patient is fully informed about all
In case of emergency
the characteristics of the entire treat
If an emergency occurs and our diagnosis is clear ment.24,29,30,42,45,47,58-61
and precise, we have a duty to explain to the patient 2. The patient has a full understanding of the
what the emergency is, how and why it should be ad treatment plan in terms of its diagnosis, prog
dressed, and what the costs of the procedure will be. nosis, anticipated benefits, therapy, timing,
In that case, always ask for written permission to certainties, risks, consequences, and the need
treat the patient and request the patient’s full com for future controls.17,30,34,51-53,56,57,59-61
pliance and signed agreement before you proceed 3. The patient has been informed of alternative
with the treatment. This applies even in a situation treatment courses and associated risks.42,62
where we know the patient well. It is important to 4. The patient is fully aware of the risks associ
understand that even in the case of an emergency we ated with refusing the recommended proce
require a patient’s full compliance via an informed dures.17,30,34,51-56,59-61
consent document, if possible signed by themselves 5. The patient is fully aware of any possible tem
or, if not possible, by another responsible adult such porary incapacitation that may occur during
as a parent or guardian. the course of treatment.17,30,34,51-56,59
16
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Informed consent
6. The patient is fully aware of what information Therefore, it is strongly advised that an informed con
the patient is rewriting in front of witnesses sent for any prosthodontic treatment plan should be
(see later), freely accepts the treatment plan, rewritten in the patient’s handwriting. In other words,
and fully intends to be treated by the clinician the document should be copied out in full by the
in full respect of the professional rules of the patient. The reason for this is that it has transpired
dental office.17,30,34,51-56,59-61 on a few occasions that simply signing an informed
7. The patient has read and discussed the consent without rewriting it is not sufficiently se
informed consent document sufficiently to cure. Instead, asking patients to rewrite it in their
know and understand its entire contents and own handwriting is a better guarantee for the dental
is fully aware of what it contains. If this is office (or a court of law) that they have understood
the case, the contents of the informed con it, are completely conscious of the treatment details,
sent document should ideally be rewritten and are willing to be treated without further doubt.
clearly in the patient’s own handwriting Finally, the patient should sign the informed con
(see later).2,18,28 sent document in front of one or more witnesses, who
8. If the patient is unable to fulfill the above point will countersign it afterwards. After the document
(7) for any reason, another person should be has been signed by all the relevant parties, one copy
appointed in the patient’s stead to do so in must be given to the patient. The original document
front of witnesses; this person should be able must remain in the safekeeping of the dental office
to take responsibility for the patient’s situation where it is stored as a confirmation and a warranty
and health.3,7,11,29,39,49,50,58 for both the clinician and the patient.
9. Finally, the informed consent form should be
signed, together with the signatures of one
Digital technology and informed
or more witnesses such as a relative of the
consent documents
patient, an office secretary or a chair assis
tant.2,6,30,39,41,52,56 Although the advent of computerized technologies
and the digitization of dental office documents has
If all these aspects of the informed consent docu optimized the storage and management of patient
ment have been honored, the intellectual honesty, documents and data, in the case of the treatment
professional integrity and empathetic intentions of plan and informed consent it is still strongly advis
the clinician will be immediately clear to anyone able to retain hard copies of all original documents.
who may consult the document later in the event This eliminates any possible questions that may
that they may want to prove negligence in some arise later concerning possible alteration of these
way.2,6,14,15,19,30,36,39,41,52,55,56 documents (ie, if they exist only as computer files),
and eliminates any possible legal doubts about the
It is important to note that any procedure honesty of the professionals and the dental office
performed in the absence of informed con- staff, which may create problems in a court of
sent is liable to prosecution in a court of law law.2,6,14,15,19,30,39,41,52,55,56 Therefore, when it comes
and could be construed as intentionally in- to signed treatment plans and informed consent
flicting physical harm on a patient. documents, it is still better to have the original hard
copies on file in our dental offices.52,56
17
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18. Whyman RA, Rose D. Informed consent for people with

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40. Burris S. Law and ethics and the decision to treat. In: of the Mental Capacity Act to dentistry. Dent Update
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Chicago: Quintessence, 1994;25–50. 54. Medical Legal Handbook for Physicians in Canada. Ver
41. Adeyemi AT, Kosoko JO, Ifesanya JU. Dentists’ knowledge sion 8.2. Ottawa: Canadian Medical Protective Associ
and attitude towards informed consent taking in a Nige ation, 2016;3–15.
rian teaching hospital. Odontostomatol Trop 2011;34:5–10. 55. Morris RB. Principles of Dental Treatment Planning.
42. Bal BS. An introduction to medical malpractice in the Philadelphia: Lea & Febinger, 1983.
United States. Clin Orthop Relat Res 2009;467:339–347. 56. Stuart CE, Stallard H. Principles involved in restoring
43. Braly BV. Occlusal analysis and treatment planning for occlusion to natural teeth. J Prosthet Dent 1960;10:304.
restorative dentistry. J Prosthet Dent 1972;27:2:168–171. 57. Martone AL. The value of “I don’t know”. J Prosthet
44. Choctaw WT. Avoiding Medical Malpractice: A Physi Dent 1957;7:4:541.
cian’s Guide to the Law. Berlin: Springer Science and 58. Regan LJ. The dentist and malpractice. J Prosthet Dent
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45. CNA Dental Professional Liability, 2016 (Claim Report). 59. Dimond B. The Mental Capacity Act 2005 and deci
46. Kakar H, Gambhir RS, Singh S, Kaur A, Nanda T. In sion-making: advance decisions. Br J Nurs 2008;17:
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47. Lal S. Consent in dentistry. Pac Health Dialog 2003; tions to risk management in orthodontics. Presentation
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48. McCabe MS. The ethical foundation of informed consent ation of Orthodontics, Toronto, 1993.
in clinical research. Semin Oncol Nurs 1999;15:76–80. 61. Graziele Rodrigues L, De Souza JB, De Torres EM,
49. Pruden WH 2nd. Problems in oral re-rehabilitations. Ferreira Silva R. Screening the use of informed consent
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Calvani_Ch_2.indd 20 12.02.20 12:04
CHAPTER THREE
Prosthodontic tools for treatment
planning
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3 Prosthodontic tools for treatment planning
How prosthodontists can help ● help to prevent further problems;

● improve the patient’s oral health;
their patients
● help to give the patient a better quality of life.
From the start of its existence in the USA at the
beginning of the last century, the specialty of den- To achieve these goals, the prerequisite of all pros-
tal prosthodontics has involved the study of the art theses should be that they:
and science of restoring broken or decayed teeth ● are minimally invasive;
and mouths in various states of edentulism. Much ● protect the remaining dental and periodontal
research as well as clinical and laboratory experi- structures;
ence and verifiable procedures have resulted in the ● are made from biocompatible materials;
publication of numerous scientific articles, books, ● are esthetically, phonetically, and functionally
manuals, photographs, films, webinars, and online effective;
lectures on the topic of prosthodontics. ● are accessible to excellent oral and dental
The Glossary of Prosthodontic Terms, an im- hygiene;
portant and useful resource currently available as a ● are simple and easily repairable;
free download from the Academy of Prosthodontics ● last as long as possible;
website, was created to define words and concepts ● cost the least amount of money.
necessary to clarify and share a common prostho-
dontic terminology for the practice and scientific
reporting of the specialty.1-3
The outcome of all of this evidence-based science
Current main prosthodontic
and practice is a number of clinical and laboratory tools
therapeutic prosthodontic tools available on the Table 3-1 outlines the main categories of prostho-
market today. These tools are intended for practical dontic tools in use today. This should be seen in
therapeutic solutions capable of restoring oral es- light of the recent progress that has taken place in
thetics and function in patients whose mouths are the prosthodontic field due to the modern techno-
in need of restoration. logical revolution.
As it is impossible to outline here all the clinical
and laboratory prosthodontic reconstructive tools
and procedures in use today, this chapter looks at
the main categories of tools currently available to
Fixed restorations
show the most common prosthodontic esthetic and Fixed prostheses such as crowns and bridges are
functional rehabilitative possibilities, as reported in termed fixed partial dentures (FPDs) or fixed com-
the literature. plete dentures (FCDs), depending on their extension
and abutment involvement.2
Fixed prostheses are considered a dream tool for
prosthodontists because they are the best and most
Aims and requirements of all natural restorations.3 The naturalness of the final
prostheses result depends on a number of clinical and techni-
The following are the main rehabilitative goals of cal factors such as laboratory materials, technical
any prosthesis. It should: possibilities, professional skills, and artistic dexter-
● replace the lost dentition and improve on it as ity.4-8 Fixed prostheses are used all over the world
much as possible; and are fabricated from various materials, including
● satisfy the patient’s needs/desires/requests; gold, depending on factors such as culture and es-
● guarantee the patient’s comfort; thetics.5,9 Their manufacture follows rules imposed
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Complete dentures
Table 3-1 Outline of the most important prosthodon- Nowadays, other new fixed prosthodontic meth-
tic tools currently in use today ods, born as a result of and crafted with the help
of new digital technologies, are revolutionizing the
Fixed restorations
clinic and laboratory. And this is just the beginning,
1. Inlays, onlays
as much more is expected with the current speed of
2. Veneers
exponential progress and growth in this field.26
3. Crown, bridges, post and cores
4. Full-arch fixed complete prostheses Today, in the case of edentulism where there is
one or more missing teeth, implants are usually con-
Removable partial dentures sidered as the first option during treatment planning
1. Tooth-borne prostheses for fixed restorations, unless physical, biological,
2. Tooth- to mucosa-borne prostheses biomechanical, psychologic or economic limitations
and/or contraindications are present.27-33 Where
Complete dentures implants are not indicated due to their negative bio-
1. Immediate prostheses logical, functional, and esthetic possibilities or the
2. Final prostheses chance of predictable short- or long-term complica-
tions,34 tooth-borne FPDs and FCDs are considered
Overdentures the secondary restorative tool, with pontic elements
1. On some remaining portion of roots replacing the edentulous areas.
2. On well-positioned implant
Fixed implant-retained prostheses

1. Partial implant prostheses
Removable partial dentures
2. Following the prolonged use of complete dentures Removable partial dentures (RPDs) are generally
(CDs) considered the third restorative option in the west-
3. Following extractions, immediate CDs, and delayed
ern world. However, in many other countries world-
implant placement
4. Following extractions and immediate implant place-
wide they are considered to be the first choice. RPDs
ment can be very helpful in various partially edentulous
cases, depending on the patient’s chief complaint, de-
Bioinformatics and digital prosthodontic tools sire, and financial situation.35-37 The relatively lower
1. Computer-aided implantology cost of these prostheses is a major factor of choice,
2. Computer-aided prosthetic designing and planning despite the difficulty in planning them biomechani-
3. Precise guided implant positioning cally and the inevitable clinical limitations that their
unnatural composite structure introduces into the
masticatory environment.38-48 This fact should spur
by ongoing research, especially that which is occur- us on to deliver a biomechanically well-conceived
ring in the field of digital technology. project in order not to damage the remaining denti-
The use of fixed restorations for endodontically tion and to preserve it for as long as possible.
treated teeth depends on the amount of the remain-
ing tooth structure and on well-established princi-
ples of tooth preparation.5,6,8,10-12,19 Even though
great improvement has taken place in this respect
Complete dentures
with resin adhesive rehabilitations,11-13 cast post Due to decades of success and their helpfulness in
and cores still show superior physical and biomech- innumerable edentulous cases, CDs have been called
anical capabilities to withstand vertical and lateral the mother of all dental prostheses.49 According to
loads as well as decementation.5,6,8,12,14-25 studies on oral health in the USA, even though there
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has been a relative decline in complete edentulism functional landmarks, and all occlusal parameters ne-
over the past 30 years due to a corresponding de- cessary to properly guide the oral rehabilitation with
cline in caries, the need for complete dentures to excellent approximation can be retrieved both in the
treat edentulism is still high due to the increase in mouth and on the working casts. This also depends
the aging population.28,50 Furthermore, edentulism on the knowledge and clinical skills of the clinician
still depends on infectious disease conditions and and the laboratory technician to replace the lost den-
related health problems that involve both the young tition with final fixed implant-supported prostheses.
and the elderly worldwide, even today.51
Although there is a large body of scientific lit-
erature about them, clinical experience shows that
in many instances CDs still remain very difficult to
Removable overdentures
create and craft properly. However, if the literature Indeed, the advent of implants helped to improve
is carefully studied and scientific engineering rules this unstable situation. However, if structurally valid
are strictly followed, the construction of CDs can roots still remain in strategic positions in the mandi-
result in a successful restoration. Experience shows ble (ie, canines or first premolars), they can be recon-
that the obvious weakness in these prostheses is structed and utilized to support, retain, and stabilize
their mobility.52,53 In this respect, they must neces- any complete denture prosthesis. This possibility is
sarily rely on the remaining available maxillary and cheaper than the use of implants, and biomechan-
mandibular primary and secondary bearing areas ical improvement can be better achieved by means
and on the characteristics of the hard and soft tis- of fixed attachments, as they may limit the number
sue comprising these areas. Their success also relies of biomechanical degrees of freedom to the mobility
on a number of other biological, physical, chem- of the overlying CDs both at rest and during func-
ical, and subjective factors that have been widely tion. Certainly, the choice to save and use the roots
described in the literature. Regardless of whether is limited by a number of structural and biomechan-
they are created in an analog or digital manner, ical parameters that must be carefully evaluated dur-
the nature of CDs makes these prostheses biome- ing the first visit and during treatment planning.71-82
chanically lacking in terms of stability, retention, Mandibular implant overdentures can be obtained
and support compared with other fixed prostheses. with two implants positioned in strategic positions. In
Nevertheless, many patients lack the economic re- these cases, the further use of bars or attachments as a
sources for fixed implant treatments, and many in means of anchoring may greatly enhance the stability,
fact do live with CDs satisfactorily and sometimes retention, and support of these types of prostheses.83-94
more than satisfactorily, which compensates for This combination has been defined as optimal and as
their biologic limitations.52-70 the standard of care for mandibular CDs.95-97
In cases where up-to-date, three-dimensional (3D) In the maxilla, usually the greater extension
digital technologies can be used to virtually plan the and the quality of the bearing surface guarantee
rehabilitation of edentulous cases with immediate better support, stability, and retention. However,
implant-supported fixed prostheses, CDs can be used in the following instances implants might also be
as excellent interim prostheses, as useful verification proposed to create maxillary implant overdentures:
jigs, and as surgical guides to position implants prop- when the amount of alveolar ridge bone is poor;
erly to recreate final full-arch implant restorations. when the palate is particularly flat and induces in-
In fact, when all anatomical dental reference stability; when the posterior palatal seal cannot be
points are lost, CDs are a precious source of anatom- properly achieved and is not enough to aid the re-
ical information and can be used to recover most of tention; and when the patient is suffering from xe-
these points in any edentulous mouth. In these cases, rostomia, which induces instability, inflammation,
lip and cheek support, dental esthetics, phonetic and and poor retention of the denture base.30
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Computerized chairside and laboratory technologies
Full-arch implant-retained bioinformatic possibilities at present to store data

and exploit in-office computer processing capabil-
fixed prostheses
ities. Large databases are immediately available on
These prostheses can be optimal in the restoration the internet for the easy retrieval of precise infor-
of all partial and fully edentulous cases. Limiting mation. This is changing the face of the dental med-
factors to this prosthetic choice may be the patient’s ical profession forever, which is true for all dental
chief complaint restrictions, specific negative gen- specialist fields but perhaps more so for prostho-
eral health conditions, predictable increased clinical dontics. The following section elaborates on a topic
and technical costs, and local limiting factors such that was outlined in Chapter 1 and which is contin-
as the possible moderate to severe bone conditions ually developing. The recent growth in digital tech-
that may not withstand further long and complex nologies has introduced computer-aided implantol-
bone regeneration and implant treatment proce ogy that has allowed for computer-aided prosthetic
dures.31-33,49,98 For more than three decades, this designing and planning and precise guided implant
prosthetic tool has become the primary prostho- positioning.14,26,101,103,112
dontic treatment option, offering the best quasi-nat-
ural improved restoration of complete edentulous
arches with various types of fixed prostheses with
the highest degree of success. Certainly, the most
Computerized chairside and
important rule for success in implant therapy is the laboratory technologies
presence of highly qualified and proficient prostho- It is possible to craft both analog and digital restor-
dontists and clinical and laboratory staff who per- ations in an excellent way. Indeed, human endeavor
form all phases of the restoration, from the initial in terms of ‘collective intelligence’ and artistic abil-
treatment planning phase, in a scientifically correct ity has always been phenomenal. Yet, with the ad-
way.27,99-101 This professionalism is an ethical and vent and rise of digital technology, this endeavor is
practical must, because the challenge to plan and rapidly and constantly progressing and improving
create implant prostheses always contains a large as a new and broad range of digital dental tech-
number of variables that are not always easy to nologies are increasingly being introduced. This is
keep under control unless one is knowledgeable having an impact on the shape and performance of
and highly experienced.31,102 To this end, a descrip- all areas of the dental medical profession, be it in
tion of many limitations and prerequisites for im- dental hospitals, universities, dental offices, surgical
plant choices useful for brainstorming purposes as theaters, operatories, and laboratories. Each day,
well as for the practice of treatment planning are the diagnostic dental medical devices and other ob-
reported in Chapter 10. jects and devices in our clinics and laboratories are
becoming exponentially ‘smarter.’ This has resulted
in a rapid change in our prosthodontic treatment
possibilities and ‘tools’, a brief description of which
Bioinformatics and the digital is presented below.
prosthodontics paradigm shift
In the present era of computers, all areas of our lives
Digital software treatment
are constantly becoming more and more digitized.
revolution
We can only imagine what the reality will look like
in 10 years’ time in the medical and dental medical The progress in software development and
professions as we attempt to grasp day by day just marketing has implications for all areas of dentistry,
a small part of what thousands of extremely gifted including prosthodontics. For instance, clinicians
scientists are creating. There are many impressive today have the ability to access digital algorithms
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to rationalize workflows, to reduce the time of clin- Digital treatment planning

ical intervention, to reduce operative costs, and to
increase the predictability of results and therefore Regarding treatment planning, increasingly per-
patient satisfaction. fected artificial narrow intelligence (ANI) algo-
rithms allow for the planning of clinical cases by
means of digital workflows and simplified proced-
In the clinic
ures, creating with excellent approximation visual
● 3D high-definition (HD) magnifying visors allow graphs that clearly show the clinician where and
us to see the smallest details that have until how to craft any fixed prostheses. This can be done
very recently been impossible to see even with without producing physical casts that are both
magnifying lenses (which are today almost costly and require storage space.
obsolete).
● 3D screens allow us to show patients detailed
Cloud dentistry
views of the operative field in order to better ex-
plain to them the reality of their oral situation. By means of digital communication media, clin-
● Improved multiple detectors in use with cone icians and dental technicians are now able to easily
beam computed tomography (CBCT) are able to communicate online and share information about
take a 3D HD radiographic scanned reproduc- the treatment on an ongoing basis. By DICOM and
tion of a patient’s head and mouth by simply other dental medical data files over the internet, the
and quickly sliding only once from one side of milling or 3D printing of dental prosthesis can be
the face to the other, dramatically reducing the activated remotely from anywhere in the world.
amount of radiation exposure for the patient.
● Temporomandibular joint (TMJ) occlusal eval-
Computer-guided implant-
uators can tell us precisely what happens in
positioning software and hardware
a patient’s TMJs at rest and while speaking,
chewing, and biting. Among other things, they This allows the clinician to place virtual implants
provide information regarding invisible occlusal and teeth according to the underlying bone position
vectors in terms of timing, intensity, and direc- as well as the future teeth. The use of this hardware
tion of the applied chewing forces. Using precise and software has vastly improved the understand-
algorithms, they allow us to study the occlu- ing and treatment planning of partially or com-
sion during both the treatment planning and pletely edentulous cases.
in the following clinical phases, according to
important static and dynamic parameters now
3D virtual articulators
visible and measurable. This was impossible to
achieve with the previous analog methods. These reproduce the best analog articulators. They
● 3D intraoral scanners progressively eliminate are diagnostic tools able to study any prosthodontic
the use of trays and impression materials, case.
recording at high magnification all possible
details of our preparations and of the sur-
Facially driven dentistry
rounding teeth and saving them in both dental
imaging and communication in medicine Clinicians at the chairside and technicians in their
(DICOM) and/or photographic files. This allows laboratories are now able to create digital dental
for fantastic magnified on-screen reproduc- guidelines and landmarks and show the patient a
tions that are ready to be studied for the design previewed 3D version of the virtual representation of
and crafting of 3D-printed or milled prostheses. the dentition and face, possible smile, and prosthetic
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The day after tomorrow
outcome of the treatment plan. This is useful for dis- House wrote in 1937,113 these AI machines are be-
cussions with the patient regarding possible present coming more and more able to create and craft ar-
and future dental treatments and their economic im- tistically what we humans are able to do with our
plications. The information and patient preferences art and dexterity. We have been the masters up until
can be stored and saved for future reference. now, but for how much longer?
Today’s technology also allows us to rapidly pro-
totype, design, and tweak predictable provisional This evident digitalized simplification of
customized mock temporary restorations, digital procedures means more ‘predictability,’ which
RPD substructures, and digital CD prostheses. These consequently also means less undesirable
files can then be saved on a dedicated database and posttreatment complications, including a
decreased risk of possible working cross-
be used to design, craft, and manufacture restor-
contamination between the clinic, the
ations using a broad range of digital milling or 3D
laboratory, and the social environment.
printing machines in our offices.
Digitally created, usefully milled, and wear-
able pretreatment mock temporary restorations
can currently be temporarily cemented and used
without any tooth preparation. They enable the
Holographic prosthodontics
patient to try out the mock-up in vivo and also in HoloLens hands-on 2 is a brand new powerful
their own environment once they leave our offices. mixed-/augmented-reality tool, interconnected
This try-in gives patients a good approximation of by means of a mixed-reality app that allows us to
the esthetics and functional aspect of the planned see what we cannot see with the naked eye, and so
and proposed prosthetic outcome. If the patient to touch, move, increase, and decrease – in a very
is satisfied with the esthetics and function of the practical and ‘quasi-normal’ intuitive way – the
temporary restorations after the try-in, the digital size of holographic virtual objects that physically
image can be scanned in the mouth, mounted on appear in front of or around us. Users move their
virtual articulators, and used to produce a digital hands in a close, dedicated 3D virtual world that
version of the final prosthesis. This is useful to ei- allows them to see, interact with, and use all types
ther create minimally invasive prosthetic ceramic of actual (real) analog devices that are connected to
pieces to be bonded over the remaining dentition, the system. This means that we do not physically
or useful guides to prepare what remains and adapt touch the instruments but rather touch and work
it to the new identical final prostheses. The newest with them from a virtual remote. We then receive
digital light processing machines and bioprinting useful written information about these devices that
machines will predictably one day be precise and ‘float in the air’ before us so we can know, analyze,
powerful enough to recreate even sound brand-new plan, and better control our workflows.
teeth for implantation. This situation is very difficult to imagine and
understand if you are not actually working with it.
However, it is extremely useful and will soon dra-
Computerized laboratory
matically change the way we live and work.
technologies
New laboratory ceramic materials increasingly re-
semble natural teeth in terms of their optical and
physical properties. 3D milling and printing ma-
The day after tomorrow
chines are increasingly changing the way the la- Apart from all that has been discussed in this chap-
boratory works and how it relates to the clinical ter, it is not possible for us to actually foresee which
office. Indeed, despite what the monumental Dr prosthodontic tools we will use in the future. Al-
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though the organization of treatment planning will decades from now, the speciality of prosthodontic
certainly change, the clinical rationale on which treatment planning and its current tools will be rad-
treatments are based will not change. Even if one ically changed.
day an artificial general intelligence (AGI) team
takes the place of humans at the chairside, the
step-by-step planning procedure is simplified and
sped up by new diagnostic methods, and workflows References
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89. Rutkunas V, Mizutani H, Peciuliene V, Bendinskaite Int J Oral Maxillofac Implants 1991;6:270–276.
R, Linkevicius T. Maxillary complete denture outcome 103. Fages M, Raynal J, Tramini P, Cuisinier FJG, Durand
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90. Sadowsky SJ, Caputo AA. Effect of anchorage sys- crown Restorations: a 7-Year Survival Rate Study. Int
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91. Tang L, Lund JP, Taché R, Clokie CM, Feine JS. A with- 2017;20:9–19.
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92. Taylor TD. Indications and treatment planning for Comput Dent 2017;20:65–73.
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2002;17:391–398. ceramic veneers: a clinical report. J Prosthet Dent
95. Bergendahl T, Engquist B. Implant-supported 2018;119:200–205.
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96. Feine JS, Carlsson GE, Awad MA, et al. The McGill for use. Compend Contin Educ Dent 2012;33:720–732.
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187–188. future/. Accessed 1 May 2019.
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Calvani_Ch_3.indd 32 12.02.20 12:04
CHAPTER FOUR
Data, findings, and dental

semiotics
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4 Data, findings, and dental semiotics
This topic is of paramount importance for diagnostic and interact directly with the patient. Through
purposes. Certain terms and concepts are emphasized this spoken interaction, we deepen our ob
because they need to be crystal clear in the mind of servation and are better able to assess evident
all clinicians, whether they are experienced or still problems, dysfunctions, illnesses or diseases.10
only novices. Sometimes, more experienced clini This second opportunity may be performed
cians, in light of their experience, tend to simplify using a second set of specialized question
procedures to save time, and thereby fall into error. naires that serve to clarify and understand
Treatment planning is very important in pros specific aspects of the patient’s health profile
thodontics. Data, findings, histories, signs, and and serve to integrate further details into the
symptoms are all necessary to any patient assess initially gathered information to make it more
ment as they work together to give us an overall comprehensive.
picture of the patient’s health situation. The infor
mation we glean from their combination is vital to
the planning of any treatment.1-7
Data and findings refer to the comprehensive
Findings
collection of information necessary to arrive at the Findings refer to the evident results obtained from
assessment of the patient’s current health situation both the hands-on clinical examination and further
such as:1-3,8 examinations such as radiographs and other diag
● histories (personal, medical, and dental); nostic tools and aids used to investigate patients’
● examinations (extraoral and intraoral); health and make a correct diagnosis. Generally,
● radiographs; findings can be grouped into symptoms and signs
● other useful diagnostic aids. that define any dysfunction, illness or disease.1-3
A useful way to think about the difference be
tween a symptom and a sign is that patients feel
the symptoms of their illness or disease and show
Data the signs. As symptoms are subjectively perceived
Data refers to the information we obtain from tak and described by each patient in a similar but dif
ing patient histories. History taking is the first and ferent way, they may either be true or not true.
main means of data gathering. Patient histories Signs, on the other hand, are always true, as they
consist of all the information given by the patient, are objectively perceived and are evident to the
including both past and present information, and clinician, who will know them and recognize them
can be categorized as follows:9 as such. Signs are perceived by our senses and by
1. The basic demographic information. the various diagnostic means at our disposal. They
2. The chief complaint. reveal their presence and characteristics without
3. The medical history. any doubt.
4. The dental history.
5. The prosthodontic history.
Symptoms
There are usually two ways of recording patient his Symptoms are subjective – only patients feel them.
tories: Symptoms are the primary alarm bells of a dysfunc
1. The initial questionnaires that patients fill out tion for a patient. They can be immediately referred
at the dental office before we meet and inter to and described by a patient as the problem in the
view them (Fig 4-1). initial patient interview.1-3
2. The interview that we perform on meeting the Pure symptoms in dental medicine can be, for
patient, during which we start to communicate example:
34
Calvani_Ch_4.indd 34 12.02.20 12:04

Findings
FIRST VISIT H I P E
Medical and Dental History
You are kindly requested to complete this questionnaire for medical and administrative purposes.
According to privacy law, your information will be saved but not shared or exposed. Thank you for your cooperation.
Today's date_____________________________________ Patient’s full name��
Gender __________________________________________ Date and place of birth ��
Address ��
Telephone (landline) _____________________________ (mobile) ��
SSN ______________________ / __________ / __________ Referred by ___________________________________________________
Marital status ___________________________________ Employment status ____________________________________________
Name of physician _______________________________ Telephone ____________________________________________________
1. CHIEF COMPLAINT __________________________________________________________________________________________

_________________________________________________________________________________________________________________
2. MEDICAL (Please circle (Y) or (N), please describe or explain further in the space provided)
Date of last physical exam ___________________ Blood pressure? ___________________ Pulse? _____________________________
Do you smoke? (Y) (N) ) (light or heavy)__________________ Do you drink alcohol? (Y) (N) (units per day)___________________
Do you have (or have you ever had) a serious illness or disease? (Y) (N) __________________________________________________
Do you have heart problems? (Y) (N) ��
Do you have high or low blood pressure? (Y) (N) ��
Do you consider yourself to be a nervous person? (Y) (N) Do you suffer from anxiety? (Y) (N) Depression? (Y) (N)
Diabetes? (Y) (N) (type) _________ Epilepsy? (Y) (N) HIV? (Y) (N) Hepatitis? (Y) (N) (type) (A, B, C)_____________________
Thyroid conditions? (Y) (N) (hypo or hyper) __________________________________________________________________________
Infectious diseases? (Y) (N) _________________________________________________________________________________________
Allergies (Y) (N) (penicillin, aspirin, local anesthesia, codeine, other)_____________________________________________________
Bleeding disorders? (Y) (N) _________________________ Blood disease? (Y) (N) ___________________________________________
Are you currently taking any medications? (Y) (N) ____________________________________________________________________
Do you use drugs? (Y) (N) ��
Are you pregnant? (Y) (N) Are you currently breastfeeding? (Y) (N)
Headaches or ear conditions? (pain, noises) (Y) (N) ��
Sinusitis or nose conditions? (Y) (N) �� Asthma? (Y) (N)
Cervical arthritis? (Y) (N) ��
Cancer condition? (Y) (N) ��
3. DENTAL
When was your last dental visit? ____________________ What was it for? ________________________________________________
How often do you visit your dentist? (every 3-4 months, 6 months, yearly, when needed) ��
Lip or cheek biting? (Y) (N) Teeth clenching or grinding? (Y) (N) Have you noticed your bite changing? (Y) (N)
Difficulty in opening your mouth wide? (Y) (N) ��
Have you ever had gum disease? (Y) (N) ��
Have you ever been treated for periodontal disease? (Y) (N) ��
Do you take regular care of your teeth? (Y) (N)��
Any comments or suggestions before treatment? _____________________________________________________________________
_________________________________________________________________________________________________________________
LC Patient’s signature ____________________________________________________
Fig 4-1 Example of a simplified format of an initial e

xamination questionnaire.
35
Calvani_Ch_4.indd 35 12.02.20 12:04

● pain; cause it is asymptomatic. Even diseases as serious

● discomfort; as cancer are often not perceivable to the patient,
● a rise in temperature; and we notice them by chance due to the presence
● sensitivity to heat or cold; of a random sign.
● altered taste; We can say that signs are the secondary alarm
● numbness of the mouth or tongue. bells of a dysfunction for a patient. They are the
evidence of dysfunction that can be discovered and
Dysfunctions, illnesses or diseases rarely manifest assessed during an examination. Signs may indi
as one symptom and are seldom diagnosed based on cate a problem, as they are often visible. When they
a single symptom. Usually, a symptom is associated are not visible, it may be possible to touch or feel
with one or more other symptoms to characterize a them (palpable), hear them (audible), or smell them.
specific health condition. We look at all the evident We can therefore say that in some way they are
symptoms together during the initial questioning measureable. Signs can be directly measured (for
and subsequent clinical examinations to evaluate instance, with a ruler) or indirectly measured (for
them as a whole in order to more precisely diagnose instance, with a radiographic examination). Signs
a patient’s problem.11 in dental medicine include:
The qualities of symptoms – their duration, 1. Caries.
course, severity, and pattern of behavior (sudden, 2. Plaque and calculus.
continuous, intermittent, episodic) – are described 3. Pain on palpation or percussion.
by patients using words such as light, heavy, terri 4. Tenderness on palpation.
ble, worsening, improving, etc. These words, com 5. Swelling.
bined in various ways, guide us in assessing the 6. Redness.
origin of the symptoms and the reason for their 7. Periodontal pocketing.
manifestation.1-3 For example, a patient’s descrip 8. Bleeding on probing.
tion of a mandibular third molar affected first by 9. Measurement of probing depth.
pericoronitis and then by a periodontal abscess 10. Furcation involvement.
may be: “It all started with episodic discomfort, with 11. Root proximity.
swelling behind the last tooth, which in a couple 12. Gingival abscess (pus).
of days changed to a continuous dull pain. After a 13. Amalgam tattoo.
while, that worsened into terrible pain, and now I 14. Oral mucosa lesions.
cannot even swallow or open my mouth. Even my 15. Bone loss.
ear is sore.” 16. Crepitus.
17. Malocclusions.
18. Wear facets.
Signs
19. Widening of periodontal ligament.
Signs are objective. We use our senses to see or 20. Open margin of a fixed prosthesis.
‘read’ them on our patients. Just because patients 21. Oral cancer (visible lesions).
may not feel a problem in their mouths does not
mean the problem is nonexistent. Mostly, patients
Simultaneous symptoms and signs
come to our offices without specific symptoms or
complaints but for a routine check-up examination A simultaneous association of a number of symp
and/or a professional tooth cleaning. Sometimes, toms and signs is also possible. These so-called
in these instances, we see a sign of a problem that symptom-signs perceived and reported by the pa
patients have not even perceived, or if they have tient and perceived and observed by the clinician
perceived it, have judged it to be unimportant be could be:
36
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Findings
1. Bad breath (clinician and patient both smell it). fractured teeth, acute pericoronitis, myofascial dys
2. Dry mouth or xerostomia (patient feels it, clin functions, etc. It is important to delve a bit deeper
ician sees it). into the origin of the pain. The definition of pain in
3. Dysphagia (patient feels it, clinician sees it). the Glossary of Prosthodontic Terms states: “Pain n
4. Bleeding. (13c): a subjective unpleasant sensory and emotional
5. Inability to speak properly. experience associated with actual or potential tissue
6. Speech changes. damage or described in terms of such damage — see
7. Loss of ability to chew. acute pain, chronic pain, heterotopic pain, mastica-
8. Esthetic problems. tory pain, musculoskeletal pain, myogenous pain,
9. Tooth mobility. neurogenous pain, odontogenous pain, primary pain,
10. Tooth fracture. projected pain, secondary pain, vascular pain, vis-
11. Tooth loss. ceral pain.”13-15
12. Fever or hyperthermia (measurable). Pain is a complex phenomenon. It is the natural
13. Altered skin color. alert for patients of a possible ongoing problem that
14. Skin moisture content. the clinician cannot see, as there is no evidence of it
15. Cancer. apart from the patient’s subjective description.16-18
16. Tooth sensitivity. As mentioned previously, pain is always relative to
17. Reaction to pulp tests such as cold, heat, a low the individual patient, as everyone perceives it dif
dosage of electricity (felt by the patient as a ferently and describes and evaluates it in a unique
symptom, induced and seen by the clinician as way.16,19,20
a sign). Some patients suffer from clinical conditions
where they are unable to perceive pain at all (anal
gesia). An example of such a condition, hereditary
Main symptoms and signs in dental
sensory and autonomic neuropathies (HSAN), is
medicine
a disorder characterized by the malfunctioning or
Pain is the main and most important symptom and nonfunctioning of pain receptors.13,19,21-23 The clas
is usually the patient’s chief complaint. Closely re sic and most dangerous example of this disorder is
lated to pain is discomfort, which is second only to type IV HSAN, called HSAN IV. It is also known
pain in terms of intensity or sensitivity. The two are as congenital insensitivity to pain with anhidro
directly related and should be considered together. sis (CIPA) or Nishida syndrome.23,24, This disorder
Other important symptoms and signs (so-called has two characteristic features: the incapacity to
‘ringing bells’) that should be taken into account feel pain and temperature, and the decrease in the
during any patient evaluation are inflammation, xe- ability or the inability to sweat (anhydrosis). These
rostomia, dysphagia, fever, and hyperthermia. These inabilities can lead to repeated injuries that may
main signs and symptoms are indicative of an ex become debilitating such as biting the tongue, lips,
isting problem and need to be investigated in terms cheeks, or fingers. In some extreme cases they can
of their severity, duration, and location in order to be dangerous, leading to severe wounds and in rare
make a precise diagnosis. They may vary according instances to the necessity to amputate the affected
to changes in the patient’s posture, temperature, or area. Other serious conditions such as hypertension
activity (ie, whether the patient is at rest or chew and diabetes may cause hypoalgesia; therefore, they
ing).1,12 need to be investigated and assessed before any oral
treatment.
Pain Furthermore, drugs may reduce a patient’s cap
Dental pain may be caused by a wide variety of acity to feel pain by inducing a decreased sensitivity
problems such as acute pulpitis, dental abscesses, to painful stimuli (hypoalgesia). When medications
37
Calvani_Ch_4.indd 37 12.02.20 12:04

affecting the sensory system are taken or abused – 1. Pain location (localized, diffused, and/or
such as analgesics (eg, carbamazepine) or nonsteroi migrating).
dal anti-inflammatory drugs (NSAIDs) (eg, aspirin, 2. Association with other symptoms or evident
ibuprofen, naproxen, and paracetamol) – they may signs.
affect a patient’s ability to sense pain and perceive 3. Specific characteristics (insurgence, quality,
damage in the oral cavity.23,25,26 Opioids, currently duration, intensity).
widely used not only in the USA but increasingly 4. Existing aggravating factors (function, tem
worldwide, may heavily reduce pain perception. perature, head posture, stress, medications).
This increases the possibility of patients hurting 5. Possible relationship with other concomitant
themselves when chewing, speaking or during cer ailments or previous problems.
tain parafunctions.
We also need to bear in mind that sometimes It is important to be aware of all these clinical pos
patients’ pain may be psychologic in nature, ie, the sibilities. In general, we should not under- or over
pain may not be actual or real, but rather imagined. estimate the importance of these symptoms as they
This is a complex topic and relates to patients’ form the basis of the decisions we make in terms of
present or past negative experiences, expectations, the diagnosis and treatment plan.12,18
fears, anxieties, and traumas.19-21,27-31 It could be
that the patient is describing as pain something Inflammation
that is actually discomfort.31,32 If reported pain is Inflammation or phlogosis (from the Greek phlogos
associated with tissue damage, clinical evidence meaning ‘flame’ – which refers to the burning sen
will prove it. It is important for us to be attentive sation that is one symptom of inflammation) is the
and sensitive in our clinical examination of patients first natural defense response of any living tissue to an
in order to verify whether pain actually exists and injury. It is the cause of symptoms and signs such as
whether it is truly related to damage or disease in swelling, discomfort, redness, pain, burning, and fever.
the oral cavity.21,30,33 Inflammation is not purely a local event but of
Anxious patients are often more likely to report ten actively involves the entire body. It is a set of
pain and discomfort for reasons such as their over cyclic modifications, called inflammatory process
estimation of danger, conditioning past perceptions moments, that occur at the vascular-connective tis
and experiences, hypersensitivity to cold and heat, sue level when the body reacts to harmful agents.
emotional expectations, loss or lack of control, These agents can be of a differing nature and origin
muscle tension or rigidity, cultural and educational and usually cause a gradual rather than immediate
attitude, etc.19,20,28 When assessing the cause of any and complete destruction of tissue.34,35
pain in a clinical examination, it is advisable to cor Furthermore, inflammation is a pathologic event
relate reported pain with the level of anxiety in the that needs the vitality of the tissues as well as excel
patient and to consider possible related psychologic lent blood and lymphatic vessel functionality. It also
signs and symptoms. In this way, we can better as needs the necessary means to convey the defense
sess whether the pain is due to real damage, dys inflammatory components locally and spread them
function or disease, and whether it relates to a real throughout the entire body.35,
sensory experience or is due to emotional trauma Inflammation may be caused by a variety of
or worry.21 agents such as:
There may be many causes of a patient’s pain 1. Physical: mechanical, thermal, electrical or
(see the definition of pain and its many subsidiary actinic injuries, foreign bodies, inert materials,
categories in the Glossary of Prosthodontic Terms, on etc.37
page 37). Each one may have different origins and 2. Chemical: poisons (ingestion or injection), ab
characteristics such as: normal metabolic products, blood levels, etc.37
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Findings
3. Biologic: presence of antigen-antibody com well as bradykinins. It can also be due to the
plexes, hydrolytic enzymes, plasmatic quinines, swollen and deformed tissue.
a small amount of activated complement, etc.38 5. Loss of function (functio laesa): the macro
4. Infectious: presence or invasion of viruses, scopic reduction or lack of functionality of the
bacterial microorganisms, bacterial endo- and inflamed area that may be due to pain and the
exotoxins, protozoa, fungi, parasites, macro-or stiffness that results from swelling.
ganisms, etc.39-42
According to general pathology doctrines, the clin
Other factors that affect the inflammatory reaction ical expressions of inflammation consist of:
process are age, nutritional deficiencies, severe 1. Circulatory alterations: the permeability of ves
metabolic diseases, immune capabilities, and the sels, local plasmatic exudation, and edema.
amount of hormones in the body such as cortisone, 2. Corpuscolated exudation: blood cells, connective
hydrocortisone, corticosteroids, etc.35,43-45 local and mobile cells.
Inflammation processes can be peracute, acute, 3. Regressive phenomena: anatomical and func
subacute or chronic. They usually require a medical tional alterations, including necrosis.
response and can last for a long period of time.35,46 4. Regenerative phenomena: substitution damaged
Aulus Cornelius Celsus, the Roman encyclope cells, new original reparatory tissue, or various
dist (25BC to 50AD) in his book De Medicina, was types of scar tissue.
the first person to highlight the four local signs of
inflammation: Inflammation can have beneficial and detrimental
1. Rubor (redness). effects, both locally and systemically. It is an ex
2. Tumor (swelling). tremely important sign in dental medicine and is
3. Calor (heat). therefore touched on later in the book (see Chapters
4. Dolor (pain). 7, 8, and 10).
There is also a fifth macroscopic sign of inflamma Xerostomia and dry mouth
tion, which is functio laesa (loss or disturbance of Xerostomia is both a symptom and a sign. It is both a
function). This was identified by Galen, who later subjective sensation of dry mouth as well as the evi
added it to the four signs identified by Celsus. Ac dent reduction or lack of saliva. It affects almost 20%
tually, the attribution to Galen is disputed, and has of elderly patients. Xerostomia is one of the most sig
variously been attributed to Thomas Sydenham and nificant problems in the oral cavity because the lack
Rudolf Virchow. Nevertheless, whoever was re of saliva may dramatically increase the frequency of
sponsible for identifying it, function laesa is a clin caries, the rate of infections due to candida, the onset
ical reality,47,48 in light of which the original four of dysphagia (difficulty swallowing), and the onset
signs of inflammation can be amended to the fol of dysarthria (difficulty articulating phonemes and
lowing five: words).49-51 It is potentially a serious problem that
1. Redness (rubor): acute hyperemia of the in may cause the onset of other clinical problems.49,52,63
flamed tissue. There are several different causes of xerostomia:
2. Swelling (tumor): edema of fluids and inflam 1. Iatrogenic causes such as medications, chemo
matory cells in the extravascular inflamed area. therapy, local radiation therapy, chronic graft-
3. Heat (calor): local higher temperature due to versus-host disease (GVHD) due to the trans
hyperemia and the vascular dilation local reac plantation of allogenic stem cells.52,53,99
tion effect. 2. Salivary gland diseases such as Sjogren’s syn
4. Pain (dolor): due to acute inflammation chem drome, diabetes mellitus, hepatitis C, sarcoido
ical mediators such as some prostaglandins as sis, HIV, biliary cirrhosis, cystic fibrosis.54-58
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3. Other causes such as inadequate intake of food, taneously for various problems, and their interac
hemochromatosis, amyloidosis, salivary gland tion may exacerbate dry mouth. Therefore, during
agenesis, Wegener’s disease, triple-A syn the initial diagnostic phase, it is important that we
drome.49,59,60 scrutinize the patient’s answers to the question
4. Drugs: This is a major cause of xerostomia. naires and investigate a bit deeper in our interview
As drugs are often responsible for xerosto with the patient to ensure that we are aware of all
mia, clinicians should ensure that they know the drugs the patient is taking. We also need to have
exactly what medications patients are taking a sound knowledge of their effects, side effects, and
and which of these could possibly cause dry interaction with each other to properly diagnose
mouth.61-63 This is one of the reasons why it is and treat our patients and avoid future unexpected
crucial to collect comprehensive medical and surprises or possible misunderstandings.63
dental drug data during the first diagnostic
phase. Dysgeusia and taste impairment
This important symptom is often underestimated
To date, there are 25 categories of medications rep and especially affects elderly patients. Taste, or gus
resenting some 133 generic drug names that have tatory perception, is a natural warning system that
xerostomia as a side effect, as follows: developed through evolution so that, apart from
1. Anorexiant. tasting when food or drink is good, humans are able
2. Antiacne. to detect when it is spoiled and may endanger their
3. Antianxiety. health and life. This includes the ability to detect
4. Antiarthritic. substances to which we may be allergic. Taste re
5. Anticholinergic/antispasmodic. ceptors are located on the tongue as well as on the
6. Anticonvulsant. roof, sides, and back of the mouth, on the epiglottis,
7. Antidepressant. and in the throat.32,64,65
8. Antidiarrheal. Dysgeusia is a condition in which a foul, salty,
9. Antihistamine. rancid or metallic taste sensation appears and re
10. Antihypertensive. mains in the mouth. Sometimes, patients report that
11. Anti-inflammatory/analgesic. this symptom started with the delivery of a pros
12. Antinauseant. thetic device or some other metal object in their
13. Antiparkinsonian. mouths. Patients may attempt to place the responsi
14. Antipsychotic. bility for the symptom on the prosthodontist/s who
15. Antisecretory. planned and delivered the restoration. We need to
16. Antispasmodic. investigate the cause of the dysgeusia carefully be
17. Antiviral. cause sometimes it is caused by something other
18. Bronchodilator. than the restoration, in which case we need to ex
19. CNS stimulant. plain this in a gentle and kind way to the patient.
20. Decongestant. The U.S. Department of Health and Human Services
21. Diuretic. – National Institutes of Health reports that in the
22. Migraine. USA some 200,000 people visit a doctor each year
23. Muscle relaxant. for problems with their chemical senses, which in
24. Narcolepsy, narcotic, analgesic. cludes taste and smell. This significant number of
25. Ophthalmic sedative. patients, which in fact may be just the tip of the ice
berg, means that many people experience problems
Composite drug therapies can cause xerostomia. It with these two senses. It is therefore usually too
is common for patients to take several drugs simul simplistic to relate the symptom of dysgeusia to a
40
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Findings
purely prosthodontic cause. Furthermore, taste and we can explain to them that it may be due to the
smell are closely related, and it is sometimes con drugs they are taking.74
fusing in certain conditions to tell whether a patient There are 46 categories of medications repre
has a taste or a smell disorder.66-69 senting some 151 generic drug names that can cause
an altered or lost sense of taste as a side effect, these
Taste as a risk factor being:
Taste disorders may create serious health problems 1. Alcohol detoxification medications.
as they can be a risk factor for stroke, diabetes, 2. Alzheimer’s disease medications.
heart disease, and other conditions where a careful 3. Analgesics (NSAIDs).
diet must be followed. Impaired taste may cause pa 4. Anesthetics (general and local).
tients to dramatically limit their food intake so that 5. Anorexiants.
they experience massive weight loss, with the teeth 6. Antacids.
having nothing to do with it.70,71 This situation may 7. Antiarthritics.
also cause depression. This is important to know 8. Anticholinergics.
and remember in the initial diagnostic phase. 9. Anticonvulsants.
Possible causes of dysgeusia and altered taste 10. Antidepressants.
disorders are: 11. Antidiabetics.
1. Drug use or abuse. 12. Antidiarrheals.
2. Poor oral hygiene. 13. Antiemetics.
3. Third molar extraction surgeries. 14. Antifungals.
4. Upper respiratory tract and middle ear infec 15. Antigouts.
tions and surgeries. 16. Antihistamines (H1) antagonists.
5. Head injuries. 17. Antihistamines (H2) antagonists.
6. Radiation therapy for head and neck cancer. 18. Antihyperlipidemics.
7. Exposure to chemicals such as insecticides. 19. Anti-infectives.
8. Central nerve system pathologies. 20. Anti-inflammatories/anti-arthritics.
21. Antiparkinsonian.
When loss of taste is a chief complaint that cannot 22. Antipsychotics.
be related to a disease in the oral cavity, we should 23. Antithyroid.
advise the patient to consult a physician, as this 24. Antivirals.
symptom may be a precursor sign (together with an 25. Anxiolytics/sedatives.
impairment of the sense of smell) of a severe nerv 26. Asthma preventives.
ous system pathology such as Parkinson’s disease 27. Bronchodilators.
or Alzheimer’s disease.72,73 28. Calcium-affecting drugs.
29. Cancer chemotherapeutics.
Drugs that may affect taste 30. Cardiovascular drugs.
When a patient reports an altered, reduced or ab 31. Central nervous system stimulants.
sent ability to taste as a chief complaint, we need 32. Decongestants.
to ensure that we see and understand the full clin 33. Diuretics.
ical picture. As described in the previous section re 34. Glucocorticoids.
garding dry mouth, an affected sense of taste may 35. Gallstone drugs.
be due to drugs the patient is taking. It is therefore 36. Solubilization medications.
important to know exactly what these are, so that if 37. Hemorheological medications.
patients claim to have an affected sense of taste due 38. Immunomodulators.
to a prosthesis or other dental work in their mouths, 39. Immunosuppressants.
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40. Methylxanthines. Fever caused by ear, nose (sinusitis), and other

41. Nicotine cessation drugs. oropharyngeal infections often occurs and may be
42. Ophthalmics. confused with fever caused by dental or periodontal
43. Systemic retinoids. problems.
44. Salivary stimulants. Fever in dental patients may mean an infection
45. Skeletal muscle relaxants. somewhere, and its origin may indeed be found in
46. Vitamins. the mouth. However, even if this is the case, it may
not necessarily be due to a localized dental or peri
Fever and hyperthermia odontal problem, but rather to a bacterial infection
Fever and hyperthermia, which are also signs and that originated intraorally and afterwards created
symptoms in dental medicine,75 have different causes infective foci elsewhere in the body. An example of
and should therefore be carefully investigated in or this is infective endocarditis (IE), which is ‘silent’
der to make a proper differential diagnosis.76 until the disease is evident.82 Many oral microbiota
Hyperthermia is an increase of body temperature are responsible for IE and many other infections,
beyond 100.4°F (38°C) due to either an external heat the main symptom of which may be even a slight
increase in the environment or internal sources such fever. They are all associated with the most common
as excessive intake of hot beverages; physical muscle routine activities such as toothbrushing, flossing,
activity; hyperthyroidism; use of drugs such as in and chewing. Therefore, during the chairside phys
terferons; excessive use of drugs such as atropines, ical examination, we need to make a differential
antiepileptic drugs, and phenothiazines; or due to diagnosis between an occurring general infection,
intoxications caused by aspirin, antibiotics or car an oropharyngeal infection, a dental infection, and
bon monoxide. These aspects need to be identified the side effect of a drug. The collection of patients’
during the examination if we are faced with an un data and findings is fundamental to ascertain how
clear increase in a patient’s body temperature.77-79 all these aspects are related.
Fever, on the other hand, is an increase in body Both young and elderly patients are particularly
temperature beyond 98.6°F (37°C). This clinical sign vulnerable to fever as their immune systems are ei
is a very important indicator of a possible disease or ther not fully developed or becoming deficient. More
condition that needs to be identified and healed.80 over, prosthodontic patients are often elderly.75,83-86
The presence of fever means two things: one nega In case of a fever, detecting the source of infec
tive and one positive. First, it indicates that the body tion is fundamental during the physical head and
is reacting to a pathogen, which is a negative sign neck examination and diagnosis, as many viral
and a warning of a present invasive problem. Sec and bacterial infections begin in the oral cavity;
ond, it indicates that the body is reacting to such a therefore, the oral cavity should be the first point
pathogen, which is a positive sign because it indi of treatment to control the pathogens and prevent
cates that the host’s defense system is functioning their spread.82,87
healthily. Consultation with the patient’s physician may
Fever induces an overall increase in lymphocyte be necessary to determine susceptibility to bacte
activity, leucocytes migration, phagocytosis, natural ria-induced infections (such as IE), and specific an
interferon production, and plasmatic iron.81 It must tibiotics are recommended for all dental procedures
be assessed to understand its causes. Furthermore, involving manipulation of the gingival tissue or the
although it needs to be respected, we should not try periapical region of teeth in this type of patient.
to eliminate it completely as it is an important sig Therefore, behind the simple symptom or sign
nal of something being wrong; instead, we should of even a slight fever there might be a number of
try to lower it, and then only if it creates discomfort causes that need to be assessed to arrive at a correct
for the patient. diagnosis.
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Semiotics and dental semiotics
Semiotics and dental Medical examinations should follow a particular

sequence that is well known: inspection, palpation,
semiotics
percussion, auscultation, and olfaction – I PPAO.4,6,7,88
The word semiotics derives from the Greek sēmeiō- These five clinical examinations are discussed below.
tikos meaning ‘observance of signs’, from sēmeion,
which means ‘sign or mark’. The word was origi Inspection or examination by viewing
nally used prior to 1676 by Henry Stubbes to define Inspection is the gathering of visual evidence.6,93,94
that branch of medical science that studies the in A number of factors should be borne in mind and
terpretation of body signs.88 the following sequence followed when inspecting
Humans (like all animals) naturally relate to the a patient:
environment through the five senses of sight, touch, 1. Examine the patient in sufficient light (prefer
hearing, smell, and taste. We do this for two main ably natural light) so that colors are as true as
reasons: food and reproduction.89 Since humans possible.
have the capacity for intellect (consciousness), their 2. Examine the patient in a well-defined standing,
senses are not as highly developed as in other ani seated or lying down position.
mals. Despite this, our five senses still serve the sur 3. Examine the anatomic area and the area sur
vival purpose for which they were intended.90 rounding it without anything covering these
The sense of taste was once used in medicine to areas.
establish the characteristics of certain secretions 4. Note not only the possible pathologies but also
and excretions. For instance, in 1675 the British their absence.
physician, Thomas Willis, coined the name ‘diabe 5. Analyze all possible pathologies in terms of:
tes mellitus’ (mellitus is Latin for honey) because he a. Morphologic changes such as location, shape,
made his diagnosis by tasting the patients’ urine, volume, borders, surface, color, etc.
which in the case of this disease is sweet. Obviously b. Functional changes such as physiologic, spon
and fortunately, this is no longer the way we test taneous, and uncontrolled movements such
for the presence of this disease clinically and in the as tremors, tics, muscle contractions, etc.
modern laboratory! c. Morphologic characteristics of the
Since we are aware that we already naturally use surrounding areas and tissues.
our senses, we must become experts at using them 6. Pay attention to the patient’s facial expression.
when meeting and examining our patients and col 7. Pay attention to the patient’s body posture.
lecting clinical information. It follows that it has 8. Pay attention to the patient’s attitude.
become a natural process to observe and study the 9. Determine whether the patient is attentive,
best way to use our senses when performing patient absentminded or has diminished eyesight.
examinations.4,6,91 The diagnostic action of using 10. Pay attention to the mode and quality of the
our senses has been formally defined by semeiotic patient’s speech.
medical science and is useful when combining signs 11. Note any possible facial symmetries and/or
and symptoms to assess the chief complaint and asymmetries.
other medical problems of which, at times, even the 12. Note the facial mobility.
patients themselves are unaware. As professionals, 13. Note the color of the face; its pallor, possible
we must be well trained in the science of semiotics cyanosis and/or other colors.
because those who are highly capable in this science 14. Note the head and neck posture.
are ultimately better clinicians. Clinicians who have 15. Note the jugular venous pressure (JVP) or the
been practicing for a long time develop, through ex rhythmic pressure of the external carotid arteries.
perience, the most sensitive and perfected semiotic 16. Note any possible lymph node swellings or
skills.92 other lumps and/or deformities.
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17. Examine the masticatory muscles (normal, ipo Percussion or examination by tapping
trophic or ipertrophic). In 1761, Auenbrugger described this method, and
18. Note any slack, trembling or parafunctional with the passage of time it has been further per
mandibular movements. fected. In medicine, percussion refers to tapping
19. If visible, note the form, dimensions, and color over several concave parts of the body such as the
of the tongue and any unnatural tongue move chest, shoulders, and abdomen to elicit sound infor
ments. mation that may help to establish the position of the
20. Note the hands and finger movements. organs. It also allows us to determine whether any
organs or parts of them have pathological changes
Further detail is provided in Chapter 7. of density, consistency, and/or air content. In dental
medicine, tapping over a tooth may elicit pain or
Palpation or examination by touching sensitivity symptoms that inform us of a masked or
This involves using the 2nd, 3rd, and 4th fingers partially hidden ongoing periapical problem.96 Also,
(in some cases only the fingertips when we need tapping over an implant may give a positive or neg
to reach certain narrow areas such as the ptery ative indication regarding its integration, or it may
goid muscles in the retrozygomatic fossa) to gently indicate the presence of a possible fracture.
touch or press the tissues as we perform a head and
neck examination. We can also use the palms of our Auscultation or examination by listening
hands for larger body surfaces.8,95 If we detect any Laennec introduced this method in 1819. In dental
nodules or swellings in this way, we should check medicine, listening to the normal or altered speech
their location, temperature, shape, consistency, vol and phonetics of patients while trying-in a new res
ume, borders, and surface texture. We should also toration is usually performed using the ears only,
note whether they move spontaneously (physio without the aid of instruments such as stethoscopes.
logic or pathologic mobility), whether they are An analog or digital stethoscope can be used when
reducible, whether they are pulsating, and their we need to amplify temporomandibular joint (TMJ)
position in relation to the surrounding tissue and murmurs, clicks, crepitus, and other sounds that
regions. guide us in making a temporomandibular disorder
We should also palpate over the three bilateral (TMD) diagnosis.97 Listening without a stethoscope
emergencies of the fifth trigeminal nerve, or over is also used for maxillofacial prosthetics, where it is
the seventh facial nerve. The latter, having different important to listen for speech defects, and in pros
sensory and motor branches, needs a more specific thodontics, where, for instance, complete denture
examination (described in Chapter 7). prosthetic teeth mounted at an excessive increased
Be sure to note if any discomfort, tenderness or vertical dimension may result in the sound of the
pain is experienced by the patient after the palpa teeth making immediate occlusal contact as well
tion examination. as other related tooth sounds when the patient is
In dental medicine and prosthodontics, the use speaking.
of instruments such as explorers and probes may
help to detect open margins, caries, cracked teeth, Olfaction or examination by smelling
calculus, pocketing, and inflammation. These in Smelling also allows us to detect both physio
struments may be included in this tactile examin logic and pathologic information that can assist
ation. us to make a correct diagnosis. This examination
Touch allows us to palpate the borders of the is useful to indicate, for instance, the immediate
peripheral seal of a complete denture to verify the evidence of alcohol or tobacco use by the patient.
existence of roughness and/or acute angles that are A sweet or fruity acetone smell could be an indi
deleterious for the patient’s oral mucosa. cation of ketoacidosis, a serious complication of
44
Calvani_Ch_4.indd 44 12.02.20 12:04

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69. Seiden AM, Duncan HJ. The diagnosis of a conductive C, Pompeu J. Oral manifestations related to dengue fe
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77. Calvani M. The heat stroke. Ped Oggi 2002;22:99–108. 96. Maslamani M, Saji S, Lucas P. Quantification of
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CHAPTER FIVE
The first visit – diagnostics
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5 The first visit – diagnostics
In 1927, prosthodontics expert Dr Stanley D. Tylman disease or illness affecting that patient. Therefore,
wrote: “Prior to undertaking reconstructive work of compiling the dataset at the first visit is essential to
any type in the mouth, there are certain factors that form a picture of the patient’s overall health status.
must enter into our final decision. Since no structure is From this we can begin to understand whether a
stronger than its foundation, this phase should receive relationship exists between various aspects of the
careful thought.” 1 patient’s overall health status. This will also help us
Indeed, before any decision is made, all clinical to define how these health issues are affecting the
cases should be analyzed very carefully.2-4 In patient’s quality of life (Table 5-1).
general medicine, the purpose of history taking – Once we have gathered, understood, and thought
medical histories, case histories, and anamnesis – is about the patient information, the objective is then
to investigate, understand, and record the past and to conceive and properly formulate all possible
present of a patient’s physical and mental health treatments and propose to the patient those we
events.5 In each different field of medicine, such consider to be the best.
as dental medicine, we need to gather not only In prosthodontics, the first visit can end up
the general medical information from the patient, taking a long time as there might be a high volume
but also the specific medical history related to of information to acquire. However, once we become
that given field. In the case of a specialized dental used to the process, once we get a better idea of how
medical field such as prosthodontics, clinicians also to pose questions and drive an interview without
need to know the prosthodontic history in order to wasting time, and once we know how to investigate
properly understand what is currently going on in and delve more deeply when something remains
the patient’s oral cavity and masticatory system.6 unclear, we will be able to reduce the overall time of
All of a patient’s medical history is connected and the first visit. Eventually, our experience, knowledge,
interrelated, therefore we need to know it all. and intuition make the process less time consuming.
With each new patient as well as with patients In the pursuit of all the above aims we need
we have not seen for a long time, we need to follow to be gentle, patient, systematic, accurate, and as
or repeat the following mandatory steps to solve thorough as possible in our initial assessment. This
the patient case. They can be memorized by the can be better achieved if we are well organized,
acronym, GEASS. The first three steps (referred to have a sound understanding of the diagnostic
as ‘diagnostics’) take place in the first patient visit: method, and take all the time we need to gather the
Gather all past and present medical and dental in- information necessary to draw the most complete
formation, including the chief complaint. and objective picture of the patient. To understand
Examine the patient with care and collect all clinical and know as much as possible about the patient,
findings. seeking clarification when something is unclear is
Assess the problem that is afflicting the patient. of paramount importance to delivering an excellent
Then… treatment with a successful and gratifying outcome.
Solve the chief complaint and/or other dental prob-
lems with the patient’s consent.
Solve any other limited or comprehensive prostho-
dontic problem with the patient’s consent.
Approaching and meeting the
patient
The first three steps (diagnostics) form the basis Various theories on how to approach, meet, and
of any medical or dental medical treatment. If we become acquainted with our patients have been
are able to take a good history and perform a good proposed in the literature over the years. The
clinical evaluation of a patient, we can come close when, where, how, and why of how we should
to a sound assessment and diagnosis of the ailment, act when we meet a new patient will always be
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Approaching and meeting the patient
Table 5-1 Suggestions for the history collection session Attitude

Some guidelines for the collection of the patient
history Caring for our patients and wanting to help them
is the appropriate and correct attitude when
• E nsure that you ask all the necessary questions
and, where necessary, delve deeper into particular trying to solve the dental medical problems of
answers any patient, new or old. If we have this attitude
• Allow the patient to talk – patients need to tell toward our patients, they will immediately feel our
you their histories, not the other way around commitment and intellectual honesty and be more
• Guide patients in a kind manner if they start to open to trusting us. With this trust comes the ability
wander off the point to collaborate effectively. Our patients should then
• Make sure there is a structure and an order to the accept our treatment care more serenely and be
history collection session more willing to receive any help we are able to offer
them.
Kindness
a topic for discussion and debate, with different
opinions being expressed. Nevertheless, we need to Kindness itself does not need to be explained. Most
remember that apart from us getting to know our people know what it is and how important it is in
patients, they need to also become acquainted with our dealings with other people. However, there are
us. It is therefore very important to always behave biologic reasons why kindness is so crucial in the
in a professional manner, have a good attitude, and medical field, and as dental medical professionals
show our patients kindness and empathy. we need to know these reasons. In medical science,
kindness has the same pharmacological dynamics
as antidepressants as it stimulates serotonin, a
Professionalism
monoamine neurotransmitter that is derived from
Professionalism implies competence, experience, tryptophan, which calms us down, makes us
and a wide range of skills. As dental medical pro- feel happy, and helps to heal wounds. Kindness
fessionals, we owe it to ourselves, to our dental of- increases the levels of serotonin in those who are
fice team, and especially to our patients to display kind, in those who receive the kindness, and in
impeccable professional behavior that always goes those who see the kindness happening. Kindness
beyond the normal call of duty. The point is, we are also helps in the production of endogenous
not acting as professionals, we are professionals! morphine, or endorphins, which are peptide
This means that we believe in what we do, we pro- hormones and endogenous opioid neuropeptides
fess a deep belief in our vocation because we devote produced by the central nervous system (CNS) and
ourselves to helping and hopefully curing patients pituitary gland. Analogous to corticosteroids, they
with commitment and passion. That is why we are natural painkillers, three times more powerful
should behave as such. An experienced teacher of than morphine. Kindness also stimulates our
the author used to advise that one should always be immune system to produce oxytocin, the so-called
patient with your patients and accepting of their id- ‘cuddle’ hormone produced by the hypothalamus
iosyncrasies because you cannot know the extent of and released by the pituitary gland, which helps us
their suffering, and they are in front of you because to socialize, to calm down, and to be more generous.
they need your help. Hence, being a professional in Apart from other functions, it also enhances the
the dental medical field means to orient our profes- activity of the immune system, increases our
sional life to taking care of those who seek and are strength and virility, and has certain functions
in need of our help. related to pregnancy.7,8
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Empathy describe their medical histories in private without

feeling rushed. Therefore, if it is not an emergency
Empathy is important in our profession. situation where the patient is in pain, it is best to
Pharmacologically, the feeling of empathy doubles spend some time with patients to make them feel
the production of dehydroepiandrosterone (DHEA) as comfortable as possible. If a member of the office
or androstenolone, which is an endogenous staff such as a dental assistant is present, that person
steroid hormone, a neurosteroid and neurotrophin should remain silent and behave professionally.
produced by the adrenal glands, brain, and gonads Pay attention to make sure that the patient
that has multiple significant effects in the CNS. does not have special needs, for example, elderly
It also acts to reduce cortisol, the so-called stress patients may require assistance to walk or speak, or
hormone.7,9 Empathy is a capacity, an ability, and a they may require oxygen. If patients are physically
sensitivity and goes hand in hand with compassion. challenged and cannot walk without a stick or a
According to Encyclopedia Britannica, empathy wheelchair, you may need to accommodate them in
means: “The ability to imagine oneself in another’s a place where there is wheelchair access. It shows
place and understand the other’s feelings, desires, professionalism and respect for everyone involved
ideas, and actions.” The Merriam-Webster Dictionary in the first visit when we are sensitive and try to
defines empathy as: “The action and capacity of accommodate and understand the needs of our new
understanding, being aware of and being sensitive to patients.10-12
and vicariously experiencing the feelings, thoughts,
and experience of another of either the past or present
without having the feelings, thoughts, and experience
fully communicated in an objectively explicit manner.”
How to communicate with
Empathy means to see, listen to, feel, and patients during the first visit
understand our patients during the treatment Nowadays, due to new technologies and more
process. Without this ability to ‘tune in’ to our communication possibilities, the pace of our lives
patients, we would not be able to care properly has accelerated and we all tend to be moving much
for them or plan and carry out appropriate and faster. This is true for our private and our professional
successful treatment. Since we have to know the lives. However, it is important to take our time to
health status and assess the chief complaint of our do things properly and with care. In the first visit,
patients, it is best to do so with empathy so that a you will meet all types of patients, from shy people
caring personal connection links our will to help who find it difficult to talk to outgoing people who
them with their willingness to be treated by us. may be overly loquacious. Always remember that
you are the professional. Be committed to devoting
a certain amount of time exclusively to the patient
who is with you in the moment. Your professional
Where we meet our patients focus should be to communicate properly in order
for the first visit to collect all the relevant information necessary to
The environment in which we meet our patients for creating a clear overall picture in your mind and on
the first time should ideally be quiet and private, a record of the health and dental status of your new
place where we can talk openly and confidentially. patient.5,13-16
Since we have to ask for and receive very personal Furthermore, remember that mostly the patient
information, patients need to feel secure and know and yourself may:
that their information will be handled with care and ● be of different ages;
be protected. Patients are usually more comfortable ● have different first languages;
if they are able to explain their problems and ● have different cultural and life experiences;
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Professional office techniques to gather information
● have very different medical knowledge and situation and help as quickly as possible. In this
experience; case, during the initial evaluation phase we need
● know and understand things in different ways; to at least gather all the basic information and,
● see things from different perspectives; when the patient is experiencing extreme pain,
● have different aims and goals. ascertain the medical history so as to allow for
immediate treatment. This would involve what type
Therefore, apart from being sincerely polite and of medications the patient is taking, their posology
kind, you need to use simple and clear language and the reasons for it, and enough medical and
because the patient must be able to understand dental history to assess how we can resolve the
you properly in order for the communication to be emergency quickly, effectively, and in the most
effective. Be prepared to repeat yourself patiently or professional way.
to rephrase your statements even more than once. Once we have established these basic facts, the
Smile and nod to encourage and reassure your next step is to perform other brief diagnostic tests
patients, working at all times to create and maintain such as radiographs and a brief clinical examination
a positive communication link. If you ask your to better investigate and address the specific
patients their personal thoughts and opinions about problem we face.
the ailment afflicting them, they will feel valued and The patient must be properly informed
respected. This will make them feel more involved and should sign an emergency agreement form
and more inclined to communicate, which, in turn, which clearly states that under the emergency
will possibly reveal important aspects of their circumstances it is not possible for you to perform
problem/s to you. All of this helps you to make a a comprehensive examination. The form needs to
precise diagnosis.17-23 state that you are willing to help the patient to solve
the immediate emergency situation, and that if the
patient is willing to be helped, information should
be supplied by the patient pertaining to any possible
Professional office techniques contraindications to the emergency therapy that is
to gather information about to be performed.
No matter how thoroughly and carefully we
perform our first interview with a new patient, it
Screening examination
is unlikely that we will gather all the diagnostic
information we need in one visit. In dental This type of examination can be performed in
medicine, there are three types of examinations that different ways and on different occasions, as
can be performed: follows:
1. In case of a large number of patients to be
treated such as in an institution or in a specific
1. Emergency examination.
2. Screening examination.
situation where it is essential to assess triage
3. Comprehensive examination. necessities as a priority.
2. In case of needing to optimize the available
resources and time necessary to address the
needs of a number of patients.
Emergency examination 3. For research purposes when study data and
information about a specific population need
The gravity and complexity of patient visits vary. to be gathered. In this case, all possible aspects
In the case of an emergency, we need to examine of the process need to be explained carefully to
patients faster than usual to get a grasp of the the patients involved in such a screening.
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Comprehensive examination The first professional

appraisal
This is a thorough examination performed to gather
all the possible relevant data and findings so that Before we delve too deeply into questions directly
we can gain a full understanding of the medical related to the chief complaint and the general medical
and dental history of a new patient, including an status of the patient, we need to use our experience
understanding of the reason for the current patient and our ‘professional eye’ to sensitively appraise the
visit. patient as a whole. The aspects related to this appraisal
A comprehensive examination has three goals: are given in the example appraisal form in Table 5-2,
1. To establish a connection that will allow us to in which some simple suggestions are provided as to
win the patient’s trust, linking our goodwill what to look for during the first appraisal.
and knowledge with the patient’s possible con- The answers to these questions will be
fidence in our abilities. instinctive, based on how the patient appears to you
2. To identify the cause of the chief complaint, the very first time you meet. The purpose of the first
and if it is a minor one, to try and solve it as appraisal is to guide our investigation. It helps us to
soon as possible. know how to conduct the first interview with the
3. To gain the patient’s approval and consent to patient. Of course, the answers to the questions on
begin a more in-depth investigation to plan the appraisal form should not be made known to
a clinical and prosthodontic solution if the the patient. They are personal considerations that
problem presented is larger or more complex or take into account our first impression and help us to
complicated. form a general picture of the patient’s personality.
Your body language is very important as it will
either put your patients at ease or make them feel
uncomfortable. When conducting the first appraisal,
Table 5-2 Example of a first appraisal form
make sure the position of your body is attentive and
First appraisal of the patient you appear to be completely engaged and prepared
1. Apparent physiologic chronologic age ( _______ ) to listen to everything the patient has to say. Face
the patient directly.
2. Apparent health status: Excellent ( ); Good ( );
Sick ( ); Suffering ( )
3. Psychologic attitude: Positive ( ); Indifferent ( ); The important basic

Negative ( ); Aggressive ( ); Shy ( )
information
4. Facial appearance and expressions: Serious ( );
Table 5-3 Information to be collected at the first visit
Depressed ( ); Happy ( ); Indifferent ( )
Be sure to collect all the following information:
5. Empathy patient shows and inspires: Much ( );
1. CHIEF COMPLAINT
Little ( ); None ( )
2. HISTORIES
6. Body posture: Open ( ); Indifferent ( ); a. Personal history
Defensive ( ); Attentive ( ); Aggressive ( )
b. Psychologic profile
7. Knowledge and culture in general: High ( ); c. Medical history
Medium ( ); Low ( ); None ( ) d. Medication history
8. Way of speaking and communicating: e. Dental history
Excellent ( ); Good ( ); Average ( ); Incoherent ( ) f. Prosthodontic history
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Chief complaint
Chief complaint health information, the better we can understand

what is currently going on and the sooner we can
Usually, our patients only make an appointment come up with a correct assessment of the existing
to visit us once in their lifetimes, and even then problem.25-39
they would probably prefer to pass quickly on Therefore, the aim when listening to our
the opposite side of the road, our offices probably patients tell us about their chief complaint in their
causing them to experience an adrenalin rush! Most own words is to try our best to understand, firstly,
patients come to see a prosthodontist only when what is bothering them, and secondly, whether this
they are referred by another dental professional, is the same as what is actually going on; perhaps
either a general practitioner or a specialist. there is something they may not even be aware of.
Occasionally, patients visit us of their own accord In the end, we will formulate a diagnosis on the
because they are in pain or discomfort, are not basis of everything we have learnt and discovered
able to chew or speak properly, or have an esthetic (Table 5-3). If urgent and necessary, with the
concern. patient’s permission, we may need to solve the
Usually, the ailment and the chief complaint problem as soon as possible; otherwise, we may
are the same thing. Patients are not always able need to compose one or more appropriate treatment
to express themselves adequately or describe plans that we will then need to discuss carefully
what they are experiencing in an eloquent or even with the patient.
coherent way. Nevertheless, our next focus after the
initial appraisal must be to establish exactly what Legal issues around the chief complaint
is bothering them. We therefore need to listen very It would be highly unethical, unprofessional,
carefully and pay attention to what they have to say and indeed unfortunate to underestimate or
and how they say it.14,24 even miss the chief complaint and any other
From a medical point of view, the chief complaint important information that may arise from our
may be one of the most important pieces of information first interview with the patient. It is therefore of
we receive to help us understand what is happening paramount importance to carefully ascertain the
in the patient’s mouth and body. It can therefore be patient’s chief complaint, note it on the patient’s
seen as a key that may open other doors. The chief chart, and, if possible, solve it. If we do not do this,
complaint could be anything. It may be a question it could be considered professional incompetence
about a possible treatment or a slight symptom (as has occurred in the past in some cases) and
of a small problem. It may be a sign or symptom may land us in a court of law. Remember to always
of a prosthetic problem or it could be a cluster of take careful notes of all the details about the chief
vaguely defined symptoms. It may even be a barely complaint.
perceivable symptom or sign of an unseen but It needs to be stressed once again that the most
serious condition, like the tip of an iceberg, with important thing at the first visit is to listen to and
the submerged disease still unknown to both the watch patients carefully. This is always wise, be-
patient and to us. cause even if patients are unable to relate their
With or without pain or discomfort, patients problems properly and satisfactorily, other aspects
have differing perceptions of the severity of of the way they express themselves may speak
their chief complaint because the threshold of loudly and clearly – for instance, the way they
understanding, levels of sensitivity, and pain speak, their phonetics, the way they look and their
endurance are different for each individual. body language, the issues they choose to describe,
Patients are often unaware of their physical the symptom/s they choose to report and the way
situation and health condition. The more we they report them, their age, and the various clini-
accumulate up-to-date and precise general and oral cal signs you may perceive while they are talking.
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All these aspects may help you to realize what the bottom of their chief complaint. You therefore need
problem may be.14 to prompt, guide, and ask questions in order to keep
the interview active and dynamic.
TOLDCHARTS
Generally, finding out why patients have come to
The histories
our office can be investigated by asking simple,
well-ordered questions, posed in such a way so Personal history
that the answers that build on each other tell a The personal history taking allows us to gather
progressively more complete and clear story. The information about patients that might help to
following ordered and carefully arranged list has explain or throw light on their behavior and
been devised after years of clinical experience. It the answers they provide on the questionnaires.
may be useful to guide your questions during the However, asking personal questions needs to be
initial interview. The acronym TOLDCHARTS may done carefully and sensitively. It is important to
help you to memorize the order of the questions to always ask patients’ permission before you begin
ask the patient (Table 5-4). any investigation into their personal life. Indeed,
it is impolite to enter too quickly into a patient’s
Table 5-4 Questions to ask the patient according to
the TOLDCHARTS acronym
personal sphere without due consideration and
respect. If you hurry and ask questions in a way that
TOLDCHARTS offends the patient, it may result in embarrassment
T – Talk about it. Would you please tell me about and have the opposite effect, leading to a shutting
the problem? down of communication.
O – Onset of the problem. When did it start and The personal history reveals and allows us to
what caused it? record aspects of a patient’s past and present life
L – Location. Where is the problem?
experiences that may be relevant to our treating that
D – Duration. How long have you had the problem?
patient. For instance, we may be able to tell what
CH – Characteristics. Can you define the problem?
A – Alleviating/aggravating factors. What alleviates patients’ financial commitments are, whether there
or aggravates the problem? are issues in their family or working life that may
R – Radiation. Is the problem localized in one place be of relevance, and what their future prospects and
only? expectations may be. In this way we can identify
T – Temporal pattern. When does the problem patients’ lifestyles, personal situations, and ways of
usually start and how long does it usually last? looking at things that might be an obstacle to any
S – Severity. If pain is the problem, ask the patient: possible dental treatment we may plan for them.
1. Do you feel discomfort, pain or any other It is important to investigate the availability of
sensation? patients because we need to know how much time
2. Did you take or are you taking any
they can devote to the prosthodontic treatment. This
medication to resolve the problem?
information needs to be clear when we are planning
3. How does it feel now?
4. Is it any better or does it feel worse? the treatment, especially in cases of comprehensive
interdisciplinary prosthodontic rehabilitations
where other specialists may become involved in
It is important to remember that, generally, the treatment. Some demanding procedures take
patients do not like silent clinicians. They feel more more laboratory time than others, and time needs
able to trust a clinician who is attentive, seems to be allowed for unexpected eventualities that
confident and professional, and asks intelligent may occur. It is not always possible, however,
questions. Your patients are relying on you, the to know beforehand exactly how much time a
clinician in charge of the situation, to get to the dental treatment will take. It is therefore always
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Chief complaint
best to inform patients from the start that their fer to have the treatment explained to them in
prosthodontic treatment might be demanding in detail. If they are intelligent and without preju-
terms of their time. dice and understand and follow the treatment,
the prognosis can be excellent.
Psychologic profile
“Let’s meet the mind of the patient before we It is useful to have the letters H I P E on the
meet the mouth” 40 initial patient questionnaire (see Chapter 4, Fig 4-1).
We need to be able to deal with and manage We can then mark the box that best matches the
the very important aspect of a patient’s psycho- personality of the patient we are interviewing.
logic profile. Experience shows that, paradoxically, To move beyond this classic but simplistic
it is easier to know what to do practically to treat personality classification, we need to ask the
patients than it is to manage their psychology! To following questions that relate to our patients’
obtain information about and understand patients’ psychologic and mental state in order to better
personalities and the possible causes guiding their understand them:
behavior is important in order to create the connec- 1. To what degree do they comprehend and un-
tion necessary to establish their collaboration. derstand what you are explaining to them?
The House classification41 for the personality 2. What is their attitude toward you and are they
assessment of edentulous patients identifies four able to converse easily and clearly with you?
different psychologic categories: hysterical, indif- 3. Are they able to relate socially?
ferent, philosophical, and exacting. Although in re- 4. Do they show empathy toward you and the
ality these traits are obviously not clear cut, patients members of the dental team?
usually tend to be one or the other, and it is useful 5. Do they repeat negative behavior patterns such
to initially assess them according to these broad cat- as becoming upset when they relate previous
egories. Later, when we become more used to their medical and/or dental issues?
unique ways of expressing themselves, behaving or 6. What emotions do they show when describing
reacting, we will develop a more nuanced under- their previous frightening or painful treat-
standing of their personalities, which is crucial to ments?
help us work successfully with them.42 7. Do they have a tendency to blame or be accusa-
A brief and general explanation of the four tory against previous medical or dental profes-
categories in the House classification is provided sionals?
below. 8. Is there evidence of a psychologic or psychi-
1. Hysterical: Patients blame other people for their atric disorder or illness such as hypochondria,
problems. They are emotionally unstable, com- psychosomatic illness, psychosis, depression,
plain constantly, and are never satisfied. etc? Note that the presence of any one of these
2. Indifferent: Patients are unmotivated and may affect the treatment.
show no interest in being treated. They do not
appreciate the efforts made by the dental team Patient anxiety
to care for them. They miss appointments and Patients who suffer from anxiety or are afraid of
easily give up on the treatment should any painful dental treatment may miss appointments.
problems arise. This has implications not only for their health
3. Philosophical: Patients cooperate with attention status but also for the dental office management. In
and trust and are willing to follow the clini- these cases, a polite call to guide a patient into more
cian’s advice and guidelines. consistent behavior may be required. Such a gentle
4. Exacting: Patients are precise, methodic, and reminder may be necessary once in a while during
demanding. They ask many questions and pre- the treatment and in the follow-up phase.43,44
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Clinician anxiety dental medicine is often seen worldwide by

A particularly difficult patient might cause anxiety laypeople as well as by medical professionals as a
for the clinician and the dental office staff.43,44 It is separate and less important branch of medicine. This
important that we remain objective and understand is of course completely untrue and damaging both for
that: dental medical care providers and their patients. All
1. Even though we would like to, we cannot medical specialties, including dental medicine, are
treat all patients. Therefore, if we do not feel part of the same scientific endeavor. The mouth
a patient will be best treated by us, we should cannot be treated in isolation, just as one would not
simply and kindly divert that patient to another separate the liver or the ear from the human body
clinician. and treat it independently. Therefore, it is essential
2. In the event that a patient insists on treatment to investigate the medical history of all patients. It
despite the anxiety caused, we need to be firm is crucial to know whether they suffer from any
and explain that, once the patient has accepted existing or previous medical conditions and what
the treatment plan, the procedure for treatment medications they are taking. This information is
will be followed professionally and precisely. helpful not only to understand the general physical
3. A careful screening of new patients is crucial to health of our patients, but also to get to the bottom
ascertain whether we will be able to commit to of their oral health status. As has been mentioned
treating them. It is the responsibility of the cli- previously, often patients’ health conditions or the
nician and the dental office staff to ensure that medications they are taking have a direct bearing
it is possible to organize a workable customized on the anatomy and functioning of the oral cavity.
treatment schedule for each new patient that
takes into account both the patient’s needs and The spread of infection
the limitations of the dental office.45 A patient may have a contagious infection. In
such a case, the medical history dataset would
A patient’s psychiatric or psychologic status can contain crucial information that would help to
sometimes be part of a larger physical problem, prevent the spread of such an infection through
which must be identified with the appropriate contamination or cross-contamination in the office
sensitivity and recorded on the patient’s clinical environment. Undervaluing the medical history can
chart.14,46,47 To this end, the American Society of therefore make us vulnerable and expose us and our
Anesthesiologists (ASA) has developed a physical office staff, laboratory technicians, families, and
status classification system, which is a simple but communities to infection. Therefore, we should not
helpful categorization of a patient’s physiologic take lightly the responsibility of the medical history
status.47 The scale of values vary from ASA I (a taking.33,49-64
normal, healthy patient) to ASA VI (a brain dead Apart from this, knowledge of the patient’s
patient). This scale can easily be adapted and used medical history is important for the more technical
in our dental speciality too. aspects of treatment planning. Therefore, before
we actively carry out the clinical examination,
Devoted clinicians as well as their staff will questions about the patient’s medical history must
always behave in a professional manner and try
be asked. In the asking of these questions and the
their best to understand and empathize with all
elicited responses, we will be looking closely at the
patients.
patient and will often be able to detect an existing
medical condition.
Medical history (or anamnesis) Having a thorough knowledge and being up
Unfortunately, the medical history taking is often to date with the medical health status of your
underrated in our dental medical field. Indeed, patients is a professional habit that will give you
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Chief complaint
peace of mind and allow you to better perform the Table 5-5 Questions about medications
prosthodontic treatments you will need to deliver. Questions about the possible use of medications
Consultations with physicians 1. Are you currently taking any medication or did
you take any medication in the recent past?
If, in your professional opinion, something about
patients’ health status is unclear or if they are unable 2. Do you remember the indications of this
medication?
to report all the necessary information, ask them to
3. What is/was the dose of the medication, and what
obtain a certified written description of their overall
effects and side effects is it having/did it have?
health status from their physician. In these cases,
4. If you are currently taking medication, are you
patients should ask their physician to send a letter
taking it carefully and correctly?
or an email about their current medical condition
6. Have you used this medication previously, and if
to your offices, including all the medicines they are
so, what effects and side effects did you notice?
taking. If things remain unclear, it may be best to
7. Have you recently used painkillers or any
call the physician to discuss the intended therapy.
medication for discomfort or pain?
Always carefully save the information the physician
8. Have you ever used recreational drugs?
gives you into the patient record. This information
might also be helpful in case of a legal dispute. 9. Have you ever used illegal drugs for medical
reasons, and if so, at what doses and for how long?
It is strongly suggested to keep the medical records
of your patients up to date, investigating their status
regularly and updating the records, during both the
treatment and the follow-up assessment. Dental history
The dental history taking follows the medical history
Medication history taking; it never precedes it, even in case of an
Knowing what medications patients are taking is emergency. Once we have taken the dental history
integral to the medical history taking and provides we can merge the information and integrate all the
us with insight into their medical condition, which medical and dental information we have gathered.
has obvious important implications for the treatment This allows us to better understand the oral issues,
planning. It is also crucial for diagnostic purposes the origins and relationships of which would
because often dental symptoms may be related to the otherwise have been less evident. Once the initial
effects, side effects or interactions of medications. questionnaire has been filled out by the patient and
The initial patient questionnaire will give checked by us, we can begin a discussion with the
you the information you need, provided patients patient to inquire about any aspects of the dental
comprehensively answer the question about what history that have not been reported clearly or
medications they are taking. If you do not get a clear comprehensively.
answer to this question on the questionnaire, it may be
possible for you to tell from the clinical examination Dental history-taking conversation
due to the clinical effect of medications and/or Guide the conversation with patients about their
patients’ responses. If you are still unsure, ask patients dental history, as follows:
a number of questions about what medications they 1. Create a timeline of patients’ dental history to
are taking because sometimes they forget or even properly understand the sequence of the ail-
try to hide information. Often, just by asking them ment or present situation in their mouths.
questions we jog their memories about medications 2. Try to gauge whether patients are completely
they may have forgotten about (Table 5-5). aware of their dental situation.
More information about medications is given in 3. Try to gauge how concerned patients are about
Chapter 13. their dental situation.
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Pay attention to the possible relationship between Clinical examinations

the chief complaint, the general medical history,
and the specific dental history. Create a relaxed The first time a new patient is clinically examined
but professional, trusting environment in which by a clinician is usually a very sensitive moment.
patients feel comfortable to speak about their issues For many patients, it is at this crucial point that
openly. they decide whether they want to be treated
by a particular clinician or not. Therefore, it is
Prosthodontic history very important that the clinical examinations
Although the prosthodontic history is part of are performed with kindness and gentleness in a
the dental history, there is a growing tendency professional manner that shows care, knowledge,
to separate them in order to better understand and excellent organizational skills.
the prosthodontic issues. This part of the There are two different types of clinical examina-
investigation is therefore more specific, with tions of any dental patient that must be performed:
questions asked about issues of a prosthodontic the extraoral and the intraoral examination. These
nature concerning patients’ past rehabilitations. examinations are described in detail in Chapters 7
This has a direct bearing on any prosthodontic and 8.
treatment we may plan for patients if they need The clinical examinations aim to provide all
to recover or gain esthetics, phonetics, and/ the relevant information you need to customize
or function. A number of aspects of patients’ a treatment plan for your patients that addresses
previous prosthodontic treatments should be their immediate issues and also helps them to focus
investigated such as: on and take proper care of their oral health in the
● the timing; future.
● the reason;
● the extent and/or invasiveness;
Radiographic examinations
● the results (positive and negative);
● the past and current acceptance; Radiographic examinations allow us to see things we
● the follow-up; cannot see with the naked eye. They are therefore
● the possible current discomforts and/or of fundamental importance in the diagnosis of every
problems; patient case.65
● the possible esthetic and functional Various radiographic examinations exist, each
limitations. with different diagnostic uses and absorption
doses. It is important for clinicians to understand
Allow patients to explain in their own words these differences to make the correct decision
whether: about which type of radiographic examination to
● they have had a positive or negative use with each patient. The aim of this section is
experience with their prosthesis; to clarify these differences in order to address any
● they are now used to their prosthesis; possible confusion or fear that clinicians may have
● they pay attention to maintaining their which may be limiting their use of radiographic
prosthesis properly. modalities and therefore reducing the success
rate of their clinical diagnosis, treatments, and
This information will give you a very good idea prosthetic rehabilitations.
about whether they will accept a certain type of Nowadays, the use of the traditional two-
prosthesis. It will also throw light on what you will dimensional (2D), full-mouth series, panorex, and
see clinically during the physical examination that bite-wing radiographs may suffice for treatment
follows. planning, for implant positioning, or for predictable
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Clinical examinations
endodontic, periodontic or prosthodontic clinical In any case, as well as radiographs, periodontal

procedures.66-78 probes are needed to make a periodontal diagnosis.
Important differences exist between 2D and Periodontal probes can supply any missing 3D
three-dimensional (3D) radiography. With simple clinical information directly in situ to give us a more
2D radiographs we can evaluate: complete and objective 3D evaluation. Recently,
● the amount of the existing alveolar bone; however, these details are being examined more
● the condition of the alveolar bone crests; and more using computer software that allows
● the amount of possible bone loss at the for precise measurements for better clinical
furcation areas; anatomical analysis and precise treatment planning
● whether there is a widening of the periodontal possibilities.66,79-86
ligament space; 3D radiographs offer a ‘real’ detailed view of
● whether there are overcontoured restorations; the anatomy, which makes it possible for us to
● the presence of caries; obtain a more realistic idea of all the anatomical
● the presence of calculus; information. In the USA, almost 20% of dental offices
● the morphology and length of roots; today already only use digital imaging devices. The
● the crown-to-root ratio; latest 3D in-office radiographic digital technologies
● the maxillary sinus position and distance from such as cone beam computed tomography (CBCT)
the roots or edentulous crest; provide better 3D images and clearer details with
● disease progression. no detriment to patient health. Major differences
exist between the new CBCT scanners and those
The limitations of 2D radiographs are as follows: originally introduced in 1971 with a single detector
● limited bidimensional view of reality; for brain study. The latest in-office CBCT scanners
● limited information about the pocket move over the patient’s face only once, from side
characteristics and 3D position of the bone to side, to illuminate all the 3D details. The older,
level and loss; more cumbersome scanners used in hospitals had
● continuous gray scale; to make multiple revolutions around the patient’s
● impossible to adjust, rotate or magnify images; head, collecting multiple fan-shaped or flat slices
● impossible to increase the number of pixels to that then needed to be overlapped and stitched to
sharpen images in high definition; create the final 3D image.77,78,87-93
● impossible to smooth, change the resolution or
color the images;
Main types of radiation
● impossible to measure images to better
understand their dimensions and their Ionizing radiation corresponds to x-rays, gamma rays,
position, focus on details, and plan implant and the higher spectrum of the ultraviolet (UV) rays.
positioning. Non-ionizing radiation corresponds to the lower
UV spectrum, visible light, infrared, microwaves, and
radio waves.
The flat vision of 2D radiographs
As we cannot clearly see how objects overlap with
2D radiographs, we may require 3D radiographs
that show other angulations in order to measure This significantly improved technical difference
the distances between objects in a particular area. of the new in-office dental scanners has been
In complex prosthodontic cases, and especially ascribed to the as low as reasonably achievable
in implant prosthodontics, 2D radiography (ALARA) principle, on the basis of an acceptable
is insufficient and is no longer an acceptable risk protocol that has been used to design and
investigating diagnostic procedure. create them.94,95
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The use of new digital software96 increasingly

Clinical radiation doses comparison
exposes patients to smaller amounts of ionizing ra-
A typical 2D full-mouth series radiographic
diation (‘ionizing’ means that the radiation carries
examination exposes a patient to about 150 μSv, and
sufficient energy to free electrons from atoms – in
a 2D digital panorex radiographical examination
the case of the human body, from the components to between 4.7 and 14.9 μSv. The average in-office
of the body cells – which is a negative effect be- CBCT full field of view (FOV) standard scan-mode
cause it changes their structure to make them pos- medium-resolution radiation exposure is about
itive or negative ions).97 It has been proven that 35 μSv. This is within the range of the amount we
increased levels of ionization of living cells can be are irradiated when we fly for about 8 hours in the
carcinogenic.98 highest stratosphere and is certainly significantly less
What is interesting is that it has been scientif- exposure than a 2D full-mouth series radiographical
ically proven that the amount of digitally created examination. To understand this further, the exposure
x-ray radiation absorbed by a dental patient under- of a medical computed tomography (CT) scan to the
head, performed in a hospital, is 1200 to 3300 μSv,
going a full-mouth CBCT examination is not more
more than 10 times larger than that of a 2D full-
than the amount of x-ray solar radiation absorbed
mouth series radiographic examination. In terms
by an airline passenger traveling for 7 to 8 hours at
of our body scale, the measurements of radiation
an altitude of 39000 feet, 7.5 miles, 12000 meters, be- exposure are made in millisieverts (mSv) and not
yond the troposphere in the low stratosphere, from in microsieverts (μSv), which is one thousand
the USA to Europe or to Australia (about 40 μSv).99- times more. In fact, in nuclear medicine, a CT body
101 Therefore, such a flight and a CBCT examination examination is usually about 10 mSv (10,000 μSv).
are almost equivalent in terms of radiation dose, To put this into perspective, the yearly normal
but in the case of flying, one is also irradiated with background radiation dose that each of us is exposed
the much more dangerous gamma rays and with to simply living at home, primarily due to the existing
whatever remains of the extremely dangerous ion- radon gas, is around 3 mSv (3,000 μSv).11,12,47,78,90,107-
110,113
izing radiations of the solar wind which do not get
trapped in, or deflected by, the Van Allen radiation
belt of the earth’s magnetosphere. And if the flight
is of a longer duration, the amount of ionizing ra- 43,864 airplanes in the USA carrying 2,586,582
diation, including the x-rays, is even larger than a civil passengers per day, which translated to one
modern CBCT emits during a radiographic exami- billion inbounding and outbounding passengers per
nation. year, and found that there was no harmful effect
Fortunately, the human body has the ability to on these passengers from radiation. Therefore,
absorb radiation and recover. If we were not able since there have been no reports of any illnesses
to tolerate these effects of radiation, flying would caused by radiation among those passengers, it
be a serious health hazard, and adequate measures seems logical that the amount of radiation needed
would already have been taken by the health for a CBCT scan does not represent a significant
authorities. Therefore, at present, millions of people threat to the overall health status of patients who
(and especially pilots and airline crew members are in need of better diagnostic examinations for
who fly for much longer hours than anyone else) more precise prosthodontic and dental medical care
continuously fly across the planet without danger treatments.102,104-106
of radiation poisoning.102
To verify and assess how dangerous this radiation Radiation risks
could be to human health, in 2000, 2013, and 2014, However, even if there are no direct epidemiologic
the United States Department of Transportation, data supporting an increase of cancer risk in a
Federal Aviation Administration assessed some radiation dose, it does not mean that there are no
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Clinical examinations
direct cancer risks. Obviously, we cannot simply 3. The rationale for CBCT imaging must be justified
administer any amount of radiation to our patients based on clinical evaluation.
just because there is no statistical epidemiologic 4. CBCT imaging should be used for the esthetic
possibility of detecting it. If present, any possible zone, pre- and post-bone grafting, sinus
cancer risk might increase even with a low dose, but augmentation, pterygoid plate, and zygomatic
this depends on a number of other factors.97 implants.
5. The region of interest (ROI) should be imaged
Conclusion regarding radiation risks using a FOV no larger than necessary.
As is shown above, one billion passengers per 6. CBCT is recommended to be used for the
year were assessed and showed no harmful effects evaluation of postoperative complications such
of radiation from flying. Furthermore, upon as postoperative neurosensory impairment, acute
evaluation, the ADA Council of Scientific Affairs rhino-sinusitis, and implant mobility.
wrote that “CBCT technologies offer an advanced
point of care imaging modality that clinicians should Other professionals and organizations also
use selectively as an adjunct to conventional dental continually report on and contribute to the discussion
radiography. The selection of CBCT for dental and on safe usage of CBCT;76,77,86,117-121,123 for instance,
maxillofacial imaging should be based on professional Kim et al124 summarized and added further detail to
judgment in accordance with the best available the latest 2019 CBCT guidelines in North America
scientific evidence, weighing potential patient benefits and reported interesting conclusions.
against the risks associated with the level of radiation To sum up, we all certainly undergo radiation
dose. Clinicians must apply the ALARA principle to exposure in varying amounts according to our
protecting patients and staff during the acquisition of location, occupation or activity,125 and dental
CBCT images. This includes appropriate justification patients should generally not be subject to any
of CBCT use, optimizing technical factors, using the further radiating sources unless absolutely necessary
smallest FOV necessary for diagnostic purposes and for rehabilitating prosthodontic procedures.126 The
using appropriate personal protective shielding.” 71,82- newest CBCT devices are becoming more and more
86,94,95,106,111,114,115 precise as well as increasingly safer, using smaller
The American College of Prosthodontists doses of emitted radiation.89,126-129 This makes
(ACP), after reviewing CBCT use in the relevant them more and more necessary (and, in some cases,
scientific literature and the existing national and indispensable) for prosthodontic pretreatment,
international guidelines on implant dentistry, made surgical, and posttreatment use.17,79,106,110,130
recommendations as to CBCT use for preoperative Finally, as the use of digital technologies such
treatment planning and postoperative follow-up as CBCT increases, it is vital that updates and
care. It stated in the 2016 Position Statement entitled safety controls are implemented on an ongoing
‘Diagnostic imaging in the treatment planning, basis to ensure that improvements continue and are
surgical, and prosthodontic aspects of implant translated into prosthodontic treatment planning
dentistry’:116 and implant algorithms.124,131,132 This should be
1. Conventional panoramic and/or intraoral consistent and thorough to better serve all patients
periapical imaging is recommended for initial undergoing treatment so that they can enjoy the
diagnostic evaluation. CBCT is not recommended benefit of more accurate and faster diagnostic
for routine initial examination. services without exposure to unjustified amounts
2. Cross-sectional imaging (CBCT is preferable of ionizing radiation.
to CT due to its significantly lower radiation
dose) is recommended for preoperative implant
assessment.
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18. Koper A. Human factors in prosthodontic treatment. J

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CHAPTER SIX
Diagnosis and prognosis
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6 Diagnosis and prognosis
The diagnosis and prognosis are the two important s ituation is exacerbated by patients’ use or abuse of
stages in the process of treatment planning that oc- one or more medications and drugs.14
cur after the collection of the patient history data, It can also happen that the initial gravity of a
the appraisal of the physical examination findings, patient’s problem is unknown, not only to us but
and the overall revision of the case in the light of also to the patient. Therefore, the patient may not
all that has been gathered. Making a clear diag- be aware that some seemingly minor symptom or
nosis is not always easy, but without a diagnosis sign is part of a larger picture, which can sometimes
there can be no treatment planning and, indeed, be serious or even life threatening.15,16
no treatment! Oral pathologies and periodontal conditions
sometimes reflect ongoing physical problems in the
case of:17
1. Endocrine disorders such as diabetes.
Diagnosis 2. Hyper- and hypothyroidism, Cushing’s
From the Greek dia (passing through) and gignōskō syndrome or Addison’s disease.
(to know), diagnosis means ‘passing through’ or 3. Infectious diseases such as streptococcal
assessing a condition, including its possible causes pharyngitis, rheumatic fever, sexually transmit-
and reasons for continued existence. A medical ted diseases (STDs), infectious mononucleosis
diagnosis is the process of determining and decid- (glandular fever), hepatitis B and C, HIV and
ing, through examination, the nature and circum- HIV superinfection, and diffused and localized
stances of a disease situation.1-8 After collecting all herpes simplex infections.
the necessary information, we come to an under- 4. Immunological dysfunctions such as lupus,
standing of the clinical case and of the problem/s Sjogren’s syndrome, blood and bleeding dis
afflicting the patient. This results in a case assess- orders, and compromised wound healing
ment, the listing of the possible causes, and the final capabilities.
diagnosis.
Differential diagnosis Table 6-1 Main duties of a clinical examiner
A differential diagnosis is “the process of differen- It is always advisable to:

tiating between two or more conditions which share ● develop clinical capabilities to see and diagnose
similar signs or symptoms.” 9 conditions that go beyond the field of prosthetic
Diagnostic indecision can result if there is no rehabilitation
single and obvious cause of a disease or disorder but ● be informed and up to date about the patient’s
rather an overlapping of signs and symptoms. This current and past physical situation
situation means we are unable to immediately iden-
tify the cause of the problem and therefore need to ● be informed and up to date about the patient’s oral
health situation
take another closer look at the case details.5 Hope-
fully, by studying the details more thoroughly we ● investigate and understand the patient’s current
will be able to arrive at a differential diagnosis, where ailment as thoroughly as possible
we weigh the various possible causes and identify ● be aware of and up to date about the oral
the main one. This is complicated because patients’ manifestations of the patient’s possible illnesses
health is often compromised by various factors, in-
● refer a patient to more expert professionals if you
cluding generalized and/or localized pathological
realize you are not able to treat that patient with
periodontal, endodontic, prosthodontic, temporo-
the required expertise
mandibular or occlusal conditions.1,2,4,10-13 This
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Prognosis
It is therefore very important to collect data and Table 6-2 Practical prognostic indicators
findings carefully and thoroughly in order to make Possible general prosthodontic questions:
an accurate differential diagnosis in cases where
● How long will the course of the disease last?
similar symptoms and signs overlap. In this regard,
we should not underestimate the importance of the ● Will there be possible intermittent or
initial visit and the first diagnostic phase. Further- unpredictable relapses?
more, we should also be open to consulting other ● How long is the decline of any disease going to
medical and dental professionals and be prepared last?
to work as part of a team (Table 6-1). ● How long is the final oral health status going to
last after the healing phase?
● How long is any existing and remaining tooth
Prognosis structure going to last and/or be able to satisfy
any prosthodontic biologic and supporting
The head, neck, and oral environment are extremely biomechanical requirement?
complex parts of our body. They constitute a deli-
● How long is a given prosthodontic rehabilitation
cate central area assembly in which several outer
going to last upon its delivery?
body openings and very delicate anatomical struc-
tures are continuously challenged, attacked, and ● How will the patient respond to the prosthodontic
possibly affected by infectious agents. The oral cav- treatment and to the new prosthesis?
ity is a hostile environment where physical forces,
rapid changes in temperature, and chemical agents
impact the soft and hard tissue, enabling and also New predictive technologies
reducing or limiting their functionality and longev-
ity. This is also true for all types of prostheses. This Digital technologies are already allowing us to
destiny, when predicted, is called the prognosis. scan the human body in ways we would never
Prognosis, from the Greek pro (before) and have thought possible a few decades ago. As these
gignōskō (to know), means to foresee or predict. A technologies develop in the future, we will be able
prognosis can be broadly defined as a forecast as to to determine more and more precisely the actual
the probable recovery from an illness or disease and pathologies and better understand human anatomy,
the likelihood of the success of a course of therapy. physiology, and disease. This will enable clinicians
Famous physicist Niels Bohr (half) jokingly said: to make better and more precise predictions about
“Prediction is very difficult, especially if it is about the patients’ health.19
future.” This is true in the dental medical field too,
especially when it comes to long-term predictions.
Prosthodontic prognoses
In our field, a prognosis is a prediction about the
probable course of action and outcome of an oral As we have seen and will continue to see, the prog-
and/or dental disease or condition and the validity nosis correlates with and is influenced by general
of an abutment or the longevity of a prosthetic re- and local factors. However, even though there is
habilitation. We have to make both pre- and post- no evidence in the literature of any classification
treatment predictions and prognoses for a number in this regard, an attempt may be made to clas-
of practical reasons. The prognoses may be affected sify the prosthodontic prognosis into two different
by the presence of a systemic or local disease that types according to the two different moments in
might have created the condition. the prosthodontic rehabilitation: the pretreatment
Practical prognostic indicators have been devel- tooth prognosis and the posttreatment case prognosis
oped that are utilized in medical science (Table 6-2).18 (Table 6-3).
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Table 6-3 Two types of prognosis we may plan an extraction or the use of implants.
● Pretreatment tooth prognosis is made after Abutment teeth that do not meet certain require-
the clinical assessment, at the point when it ments are usually the main reason for replacing
becomes necessary to plan the treatment – it is teeth with implants.
the prediction of the degree of validity or not of More specifically, the pretreatment tooth
each existing tooth as a reliable biomechanical prognosis is the necessary important prediction
structure and abutment as well as its surrounding based on a careful clinical and radiographic
periodontal structures for any reconstructive analysis of each individual tooth and an assessment
technical purpose of all the information collected. It enables the
● Posttreatment case prognosis is usually only prosthodontist to foresee, with a good margin of
possible at the end of the prosthodontic dental accuracy, how much of the damaged dental and
care and upon the delivery of the final prosthesis periodontal structures remain. As a result, using
and involves predicting its longevity this specific clinical data and findings, one or more
prosthodontic treatment plans may be formulated
in which some teeth may be saved while others will
Pretreatment tooth prognosis have to be extracted and implants or another type
This is the necessary prediction prosthodontists of rehabilitation planned.20-29
perform after the initial clinical and radiographic The pretreatment tooth prognosis allows us then
assessment. It is based on what we can see and to explain to our patients the process of assessment,
understand about the status of the patient’s teeth prediction, and possible plans for rehabilitation.
and mouth. It concerns the prosthodontic value
of the existing teeth, surrounding periodontium, Posttreatment case prognosis
and edentulous areas in terms of their usefulness This is not only tooth related but also relates to the
and/or necessity in the treatment planning of the overall prosthetic rehabilitation and outcome in the
prosthetic rehabilitation. future. It is a prediction based on foreseeing the
longevity of the final rehabilitation in the short (less
In the field of engineering, there are than 3 years), mid (between 3 and 7 years), and long
mathematical and mechanical rules which term (over 7 years).
briefly state that any structure such as a If carried out properly, both types of prognosis
building or bridge may last as long as the can be very precise. The value of the posttreatment
weakest of its pillars. The same rule applies
case prognosis is based not only on the evidence
to any type of prosthesis in the field of dental
or limitations of the current clinical situation, but
prosthodontics.
also on other factors that may have multifactorial
origins that are sometimes difficult to control (Table
6-4).
The pretreatment tooth prognosis supplies ne- Besides the variables shown in Table 6-4, the
cessary information, giving us more precise indi- accuracy of the posttreatment case prognosis is
cations regarding how to compose and orient the based on several other factors, the predictive power
treatment plan for each patient. This helps us to de- of which also depends on clinical events that may
sign and choose a customized prosthesis best suited happen in the future (Table 6-5).
to rehabilitate that patient. Biomechanically, a ‘re- Therefore, at the delivery of the prosthesis, our
liable structure’ means an abutment able to with- case prediction and clinical judgement may be more
stand occlusal loads for a long time. Indeed, if dur- precise because we are more conscious of the perio-
ing the treatment planning we see that the available dontic, endodontic, orthodontic, and prosthodontic
abutment teeth do not respect certain parameters, limitations that already occurred during the treat-
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Prognosis
Table 6-4 Factors that may affect the posttreatment Table 6-5 Factors on which the accuracy of the post-
case prognosis treatment case prognosis is based
● The more or less compromised initial clinical ● H

ow and when all possible specialty care has
situation of the case under rehabilitation been performed during the various healing and
● The results of evidence-based clinical studies of restorative phases
that type of treatment ● A
ll possible complications and secondary problems
● The prosthodontist’s clinical, technical, and overall that may arise during the treatment
knowledge and experience ● T
he clinical healing course of the treatment and its
● The prosthodontist’s clinical, technical dexterity timing
and skills ● H
ow the compliance of the patient during
treatment will affect the healing
● The knowledge, experience, dexterity, and skills of
other collaborating specialists ● H
ow well the patient will finally heal from a
clinical point of view
● The patient’s level of personal oral hygiene
● Any possible unexpected accident or trauma
● Any possible current or future parafunctional
habits 1. Despite all the current advances in science,
● How the patient will use the new prosthesis
technology, and dental medicine, there are no
100% certainties in the assessment of the health
● How the patient will comply with personal home-
care oral hygiene status of a patient who is being examined.
2. It is uncertain whether immediately after our
● Whether and how the patient will adhere to dental
office recalls assessment and prediction one or more un-
derlying problems and related pathologies
● The evident probability, which relates to the
apparent state of the patient’s current well-being that may currently be asymptomatic will not
manifest.
3. The human body does not have a perfect
disease alarm system that is able to warn us in
ment and that may affect what remains of the treat- advance of pathologies that may occur in the
ment. We are also more aware of the reasons why future, especially if there are no symptoms in
possible restorative variations occurred during the the present.
healing and the rehabilitating procedures.10,30-39 4. We exist in a constant state of potential danger
What remains unknown at that point in the case to our health in a world full of bacteria and vi-
prognosis relates to possible biologic health and/ ruses. Our health status and ultimately our lives
or traumatic events the patient may experience as depend on the health of our immune systems.
well as the unpredictability of the patient’s compli- Mostly, our bodies are able to defend them-
ance with home-care oral hygiene and follow-up selves against aggressive microbiota, which is
recalls. why we survive both as individuals and as a
species, but at times our bodies succumb and
‘Apparent’ used as a medical term for we become infected.
diagnosis and prognosis 5. Dental medicine is concerned with the health
For the following reasons, when we make a pre- status of the oral cavity. This is the body’s
diction in dental medicine based on the evidence largest outer opening. The mouth is not one of
of positive good-health indicators, it is prudent to the most sterile areas of our body as it is con-
use the word ‘apparent’ when referring to the pa- tinuously invaded and populated by bacteria
tient’s health status (‘the patient is currently in an and viruses that challenge our early defense
apparent state of well-being’).25,40 system. It is therefore difficult to predict
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Calvani_Ch_6.indd 73 12.02.20 12:04

whether or not our patients will be able to fight General and clinical co-factors affecting
off infection. the prognosis
6. Where symptoms and signs are not evident or The following is a list of general environmental
we fail to recognize them, we cannot diagnose and clinical risk co-factors13,14,30,32,37,42-50 that may
a disease that may develop shortly after our influence our predictions.
assessment and prognosis.
7. Sudden traumatic events may radically change General risk co-factors (patient)
our current health status and therefore also 1. Age.
alter the prognostic forecast made even a min- 2. Personality.
ute earlier, despite the quality of that prognosis. 3. Socioeconomic financial status.
This is out of our hands as clinicians, although 4. Dental awareness.
as the last clinician to see the patient, we could 5. Compliance.
be held responsible for performing too ‘superfi- 6. Level of oral hygiene.
cial’ an evaluation. 7. Frequency of care.
Therefore, it is wise to use the word ‘apparent’ in Genetic factors (hereditary)

written diagnostic and prognostic evaluations, from 1. Systemic diseases and health conditions.
both a realistic and legal point of view.41 2. Disease severity and aggressiveness.
3. Stress.
General and specific factors affecting the 4. Level of plaque control and retention.
prognosis 5. Smoking.
Both the pre- and posttreatment restorative progno- 6. Taking medications.
sis can be profoundly influenced by the etiology, the 7. Host resistance.
gravity of the problem itself, and the initial and final 8. Immune status and/or suppression.
risk factors that may alter the timing and course of 9. Pregnancy.
the final healing and the timing of the delivery of 10. Trisomy conditions and other syndromes.
the prosthesis (Table 6-6). 11. Nutritional issues.
12. Allergies.
Table 6-6 Etiology, gravity, and risk factors affecting Periodontal conditioning etiologic and
the prognosis risk factors
The dental and prosthodontic outcome of any case
Etiology refers to the fact that some oral diseases, is related to the health of the soft and hard tissue.
ailments, and conditions form part of other more Therefore, the etiologic and risk factors (see following
general conditions
lists) have to be carefully controlled.23,37,51-64
Gravity refers to how dangerous a problem is in Periodontal etiologic factors

terms of the patient’s overall health status Classic examples affecting the prognosis are listed
below according to their increasing gravity:
Risk factors refer to general or specific local co- 1. Gingivitis.
factors that may accelerate the negative effects of 2. Chronic periodontitis.
a disease, reducing the longevity of the tooth and 3. Aggressive periodontitis.
the related prosthesis and thereby influencing the 4. Periodontitis as a manifestation of systemic
predictability of the prognosis disease.
5. Necrotizing ulcerative gingivitis/periodontitis.
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Prognosis
6. Abscesses of the periodontium. Table 6-7 The AAP classification of clinical attachment

7. Combined periodontal-endodontic lesions. loss
1. Mild: 1 to 2 mm (0.039 to 0.079 inches)

Periodontal risk factors
1. Clinician’s skills, dexterity, and knowledge. 2. Moderate: 3 to 4 mm (0.12 to 0.16 inches)
2. Plaque and calculus. 3. Severe: ≥ 5 mm (0.20 inches)
3. Presence of spontaneous bleeding.
4. Presence of pus (nature of specific pathogens Table 6-8 Furcation involvement definition and classi-
may be an important variable). fication
5. Host resistance capabilities (immunocompro-
1. Grade I: Incipient defect (< 1 mm probing into the
mised patients due to several causes).
furcation)
6. Patient’s genetic make-up or susceptibility
(increased likelihood of developing a particular 2. Grade II: Moderate involvement (> 1 mm and
disease). < 3 mm probing, but not extending through to the
7. Clinical attachment loss (amount and location) other side)
(Table 6-7).
3. Grade III: Soft tissue covering (through-and-
8. Bone loss, amount, and location (horizontal,
through lesion)
vertical/angular).
9. Presence of gingival recession (cementoenamel 4. Grade IV: Through-and-through lesion with no
junction [CEJ]-gingival margin relationship). tissue coverage
10. Trauma from occlusion.
11. Tooth mobility (related to trauma from occlu-
sion).
12. Short, tapered roots (root length). This is known as the clinical attachment loss, the
13. Crown-to-root ratio. classification of severity of which is shown in
14. Root concavities. Table 6-7.
15. Severe furcation involvement (Table 6-8).
16. Loss of keratinized gingiva (< 2 mm). Endodontic conditioning etiologic and
17. Deep probing depth (presence or not of risk factors
bleeding). This is one of the first treatments to perform as
18. Violation of the biologic width (restoration fin- the etiology is always the presence of caries and of
ish line > 2 mm below the gingival margin). chronic or acute infections, which may jeopardize
19. Unsatisfactory root form. the long-term health of the teeth as possible
20. Malpositioning of a tooth. prosthetic abutments.6,26,34,36,39,49,65-69
21. Root proximity. Endodontic etiologic and risk factors that may
22. Endodontic involvement. influence the prognostic outcome are summarized
23. Unbalanced diabetes. as follows:
24. Smoking. 1. Clinician’s skills, dexterity, and knowledge.
25. Medication/drug use. 2. Presence of preoperative periradicular bone
rarefaction.
The attachment level is the relationship between the 3. Persistence of bacterial infection in the canal
CEJ and the bottom of the pocket. According to the space.
American Academy of Periodontology (AAP), the 4. Persistence of bacterial infection in the peri-
severity of every oral disease is measured according radicular area.
to the amount of lost periodontal ligament fibers. 5. Postoperative tooth and root discoloration.
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Calvani_Ch_6.indd 75 12.02.20 12:04

6. Postoperative insufficient gutta-percha canal 8. Possible pain.

filling. 9. Correct or incorrect posttreatment occlusal
7. Postoperative insufficient apical sealing. stabilization and control.
8. Postoperative post-space preparation and 10. Posttreatment periodontal problems.
gutta-percha removal. 11. Posttreatment external apical root resorption
9. Postoperative excessive canal space. (EARR).
10. Postoperative coronal, furcal, strip, and root 12. Posttreatment tooth mobility.
perforations. 13. Posttreatment misalignment.
11. Postoperative residual broken instrument tip. 14. Posttreatment relapse.
12. Postoperative instrument separation. 15. Posttreatment crowding.
13. Postoperative root fractures. 16. Posttreatment occlusal instability.
14. Postoperative displacement luxation, subluxa- 17. Prolonged orthodontic treatment.
tion, extrusive or intrusive luxations.
15. Postoperative pain. Maxillofacial conditioning etiologic and
risk factors
Orthodontic conditioning etiologic and This is a variously invasive treatment in which
risk factors surgery of the mouth, jaws, temporomandibular
This may be a long-lasting treatment depending joints (TMJs), face, neck, and skull may be
on the complexity of the treatment, the number necessary due to etiologic problems such as trauma
of teeth involved, and the aim of the orthodontic or disease, including cancer.100-113 The specific
intervention. It can start before or be performed maxillofacial planning of various surgeries must be
during the prosthodontic treatment. If not well in keeping with the prosthodontic and orthodontic
planned and/or well performed, it may delay the requirements, as often different types of prostheses
overall prosthetic rehabilitation and affect the and orthodontic ligature ties need to be made and
prognosis and longevity of each tooth that has applied before, during or after the surgeries.
been moved, the arch form, and the overall stability Maxillofacial etiologic and risk factors that may
of the entire dentition and rehabilitations.70-99 influence the prognostic outcome are summarized
A prosthodontic treatment planning reevaluation as follows:
should always be performed at the completion of 1. Clinician’s skills, dexterity, and knowledge.
the orthodontic therapy. 2. Correct or incorrect surgical planning.
The following are some of the etiologic problems 3. Age associated with increased possibility of
and predictable and/or unpredictable risk factors complications.
that may contribute to a change in the treatment 4. Preoperative infection.
duration, the original prosthodontic treatment plan 5. Evidence of periodontal disease.
and its outcome, and therefore the prognosis: 6. Duration of increased intraoperative
1. Clinician’s skills, dexterity, and knowledge. intervention.
2. Correct or incorrect orthodontic planning. 7. Extensive postoperative defects.
3. Incorrect application of forces on teeth. 8. Postoperative facial neurovascular compromise.
4. Poor commitment to good oral hygiene by the 9. Postoperative shivering (due to anesthesia).
patient. 10. Postoperative bleeding, hematoma, and
5. Poor physical dexterity of the patient during swelling.
oral hygiene. 11. Postoperative craniofacial pain.
6. Immediate or localized or/and generalized post- 12. Postoperative site infections.
treatment bone loss. 13. Postoperative defective calcification of bone
7. Possible mild pulpitis and loss of vitality. fragments.
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Prognosis
14. Postoperative pulmonary complications. 15. Amount of remaining edentulous bone.

15. Slow postoperative healing. 16. Amount of remaining tooth structure.
16. Postoperative xerostomia. 17. Adequate preparation resistance and retention
17. Postoperative functional limitation of the tongue. form.
18. Postoperative available mouth opening. 18. Crown-to-root ratio after the restoration.
19. Postoperative altered maxillomandibular rela- 19. Applied torqueing forces.
tionship. 20. Cross arch stabilization.
20. Postoperative mandibular malposition and 21. Occlusal prematurities.
functional deviation. 22. Lack of anterior guidance.
21. Postoperative tongue anatomical and functional 23. Improper posterior occlusal support.
compromise. 24. Gastric reflux.
22. Postoperative compromise of vestibular exten- 25. Marginal integrity.
sions. 26. Improper prosthetic structural design.
27. Structural durability.
Prosthodontic conditioning etiologic and 28. Long-span bridges.
risk factors 29. Margin location and biologic width.
Finally, the etiologic problems that can jeopardize 30. Noncompliance of the recall schedule.
the long-term survival of a prosthetic treatment
are the same as those affecting the periodontium, Time and quality of the prognostic
as these may jeopardize the longevity of the assessment
remaining teeth and the prosthetic abutments. Knowledge of the diagnostic and prognostic con-
However, the prosthetic risk factors conditioning cepts and procedures that have been covered in
the prognosis do not depend only on these this chapter is of paramount importance during our
biologic infectious problems of the local abutments course of specialist study and in our professional
and surrounding teeth, but also on technical, lives. Our understanding of these concepts will de-
chemical, physical, biomechanical, and psychologic termine our awareness when treating our patients
factors10,13,14,38,46,47,50,114-138 such as: and the success of the treatment outcome.139-146
1. Clinician’s skills, dexterity, and knowledge. Two characteristics of the prognosis are time and
2. Correct or incorrect treatment planning. quality.
3. Patient’s ability to maintain the abutments and Time is defined by physics as a dynamic and
the prosthesis. relative value. For the purposes of prosthodontic
4. Patient’s ability to maintain one or more osseo- prediction, treatment time can be quantified ac-
integrated dental implants. cording to three different timeframes based on ev-
5. Correct or incorrect prosthetic choice for that idence-based reports in the literature and common
patient. clinical experience:
6. Heavily restored dentitions. 1. Short-term prognosis: < 3 years.
7. Removable dental prostheses. 2. Mid-term prognosis: from 3 to 7 years.
8. Caries. 3. Long-term prognosis: > 7 years.
9. Parafunctional habits.
10. Trauma from occlusion. Quality is a measure of a state of being. In med-
11. Conditions of the TMJs. icine, the quality of a prognosis may be assessed
12. Esthetic requirements and demands. by means of health and sound indicators that allow
13. Detected and undetected root fractures. us to value the degree of health and sanity of the
14. Strategic biomechanical engineered value of a body in order to predict the overall health status or
tooth in the arch. well-being of a patient. Therefore, in medicine and
77
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Table 6-9 Classification of medical prognoses Table 6-10 Classification of dental prognoses
1. Good: when we predict that there will be healing 1. Excellent prognosis

and remission of an ailment
2. Good prognosis
2. Bad: when we predict that there will be little
3. Fair prognosis
chance of healing and remission of an ailment
4. Poor prognosis
3. Reserved: when there is a significant or unknown
chance of possible worsening 5. Questionable prognosis
4. Terminal: when death is the inevitable end 6. Hopeless prognosis
surgery, the prognosis is usually termed good, bad, evidence of sound periodontal support and the
reserved or terminal (Table 6-9). radiographic controls show that the case will be
In dental medicine and prosthodontics, the risk easy to maintain by the patient and the clinician,
of loss of life is extremely low. We therefore con- providing proper maintenance is continued. In the
sider the periodontal, endodontic, maxillofacial, case of this prognosis, all treatment indicators are
orthodontic, and/or prosthodontic health status as positive.
well as the related chances of problems that may
arise due to the numerous interdisciplinary risk Fair prognosis
factors (listed above). The pretreatment and post- Periodontically, this prognosis requires evidence
treatment prognoses are defined using a larger of a clinical and radiographic 25% attachment loss
number of terms (Table 6-10) that show a greater and/or a Class I furcation involvement. However,
variance. This broader prognostic classification is since the depth and location of the furcation affects
used because the categories vary according to more maintenance, this prognosis depends on whether
specific health and sound indicators to predict the the patient maintains good oral hygiene. For this
status of each tooth as well as the entire case re- prognosis, we realize that things are good but
habilitation.18,22,25,32,34,37,41,46,53-58,60,62,64,118,138,147-149 not that good in terms of predictability. In fact,
we cannot rely on the same anatomical integrity
Excellent prognosis existing in all cases, and therefore we cannot
When all systemic, periodontal, and prosthodontic count on the same clinically and physically sound
health indicators are positive, together with good situation. Therefore, this prognosis is given in the
patient cooperation and no negative environmental case of a health status that requires some attention
factors, we speak of an excellent prognosis. The during care and recovery.
long-lasting nature of the prediction is evident, and
what is ‘apparent’ is, in fact, reality. Poor prognosis
In this case, the amount of existing damage dra-
Good prognosis matically reduces the possibility of recovery and
We give this prognosis according to clinical evidence, complete healing (restitutio ad integrum). Periodon-
the clinician’s experience, and the probability that tically, the evidence is of a 50% attachment loss and
the health status of the patient will remain positive. Class II furcation involvement exists. The depth and
Usually, this prognosis is given to any dental care location of the furcation means that maintenance
and/or restoration that shows evident signs of will not be easy to perform. In this case, the predict-
health, and when the course of the positive health ability and the outcome of treatment is questionable
status is likely to continue. Periodontally, both the and must be discussed openly and honestly with the
78
Calvani_Ch_6.indd 78 12.02.20 12:04

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117. Shillenburg HT, Hobo S, Whitsett LD, Jacobi R, 131. Simon JF. Retain or extract: the decision process.
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84
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CHAPTER SEVEN
Physical examination
Part I: extraoral examination
Calvani_Ch_7 sue.indd 1 6/1/20 3:49 PM

7 Physical examination | Part I: extraoral examination
The aim of Chapters 7 and 8 is to describe the history data and the physical examination findings
head, neck, and oral examinations necessary to are connected and work synergically, provided
start assessing the physical and oral health situ- that we are able to make rational correlations and
ation of the patient.1 We have seen that to arrive associations between the existing signs and symp-
at a correct diagnosis we need to follow a number toms.11
of well-established procedures in terms of history
gathering, physical and radiographic examina-
tions, and any analog or virtual study casts, where
necessary (Table 7-1).2
Clinician qualities
The previous chapters have described what we In general, whether we are examining a patient for
need to know to collect the patient history data. the first time or not, we need to behave profession-
This chapter provides necessary guideline infor- ally. The qualities we require are organization, dis-
mation for performing the prosthodontic physical cipline, politeness, balance, patience, availability,
extraoral examination.3,4 compassion, humility, and kindness. We need to
The first rule for the clinical examination is that nurture these qualities so that as we progress in our
no aspects of the first visit should be missed – from practice as honorable professionals we grow and
the interview to the physical and radiographic ex- become more confident, attentive, precise, sensitive,
aminations – because they all have the same diag- committed, and helpful.12
nostic value and importance in forming an objective Your initial planning of the first visit is funda-
and realistic picture of the patient’s current health mental to begin your physical examination in the
situation.5,6 proper way. Learn how to create mental examining
Clinical pictures can often overlap, as frequently schemes and use and improve upon them when you
new patients arrive with existing ailments, infec- repeat procedures. This will enhance your overall
tions, and inflammatory processes.7,8 As the stoma- course of action development and will reduce the
tognathic system is an integral part of the head and amount of time you spend as well as possible er-
neck anatomy and a central part of the entire body rors.13
complex, issues in the oral cavity are often con- As already mentioned, the anatomical systems of
nected to other issues and should not be considered the head and neck and the related structures should
in isolation.1,9,10 be investigated as well as the oral cavity because
It is important to know and remember that a these systems are all interrelated.14
well-conducted physical examination can tell us We have an excellent opportunity as dental med-
much more about patients’ past and present health ical professionals to check not only the oral cavity
history than what they are able to tell us in the but also the stomatognathic system of our patients
interview. However, bear in mind that the patient several times a year to help prevent further possible
problems.15,16
Table 7-1 Basic procedures used to arrive at a correct

diagnosis Steps of the physical
●● History gathering examination
●● Physical examinations When beginning your assessment of a new patient,
●● Radiographic and other technology driven do not start with the oral cavity and the teeth, as
examinations that would be unethical and you may miss im-
●● Evaluation of analog or virtual study casts portant signs and symptoms. A physical examina-
mounted on analog or digital articulators
tion has five main goals, summarized in Table 7-2.

Steps of the physical examination
Table 7-2 Medical goals of a physical examination Prepare the environment

The physical examination involves the
For the patient’s first visit, choose an environment
assessment:
where noise and distractions can be avoided. It
●● of the organs for any possible problem and func- should be well but not excessively lit, and the pa-
tional limitation tient should be at a suitable distance from you so
●● for possible evidence of general and/or local that you are able to successfully perform all the se-
pathologies and inflammation miotic procedures you need to carry out.18
●● for possible signs of general and/or local oral
pathologies and inflammation
Make the patient feel at ease
●● for a possible relationship between extraoral and
intraoral symptoms and signs New patients will be more relaxed and respon-
●● for the possible differential diagnosis and final sive if you ensure that they are comfortable and
diagnosis at ease.18 Always explain what you are doing and
why. Have ready a sterilized tray, a sealed set of
Some initial recommendations are given below examining instruments (Fig 7-1), and the face mask
to create an appropriate environment for a success- you will need for the intraoral examination that
ful first visit.17 follows (Chapter 8). You may want to wear the
Fig 7-1 Prosthodontic examination set.

mask immediately and to open the sealed instru- Physical examination checklist
ments in front of patients for their peace of mind
regarding contamination.19 For the current ex- It is a good idea to make use of an examination
traoral examination, apart from your knowledge, checklist of all the aspects of the physical exami-
senses, and experience, you will need one pair of nation. This will allow you to be efficient and not
surgical gloves. Incline the patient chair in a po- waste time. It will also ensure that you do not for-
sition that allows you to move freely around the get any step and thereby miss valuable information.
patient and proceed. With time and experience, this list of steps will be-
come engraved in your memory and the procedure
will become a professional habit.
Check the evaluation questionnaire
The checklist provided below is based on a prac-
with the patient
tical, experienced dental medical working ration-
Reviewing patients’ initial evaluation question- ale. The checklist is followed by a discussion of the
naire together with them is a sign of your inter- items that make up the list. The intraoral examina-
est in them and your willingness to communicate tion checklist is presented in Chapter 8.
and understand their concerns. It also gives you
the opportunity to assess their facial expressions
and body language.20-22 Continue by posing ques-
Extraoral examination checklist
tions in a gentle and professional manner, and
delve more deeply into anything that is unclear. A. Physical inspection of the body, ausculta-
You are entitled to ask questions that are relevant tion, and odor examination:
to the investigation of the patient’s health, and if 1. General appearance.
you pose these questions sensitively patients will 2. Body posture.
usually be responsive. With the initial evaluation 3. Movements and muscle coordination.
questionnaire in your hands, allow the patient 4. Nails, skin, and hair.
time to speak and to answer your questions. Listen 5. Breathing patterns.
without interrupting. This is an excellent oppor- 6. Odors.
tunity to get to know and understand your new 7. Speaking ability.
patient.23 8. Speech peculiarities.
Think about what you have read on the question- 9. Understanding ability.
naire. Does it make sense? Has the patient commu- 10. Vital statistics.
nicated clearly and fully? Is the information com- B. Head and neck inspection – examination:
plete? Sometimes patients will not have expressed 1. Face.
themselves well, so take your time and ask for clar- 2. Eyes.
ification if anything is unclear or incomplete. 3. Ears.
Once you are clear on all the issues on the 4. Nose.
questionnaire, you are ready to begin the physical 5. Mouth.
hands-on examination. Hopefully, this will elabo- C. Head and neck inspection – palpation
examination:
rate on what you already know and clear up any
1. Nerves.
possible unknowns or doubts, and your ideas will
2. Muscles.
take shape and begin to make sense.24
3. Temporomandibular joints (TMJs).
As you gain experience in handling this initial
4. Lymphatic system.
phase properly, you will understand the impor-
5. Salivary glands.
tance of an excellent and professional initial ap-
6. Thyroid gland.
proach.7,8,15,18

Physical inspection of the body, auscultation, and odor examination
Physical inspection of the Body posture

body, auscultation, and odor
Usually, our posture shows whether we are in dis-
examination comfort or pain. The body takes on a defensive po-
The initial physical inspection (observation), to- sition, both to hide the pain and to not feel it as in-
gether with auscultation (listening) and the odor tensely. Some illnesses, disorders or conditions force
examination (smelling) of the patient offers the first us to assume specific postures due to asymptomatic
medical physical and psychologic insight into the natural or pathologic changes in our skeleton and
patient’s health status. This is one of the aims of the muscle trophism or because of (often related) psy-
extraoral examination. chologic issues. Age is certainly not a disease, but
Some physical information can be retrieved our posture does change over time due to the nat-
simply by looking at the patient. What you ob- ural involution of our bodies. This can sometimes
serve may confirm the information on the initial cause confusion when we examine older patients
evaluation questionnaire20,25 or it may indicate because we may incorrectly assume a pathology
that something is missing or that some condition that does not exist.7,8,9,29
exists that the patient is unaware of or has forgot-
ten about.
Movements and muscle
Add notes of any missing information or signs
coordination
and symptoms that may help you to form a more
complete picture and make a correct diagnosis. Specific illnesses caused by aging may result in
some muscular signs and symptoms such as trem-
ors or involuntary facial movements, head and/
General appearance
or neck muscle contractions, sudden uncontrolled
Be alert and prepared to examine the general ap- movements or uncoordinated muscles. However,
pearance of new patients when you meet them. Al- similar problems may occur in patients suffering
though you are in examination mode, do not show from anxiety or in those taking certain medications
this to patients as you do not want to alarm them or recreational drugs. Neuromuscular problems
and receive a conditioned response. Be natural, but that result in the incapacity of patients to control
also attentive to all that the general appearance of their muscles indicate a limitation for prosthodontic
the patient can tell you.20,25 treatment or warn us of the difficulty of perform-
Observe without creating embarrassment. Take ing delicate intraoral procedures on them. In these
the appropriate amount of time and allow your cases, it is wise to get in touch with the patient’s
knowledge, intelligence, instincts, and profession- physician to understand what the problem is and
alism to guide you. Be confident, considerate, and whether it is possible to control it.7,8
ethical at all times. A well-trained professional
should be able to begin to understand from the first
Nails, skin, and hair
meeting what is going on with a patient.26-28
The skin is the largest organ of the human body. To-
gether with the nails and the hair, the altered troph-
ism of the skin can indicate disease and/or illness.
Therefore, altered skin color, cyanosis, jaundice,
Clinical experience teaches that a superficial blanching, flushing, and sweating may indicate
or perfunctory physical examination weakens changes of the vasomotor reflexes due to a clinical
the entire treatment of care, from diagnosis to
and/or physiologic abnormality. It can also point to
treatment planning and beyond.
anxiety in the patient.

Breathing patterns Odors

The respiratory system is an organ that is anatomi- The way patients smell can provide much infor-
cally divided into two parts with different functions: mation, not only about their personal hygiene and
1. The upper respiratory tract that extends from personality but also about possible ongoing condi-
the nose, through the trachea to the bronchi- tions. For instance, the smell of patients’ clothes and
oles (also called the conducting area or zone), breath can indicate whether they smoke, drink alco-
where the first inhalation of gases takes place. hol, are taking medication, and/or are using specific
2. The lower respiratory tract (or true respiratory dental materials or temporary medication in the
part of the system), comprising the alveolar mouth. Breath can also indicate the possible pres-
duct, sac, and alveoli, which allow for the ex- ence of blood, pus, and diseases such as ketoacido-
change of gases to and from the blood. sis or gastrointestinal problems such as gastritis or
gastroesophageal reflux disease (GERD).34,35 Odors
The way a patient breathes may indicate cardio cir- are therefore also useful as we compose the overall
culatory and/or respiratory pathologies. This may picture of a patient’s current health situation and
be a sign of other physical and/or psychologic is- orient further questions and/or examinations.
sues of which the patient may or may not be aware.5
Patients may have breathing pattern disorders
Speaking ability
(BPDs) that range from accelerated light breath-
ing to hyperventilation. This may create muscle The lack of the ability to speak is a crucial sign that a
and behavioral problems as well as altered meta- patient has a problem or a disease/condition such as
bolic ailments, which in turn could result in various congenital or acquired mutism, or deaf mutism.36 In
emotional reactions. BPDs may be caused by age these situations, it is sometimes difficult to relate to
and posture, altered pain threshold, altered blood and communicate with the patient. We are required
pH values with possible alkalosis, tissue hypoxia, to stand directly in front of the patient, articulate
and muscle problems. Anxiety, depression, chronic clearly, and use gestures to express ourselves, if ne-
fatigue, fibromyalgia, premenstrual syndrome, neck cessary. If patients are unable to speak, we need to
pain, and back pain are some of the symptoms that understand why. We also need to know how best to
may be present.13,14,30,31 communicate with them so that nothing is missed
From both a clinical and prosthodontic point of during their visits and we are able to treat them.37
view, it is important for our evaluations to know Sometimes, for cognitive or educational reasons,
whether there are breathing problems because they the patient is simply not able to communicate prop-
will have implications for whether the patient can erly.38 At other times, a patient’s silence may indi-
undergo a lengthy and demanding prosthodontic cate a physical or psychologic issue that needs to
treatment that will require active patient participa- be investigated and solved to avoid further possible
tion and cooperation.16,32,33 problems relating to communication, understand-
If in doubt, consult the patient’s physician in or- ing, and collaboration.20,39 Again, consulting the pa-
der to understand whether it is possible to put the tient’s physician, a family member or a person ac-
patient at ease during all procedures in order to al- companying the patient can help us to understand
low for the best treatment possible. Pharmacologic the problem and whether it is possible to solve or
therapy may be required to control or improve the overcome it.
clinical consequences of these disorders during the
prosthodontic treatment.

Physical inspection of the body, auscultation, and odor examination
Speech peculiarities ically rehabilitate edentulous or partly edentulous

patients, we have to help them to collaborate with
The way patients speak, whether it is normal or al- us in order to reconstitute their way of speaking as
tered speech, gives us important information about best we can.41,46,47
how to better rehabilitate them.40,41 Certain speech defects such as the prosthodon-
In the case of edentulous or partly edentulous tically challenging lisping defect are genetically in-
patients, speech is sometimes affected, although herited; however, speech defects can also be due to
people have a natural ability to adapt to speech dif- the initial and progressive conditioning effect we
ficulties and to compensate for them,42 for instance passively learn from our mother-tongue language
when speaking with complete dentures or an im- and local dialects. They can also be due to the dele-
plant-retained full-mouth rehabilitation. Certainly, terious effect of disease or trauma that has affected
if a clinician does not respect the anatomy and the speech organs, together with the possible oc-
physiology of the oral cavity, enormous difficulties clusal and anterior changes of tooth position and
will be introduced and the patient will never speak shape.36,40
properly again.40,43,44 Losing the anterior dentition technically means
In maxillofacial prosthodontics, speech evalua- losing the tools we need to speak. Some people con-
tion is very important for many clinical, functional, sider the way they speak to be personal and distinct
and technical reasons. Normal speech depends on and want a restoration that allows them to speak
the proper functioning of five important mecha- the way they did before they lost their teeth.49 In
nisms: such cases, we need to understand this expectation
1. Motor: lungs and muscles. by listening and carefully studying the patient’s
2. Vibrator: vocal cords. speech; we also need to explain to the patient that
3. Resonator: oral, nasal, pharyngeal, and para- some defects or peculiarities are often impossible to
nasal cavities (relevant to prosthodontics). correct and regain in full when we rehabilitate the
4. Enunciator or articulator: lips, tongue, pal- anterior dentition.17
ate, teeth (relevant to prosthodontics). Make a commitment to try to help the patient
5. Initiator: motor speech brain area, nerve path- to speak as before by taking both the esthetic and
ways. phonetic needs into account when crafting the new
teeth, but do not promise this, as it is often an im-
The resonator and enunciator or articulator mecha- possible task. Be careful not to create false expect-
nisms are relevant to prosthodontics and maxillofa- ation in this initial phase.39-41,43,46,47
cial prosthodontics. It is important to remind patients that in the
There are four principal motor nerves for the temporary restoration stage there will be a chance
speech muscles, being the trigeminal, facial, glos- to modify the provisional restoration to hopefully
sopharyngeal, and hypoglossal nerves (see Table allow for a recovery of their previous way of speak-
7-4). We can inspect their functionality during the ing as far as possible. In this regard, clinical experi-
first or a successive visit. ence has shown that complete and often immediate
Speech articulation or the emission of voiced denture prostheses may result in severe phonetic
and phonated sounds as vowels and consonants problems, sore spots, and other difficulties because
depends on the genetics, mother-tongue language, they subject patients to functional, esthetic, and
and accent of the individual. It results from the ideal psychologic stress that needs to be addressed from
combined position and movement of five different the beginning. For this reason, before prosthodontic
structures that need to be assessed during this ini- treatment begins, patients should be given a written
tial diagnostic phase: the lips, teeth, tongue, palate, warning that there may be a temporary impediment
and mandible.36,37,45 Therefore, when we prosthet- to their speech, and that adaptation to complete

dentures (provided they are properly made) usually Head and neck inspection –
takes about 2 to 4 weeks.49 They should also receive
examination
written instructions to take home regarding how to
overcome any possible problems that may arise. It is advisable to always be methodical and repet-
Also, it is important to remind patients that to itive when clinically examining patients to ensure
enhance the adaptation to their prostheses in terms accuracy and thoroughness. It makes things easier
of their speech, proper logopedic exercises may be if one or more practical evaluation schemes are fol-
required at first, and that it may take time and pa- lowed. Always be professional, gentle, and sensitive
tience for their speech to improve. If speech prob- when examining a patient. The frontal and lateral
lems persist despite the correct vertical dimension views of the head and neck should be considered in
of occlusion (VDO), occlusal plane, palatal contour, order to properly evaluate all the anatomical struc-
and anterior and posterior tooth positioning, con- tures in three dimensions. Using this method, the
sultation with a speech therapist should be sug- structures discussed below should be analyzed.
gested.39-41,43,44,46,47,50
Therefore, if during the initial evaluation we per-
Face
ceive that problems exist or may arise in this regard,
we have a duty to explain this clinical evidence to The examination should take into consideration
the patient, and note on the treatment plan that a whether there are any frontal or lateral asymmetries
possible consultation with a speech therapist at the or swellings and whether any abnormal skin colors
end of the prosthetic treatment could be useful. are present around the mouth or elsewhere on the
face (Figs 7-2 to 7-4).22,55,57
Understanding ability
Eyes
Communicating with patients who ‘understand’
what we say is important to avoid problems of com- The eyes should be examined carefully as they may
munication. A lack of understanding may be due mirror a number of pathologies and conditions of
to extrinsic causes such as education, personality, which the patient may or may not be aware. The
anxiety, medications, recreational drugs, or physical anatomical components of the eyes can tell us if
limitations.11 patients have a neuromuscular condition, are tak-
When we face patients who are physically una- ing medication, are receiving chemotherapy, and/
ble to understand their current situation and what or if they are addicted to any recreational drug/s.
we are trying to do to treat them, it is best to make Besides the pathologic conditions we can see in the
contact with a parent, guardian, family member or eyes, they may also inform us of a patient’s psycho-
accompanying adult who can communicate with logic and emotional state. This may provide insight
the patient to clear up any doubts and/or explain and guidance as to how best to proceed with the
unclear aspects of the treatment plan. It is also ad- examination and treatment (Fig 7-5).
visable to contact the patient’s attending physician
to better understand if we can manage the clinical
situation or perhaps not take on the patient at all.
Table 7-3 Vital statistics
Height: 000 cm (0ˈ 0ˈˈ)

Vital statistics Weight: 00 kg (000 lbs)
It is necessary to record the vital statistics of pa- Blood pressure: 00/00 mm/Hg
tients during the first visit and whenever necessary Pulse rate: 00 bpm (beats per minute)
Respiration: 00 brpm (breath rate per minute)
thereafter (Table 7-3).

Head and neck inspection – examination
Hairline
Nasal ala Upper third
Glabella
Interpupillary line
Middle third
Subnasale
Labial commissure
Lower third
Lip corner
Zigomatic protuberance
Menton
Midline
Fig 7-2 Frontal view: optimal facial symmetries and main lines of interest.
Interpupillary line
Lip corners line
Lip corner
Fig 7-3 Frontal view, full smile: optimal dentolabial f acial symmetries.

Facial plane
Nasofrontal angle: 115 to 135 degrees
Nasofacial angle: 30 to 40 degrees
Nasomental angle: 120 to 132 degrees
Nasolabial angle: 90 to 105 degrees
Mentocervical angle: 80 to 95 degrees
Fig 7-4 Profile view: facial analysis with the five e

sthetic triangles of Powell and Humphreys.
a b
Fig 7-5 a Normal dilation of the pupil. b Mydriasis due to cocaine use.
10

Head and neck inspection – examination
Ears Nose
Assess whether patients suffer from hearing and/or The nose is extremely important due to its proxim-
balance disorders.28 ity to the oral cavity and because of its link to the
●● Assess whether they are able to hear properly nasopharynx. Any natural or pathologic obstruc-
or whether there is any degree of permanent tion of a patient’s airway passages, whether partial
deafness. or complete, may clinically affect the oral cavity
●● Assess whether they use a hearing aid and, and may be a serious obstacle during (especially
if so, whether the device works adequately. lengthy) treatment.56
Position yourself in front of patients as it is im- While breathing is unconscious and automatic in
portant to communicate and to be understood a healthy person, if one of the two airway passages
properly. is obstructed, breathing becomes more conscious and
●● If there are any balance disorders, assess difficult. If a patient is a mouth breather, saliva and
whether they are temporary or permanent. water introduced into the oral cavity (often in large
Ask patients to get into and stay in an inclined amounts) during treatment may cause the patient to
position. Test any immediate or prolonged experience breathing difficulties. Possible temporary
head and neck rotation and eye movement or transitory problems can be managed with local
while patients are lying down. symptomatic nasal therapy and by using effective
surgical suction tips intraorally during treatment to
If there are permanent balance problems, this may quickly remove these liquids from the patient’s mouth.
affect the prosthodontic treatment because patients Look for any permanent obstruction in the nose
may not be able to recline for any length of time. that may be causing xerostomia, usually character-
This means you would need to perform your task ised by a diffused inflammatory mucosal situation;
while they are in a less-than-ideal position, which periodontal problems; caries lesions; chronic or
will be tiring for you and for them. Therefore, un- acute pharyngitis or rhinopharyngitis with areas of
less patients are in control of the situation, it is localized or diffused redness, swelling, and some-
advisable to call their physician for a consultation times bleeding of the mucosa, with possible local
(Fig 7-6).53-55 pain, discomfort, and swelling of the supraclavic-
ular lymph node (SCLN) and/or the deep cervical
lymph nodes (DCLNs). These are biologic and prost-
hodontic problems that might be a negative indi-
cator for prosthodontic treatment, especially if the
patient is wearing removable prostheses.57-60
Mouth
The extraoral examination of the mouth must com-
prise a careful analysis of the lower one third of
the face, including not only the cheeks and lips but
also other related anatomical structures. A compre-
hensive analysis of the mouth will give us informa-
tion regarding the shape and form as well as any
previous or possible ongoing conditions inside the
mouth, which we will check intraorally after the ex-
Fig 7-6 Patient with a hearing aid. traoral examination.61-63
11

The features to include in the examination are trust of their patients during these first moments; it
listed below. Note: is therefore an important moment of trust between
1. The form, shape, and fullness of the cheeks and you and your patient. It will give the patient an idea
lips. of your professionality, expertise, and manner. It is
2. The form and trophism of the masseter muscles. therefore crucial to approach this examination with
3. The maxillomandibular skeletal class (Angle’s a generous measure of kindness, gentleness, and
classification). professionalism, using only safe procedures.7,8,18
4. Whether the teeth show during smile, which
may indicate an esthetic problem behind the lips.
Static and dynamic possibilities
5. Whether any concavity exists on the surface of
the cheeks or lips that may be due to missing or There are two chances to palpate the same anatom-
malpositioned teeth. ical extraoral structures: while at rest and while in
6. Whether any swelling exists that would be a action.1
sign of inflammatory problems. Look for lip Some structures such as nerves, can only be pal-
fissures, scars, and the presence of saliva at pated at rest by gently pressing over where they
the corners of the mouth (this may be a sign emerge or where they pass under, over or inside the
of a possible loss of VDO or of a local bacterial other more superficial anatomical structures cover-
superinfection). ing them.64 Other structures such as muscles, TMJs,
7. Whether a retrusion or protrusion of the upper lymph nodes, salivary glands, and the thyroid gland
lip exists. This may be evidence of excessive or can be examined during active or passive movement.65
defective lip support by the maxillary incisors Therefore, you can ask patients to perform spe-
or it could be due to maxillomandibular skel- cific actions to mobilize these structures while press-
etal conditions. If this sign is accompanied by ing delicately with your palms, fingers or fingertips
diastemas between the maxillary incisors, these over certain areas. Patients could, for example:
signs together may indicate the possible loss ●● move their head in specific directions or place
of posterior teeth or of inadequate posterior themselves in specific positions;
occlusal support over time or a parafunctional ●● swallow;
habit. ●● open and close the mouth;
8. Whether there are signs of ongoing parafunc- ●● bite.
tional bruxing or clenching (ipsilateral or both
masseter and temporalis muscles contracting This will enable you to physically evaluate these
during function, and possibly ipertrophic). structures and to assess whether there is any swell-
9. Whether there are signs of any other parafunc- ing due to inflammation, or tenderness or pain on
tional habits (lip and cheek biting, tongue palpation.
thrusting or biting, nail biting).
Palpation techniques
Patients may also show signs while they are speak-
ing or listening to us, often due to anxiety. Head and neck palpation can be undertaken in two
different ways:
1. With one hand, usually performed with you
standing in front of or to the side of the patient.
Head and neck inspection – 2. With two hands (bimanually), usually from
palpation examination behind the patient. This method is useful if you
The palpation examination is the first physical con- want to bilaterally compare two identical struc-
tact with the patient. Many clinicians have lost the tures.
12

Nerves
Frontal palpation is generally preferred as it allows This examination may give us precise informa-
visible access to all areas and also because it allows tion regarding the functionality of a few important
you to see the patient’s facial expression when pal- pairs of head and neck nerves that might be useful
pating, which may reveal sensitivity or pain during for successful prosthodontic treatment due to their
the examination. However, a well-trained clinician specific relationship with the oral cavity and masti-
will obtain the same results from a posterior palpa- catory system.6,7,8,64,65
tion, and it is advisable and preferable to compare For the neurological examination you should
identical structures on both sides simultaneously. consider:
1. Motor functionality (CN V, CN VII, CN XII).
2. Superficial sensitivity (CN V3, CN IX, CN X).
3. Sensory functionality (CN VII, CN IX, CN X).
Nerves 4. Muscle reflexes (CN V2, CN V3, CN VII).
There are 12 pairs of cranial nerves, but only six
pairs pertain to the stomatognathic system (these Motor functionality
appear in bold in Table 7-4). You can memorize the Trigeminal nerves (pair CN V, CN V3 [motor
acronym TFGVAH to remember the six pairs of component])
nerves that should be investigated during the clini- This nerve innervates the masticatory muscles. In-
cal examination in order to assess their anatomical spect it by asking the patient to bite and to protrude
and functional integrity. Bear in mind you will not and move the mandible laterally. Compare the right
be able to palpate all of them. and left functionality by gently opposing resistance
with your fingers.
Neurologic examination
Facial nerves (pair CN VII)
Clinicians should know the basic principles of the The functionality of the facial nerve can be com-
head and neck neurologic examination and be able promised by rheumatic, traumatic, inflammatory,
to perform it, if necessary, during a first visit or cancerous, and surgical causes. Since it is strongly
whenever necessary such as if clinical evidence of involved with the sphincteric eye muscles, the
problems is suspected. slightest problem can usually be immediately de-
tected by examining the trophism and functionality
of the upper and lower eyelid muscles, which will
Table 7-4 The 12 pairs of cranial nerves
usually be an indication of a problem before any
other muscles of facial expression. Inspect all the
Cranial nerves muscles of facial expression for motor functionality.
1. Olfactory (CN I)
2. Optic (CN II)
Hypoglossal nerves (pair CN XII)
3. Oculomotor (CN III)
4. Trochlear (CN IV) These nerves innervate the tongue. Inspect them for
5. Trigeminal (CN V) motor functionality of the tongue. A tongue lesion
6. Abducens (CN VI) may be caused by a number of infectious diseases
7. Facial (CN VII) such as cancer. Traumatic problems may also limit
8. Vestibulocochlear, (acusticus) (CN VIII) the functionality of this organ.
9. Glossopharyngeal (CN IX)
10. Vagus (CN X) Superficial sensitivity
11. Accessory, (accessorius vagi, spinal accessory) Trigeminal nerves (pair CN V)
(CN XI) Palpate this nerve pair to examine for superficial
12. Hypoglossal (CN XII)
sensitivity of the face. In case of inflammation, when
13

gently locating and compressing over the ophthal- absent, it may mean that there is an optic nerve
mic (CN V1), maxillary (CN V2), and/or mandibular (CN II) or oculomotor nerve (CN III) lesion.
(CN V3) emergences of this nerve, a painful sensa- It could also mean that the patient is taking
tion might result in one or all three branches, which medication or drugs such as opiates, narcotics,
innervate the related facial skin territories. Depend- antidepressants or barbiturates.
ing on the different type of spontaneous or caused
pain, a differential diagnosis can be made between Inspection and palpation are useful ways to test the
simple and/or complicated sinusitis or trigeminal trigeminal and facial nerve branches.6,7,8,64,65
neuralgia or cluster headache. The assessment of possible signs and symptoms
may be useful to make a differential diagnosis be-
Sensory functionality tween intraoral and extraoral conditions and/or
The prosthodontic examination comprises the eval- pathologies. Quasi-overlapping symptomatic ex-
uation of the following cranial nerves: pressions may be present such as between maxil-
1. The trigeminal nerves (pair CN V, first branch, lary sinusitis and a maxillary periodontal or dental
lacrimal nerve) have an important sensory abscess or inflammation, or between initial Bell’s
function because during any trigeminal inflam- palsy tingling and an initial mumps infection or a
mation there might be a number of signs that taste and/or smell disorder.
reveal possible neural problems.
2. The facial nerves (pair CN VII) are involved in
Trigeminal nerve (sensory
lachrymation (abnormal or excessive secretion
component of the nerve)
of tears).
3. The vagus nerves (pair CN X) carry fibers from Inspection: The sensory component of the trigemi-
the root of the tongue and the epiglottis and nal nerve (CN V) sends signals to the brain from all
have a minor role in the sense of taste. the parts of the face that it innervates. The inspec-
tion of this nerve may be indicated in the presence
Reflexes of skin redness, dystrophic skin conditions, a vari-
It may be useful to examine the reflexes in order to able degree of xerostomia, muscle spasms, reduced
evaluate their functionality. secretions of the mouth and nose, reduced lachry-
1. Masseteric reflex: percussion of the zygomatic mation in one or both eyes, keratitis, and pain.66
insertion of the masseter muscle usually elicits
a response of the masseteric nerve, a branch of How to palpate the trigeminal nerves
the mandibular nerve (CN V3) that is, in turn, Once you have assessed that no neuralgia is pres-
a branch of the trigeminal nerve. Absence of ent, palpate the three facial sensory branches of the
this reflex may be a possible sign of trigeminal trigeminal nerve (CN V1: ophthalmic; CN V2: max-
nerve damage. illary; CN V3: mandibular) where they emerge and
2. Conjunctival reflex: stimulating the eyelid con- exit the skull, on both sides of the face. Usually this
junctiva usually results in the patient blinking examination is performed chairside, with the clini-
the eyes. Absence of this reflex may be a sign cian seated behind the patient.6,7,8,64,65
of possible maxillary nerve (CN V2) damage, ●● Palpate the supraorbital foramen (CN V1) on
or damage of the origin nerve, the trigeminal both sides, asking the patient to say if there
(CN V). is sensitivity. If the patient experiences an
3. Pupillary light reflex (PLR): if you shine a light increased ipsilateral or bilateral sensitivity
into the eye, the pupil usually constricts (optic to pressure, this may be due to inflammation
nerve pair, CN II). Shine the light first into the of the membrane that lines the frontal and
one eye and then into the other. If this reflex is ethmoidal sinuses, or of the eye, or of the
14

Nerves
posterosuperior portion of the nose, or of the be assessed with potential abscesses or dental
lacrimal glands. These structures are inner- pathologies related to that area. In fact, the
vated by branches of the ophthalmic nerve. pain and symptomatology from zygomatic
There is no relationship with the oral cavity sinusitis can easily be confused with these oral
and the teeth, but any discomfort and/or pain- cavity problems.
ful sensation to pressure will need to be solved ●● Palpate the mandibular foramen (CN V3) on
as it may slow the prosthodontic treatment. If both sides, asking the patient to say if there is
this is indicated, the patient should be referred sensitivity. If the patient experiences sensitiv-
to an otorhinolaryngologist for further inves- ity, investigate all the mandibular teeth as well
tigations. as the lower lip both clinically and radiologic-
●● Palpate the infraorbital foramen (CN V2) on ally.
both sides, asking the patient to say if there is
any change of sensitivity. If the patient expe-
Facial nerve (sensory and motor
riences any ipsilateral or bilateral sensitivity
components of the nerve)
to pressure, this may be due to inflammation
of the Schneiderian membrane lining the This nerve, with its five external component
maxillary sinus that increases the sensitivity branches – temporal, zygomatic, buccal, man-
of the maxillary zygomatic branch of this dibular, and cervical (te-zy-bu-ma-ce) – innervates
nerve. You may want to refer the patient to an the muscles of facial expression.67
otorhinolaryngologist. In case of a negative Inspection: This may be clinically related to the
response to palpation, but where the patient presence or not of a variable degree of Bell’s palsy
is still complaining of discomfort or pain on or of hemifacial muscle spasms.
a particular side, a differential diagnosis must As far as its internal sensory components are
concerned, there are two important questions that
need to be answered during the physical examina-
tion:
Trigeminal neuralgia 1. Ask whether there has been any change in the
patient’s sense of hearing. This question is re-
This condition is caused by a compression of an
adjacent artery over the trigeminal nerve (CN V),
lated to the internal sensory component, which
where the blood vessel exits the skull at the base innervates the stapedius muscle, the smallest
of the brain, usually the superior cerebellar artery and shortest muscle in the body (1 mm). In case
(SCA). This results in sudden pain during chewing, of problems with the facial nerve (CN VII), the
smiling, eating, drinking, talking, touching the stapedius will be affected, variably paralyzing
face, shaving, washing or making up the face. the ear stapes on the side where it inserts. As a
The condition may start with brief attacks but in result, the patient will experience hyperacusis
time may progress to powerful stabbing, searing (the sense of hearing being louder on the prob-
or burning sensations localized or diffused on lematic side).
one side of the face, similar to an electric shock
2. Ask whether there has been any change in the
that may last for seconds or minutes, with either
patient’s sense of taste. This question is related
continuous or intermittent pain. With time, even
the most balanced patients usually experience
to the corda tympani branch’s internal sensory
anxiety, which in some cases can lead to psychosis. component, which innervates the anterior two
Pharmacological and/or surgical therapies are thirds of the tongue. Any taste change may
usually performed to reduce or eliminate this involve the facial nerve (CN VII) at this or a
(sometimes chronic) condition. higher level, in which case the patient’s sense
of taste will be diminished.
15

Table 7-6 Muscles of facial expression

The remaining four pairs of cranial nerves that
relate to the stomatognathic system (see Table Sixteen muscles, all innervated by the facial nerve
7-4) – glossopharyngeal (CN IX), vagus (CN X), (CN VII), four groups with two pairs in each group
accessory (CN XI), and hypoglossal (CN XII) – A. Muscles at the orbital opening (OC)
innervate the tongue as well as other anatomical 1. Orbicularis oculi (closes the eyelids)
structures. The most important aspects of their 2. Corrugator supercilii (wrinkles the forehead)
functionality are discussed in Chapter 8. B. Muscles of the nose (NP)
1. Nasal (corrugates the skin on the nose and
flares the nostrils)
2. Procerus (assists in flaring the nostrils)
C. Muscles of the mouth (LLZZ LRDD MOB)
Muscles 1. Levator labii superioris alaeque nasi (elevates
the medial part of the upper lip)
During the first visit, the trophism and functional- 2. Levator labii superioris (elevates the lateral
ity of the head and neck muscles should be inves- part of the upper lip)
tigated. This is undertaken to determine any possi- 3. Zygomaticus minor (draws upper lip
ble temporary or permanent muscular pathologic backward, upward, and outward)
conditions that may have an influence on the fa- 4. Zygomaticus major (elevates the corner of the
cial expressions and on the speaking, chewing, and upper lip)
5. Levator anguli oris (elevates and retracts the
swallowing functionality as well as on the ability of
corner of the upper lip)
the patient to use certain types of prostheses and
6. Risorius (elevates and retracts the corner of
undergo the prosthodontic treatment comforta- the upper lip)
bly.6,7,8,57,64,65 7. Depressor anguli oris (triangularis) (lowers the
The muscles of the head that are of prosthodon- corner of the lower lip)
tic interest can be grouped as follows: 8. Depressor labii inferioris (lowers the lateral
1. The masticatory muscles (Table 7-5; Figs 7-7 to part of the lower lip)
7-10). 9. Mentalis (elevates the lower lip)
2. The muscles of facial expression (Table 7-6). 10. Orbicularis oris (its upper and lower
contraction closes the mouth)
11. Buccinator (pulls the corner of the mouth
backward)
D. Muscles of the neck (P)
1. Platysma (assists in drawing the corners of the
lips sideward and downward)
Table 7-5 Masticatory muscles
Six muscles, divided into four primary muscles and two accessory muscles
A. Primary: chew and grind food (TMML)
1. Temporalis muscle (innervated by the temporal nerve): elevates and retracts the mandible
2. Masseter muscle (innervated by the masseteric nerve): elevates and retracts the mandible
3. Medial (internal) pterygoid muscle (innervated by the medial pterygoid nerve): elevates the mandible
4. Lateral pterygoid muscle, upper and lower (innervated by the lateral pterygoid nerve): moves mandible
forward, downward, and side to side
B. Accessory: assist in supporting fluid, lowering the mandible, and retrusion (DG)
1. Digastric muscle (innervated by the mylohyoid nerve): lowers and retreads the mandible centrally and
laterally
2. Geniohyoid muscle (innervated by the ansa cervicalis fibers): lowers and retreads the mandible centrally
16

Muscles
Temporalis muscle
Masseter muscle
Temporalis muscle Lateral pterygoid muscle
Masseter muscle
Medial pterygoid muscle
Figs 7-7 and 7-8 Masticatory muscles.
17

Fig 7-9 Lower third of the face: facial expression mus- Fig 7-10 Lower third of the face: facial expression
cles at rest. [ZMa: Zygomaticus major; ZMi: Zygomaticus muscles during function. [ZMa: Zygomaticus major;
minor; LLS: Levator labii superioris; LLSan: Levator labii ZMi: Zygomaticus minor; LLS: Levator labii superioris;
superioris alaeque nasi; M: Mentalis; B: Buccinator; LLSan: Levator labii superioris alaeque nasi; M: Mentalis;
O: Orbicularis oris; DLI: Depressor labii inferioris; B: Buccinator; O: Orbicularis oris; DLI: Depressor labii
DAO: Depressor anguli oris] inferioris; DAO: Depressor anguli oris]
Masticatory muscles with your pinky or index finger to the area lat-
eral to the maxillary tuberosity and medial to the
Inspection: The primary masticatory muscles (tem- coronoid process, then delicately press upwards
poralis and masseter) are easily visible in the case and inwards over the short bodies of these mus-
of hyperthrophism and/or when the patient bites cles. Always ask the patient to slightly close the
hard in the maximum intercuspation position mouth when performing this palpation. If there is
(MIP). spontaneous or provoked tenderness or pain, both
Palpation: The masseter and temporalis muscles at rest or during function, this is often a sign of
are superficial and can be palpated both at rest temporomandibular and/or occlusal problems
and during function by placing the fingertips over (Fig 7-11).
them. They may show signs of tenderness, a burn- The accessory masticatory muscles, the digastric
ing sensation or even pain, both at rest or when and geniohyoid muscles, are also deep but can be ap-
biting, if they have been continuously working. proached and palpated extraorally under the man-
This may be due to functional and/or parafunc- dible as they both lie below the mylohyoid muscle,
tional activities and to the resulting production together with the two stylohyoid muscles, and the
and accumulation of lactate, often called lactic two more lateral styloglossus muscles. Together
acid, and of other metabolites that cannot be im- with other anatomical parts that are not muscular,
mediately removed. the overall assembly of these muscles constitutes
The medial and lateral upper and lower pterygoid the floor of the mouth. The function of the acces-
muscles are located behind the ramus of the mandi- sory masticatory muscles is to depress the mandi-
ble and the coronoid process in the retrozygomatic ble to open the mouth (digastric) and to elevate the
fossa. As they are deep, external palpation is not hyoid bone while chewing, swallowing, breathing,
possible, but these muscles can be palpated during and speaking (digastric, geniohyoid, stylohyoid,
the intraoral examination. To do this, gently reach and styloglossus) (Fig 7-12).68-70
18

Muscles
Fig 7-11 Suggested method for reaching the area of Fig 7-12 Patient with longstanding severe bruxism and
the pterygoid muscles with the pinky finger. related hypertrophy of the masseter and temporalis
muscles.
Muscles of facial expression cles are functioning properly. Also, you may want
to create resistance with two of your fingers to op-
Inspection: These muscles can be inspected and pal- pose their action when they try to open their eyelid,
pated both at rest and during function. Since they or press gently on their cheeks with two fingers as
are all innervated by the facial nerve (CN VII), if they try to fill them with air while their lips are
asymmetries exist due to lesions of this nerve, these closed tight. Any ipsilateral deficiency of the facial
start to be evident at rest and then show progres- nerve (CN VII), which is the most common evidence
sively more asymmetry during activity and on con- of a problem in this regard, will show the degree of
traction.61,85 the functional deficiency of the ipsilateral muscles
Inspection of the primary muscles of facial ex- compared with the contralateral groups.52,61
pression may highlight their physical dimensions, Palpation: Only a few of the muscles of facial
functionality (and therefore possible reduced troph- expression can be palpated individually such as
ism) as well as evidence of symmetric or increased the corrugator supercilii, orbicularis oris, mentalis,
ipsilateral activity. On the other hand, inspection of depressor anguli oris, and platysma. The others are
the accessory muscles of facial expression can only short, flattened, and very difficult to distinguish as
be performed when these muscles are in action, they are either anatomically adjacent or they over-
when the functionality of the specific mandibular lap and/or are delicately interconnected by facial
movements that depend on them can be observed connective tissue.
(Table 7-6).62,64,65 The muscles of facial expression that are of main
Guided by the patient history data, you may prosthodontic relevance are those situated on the
want to ask patients to speak, close their eyes tight, lower third of the face and cheeks, including the
close their mouths tight and then try to blow air out lip muscles (see Figs 7-9 and 7-10). These muscles
of it, or perform various facial expressions. These assist with the functions of chewing, swallowing,
actions will allow you to see whether these mus- and speaking, and any deficiency may create prob-
19

a b
Fig 7-13 a and b TMJ functionality inspection. The chair is reclined with the patient’s head on the headrest. The
posterior-superior view of the mouth allows for a better view of any possible path off the midline and lateraliza-
tion of the mandible during opening and closing. In this position, both TMJs are also more easily reachable and
comparable to bimanual palpation and to auscultation. This patient was asymptomatic, but with the right TMJ
and mandibular laterodeviation on opening.
lems in terms of these actions as well as have im- nology currently on the market for this purpose
plications for the wearing of removable prostheses includes three-dimensional (3D) cone beam com-
and for achieving favorable results in terms of facial puted tomography (CBCT) scanners and TMJ oc-
support and esthetics.6,7,8,61,62 clusal evaluators, which are becoming increasingly
efficient and precise. Nevertheless, the knowledge
and experience of the clinician is still of paramount
Temporomandibular joints importance in order to merge all the information
and come up with a correct diagnosis.
TMJ articulations are called the posterior deter-
Neurological examination
minants of occlusion due to their function, and to-
The healthy status of the TMJs is a fundamental gether with the anterior determinants, the occlusal
prerequisite for any successful prosthodontic treat- surfaces of the teeth, and the neuromuscular deter-
ment. Therefore, prosthodontic treatment planning minants, they are extremely important for prost-
needs to take into account whether or not the TMJs hodontics to recreate tridimensional and proper
are sound. Temporomandibular dysfunction (TMD) anatomic and well-shaped functioning teeth and
relates to neuromuscular disorders of the TMJs that occlusion.68-77
often show clear and well-defined signs and symp- These articulations are located between the tem-
toms, comprising mainly pain, discomfort, and var- poral bones and the condyles or heads of the mandi-
ious sounds when the patient opens or closes the ble, called ginglymoarthrodial diarthrosis. They are
mouth, together with evidence of non-physiologic a sliding hinge joint (SHJ) due to their unique ability
paths of opening and closing movement that are to rotate first and then slide anteriorly on mouth
easy to detect and see.68-77 opening, with the opposing function on mouth clos-
However, TMD is often not well understood ing.68-77
and is not necessarily easy to investigate. TMD can Extraoral palpation can be performed at rest,
sometimes be asymptomatic and only show specific gently placing the tips of the index and third fingers
signs of changes or disease with deeper clinical, oc- over the external area corresponding to the TMJ
clusal, and radiographic investigations. In this re- articulating areas, and trying to detect sensitivity,
gard, advances in digital technology today allow us discomfort or pain on palpation. You may also in-
to detect and diagnose TMD more easily. The tech- troduce one pinky finger into the external auditory
20

Temporomandibular joints
a b
Fig 7-14 a and b TMJ extraoral palpation.
meatus and, if possible, press gently on the anterior The AAOP questions to investigate for TMD can
part of it, asking the patient to open and close the be summarized as follows:
mouth very slowly (Figs 7-13 and 7-14).68-77 1. Do you have difficulty, pain, or both when
During the opening and closing examination we opening your mouth, for instance, when yawning?
look for possible: 2. Does your jaw get stuck, locked, or go out of joint?
●● signs of articular movement anomalies; 3. Do you have difficulty, pain, or both when
●● symptoms that the patient may report during chewing, talking, or using your jaws?
opening and closing; 4. Are you aware of noises in the jaw joints?
5. Do your jaws regularly feel stiff, tight, or tired?
●● signs of anatomical dysfunctions of the me-
6. Do you have pain in or about the ears, temples, or
niscus interposed between the two articular
cheeks?
bones, which may exhibit clicks, pops, and 7. Do you have frequent headaches and/or neck
other ipsilateral or bilateral vibrations clearly aches?
perceivable under your fingertips, which are 8. Have you had a recent injury to your head, neck,
often also audible if you place your ear close to or jaw?
the patient’s head. 9. Have you been aware of any recent changes in
your bite?
The method in the TMJ evaluation form (see Chap- 10. Have you previously been treated for a jaw-joint
ter 8) may be helpful for you to follow when exam- problem? If so, when?
ining the TMJs to establish a picture of the current
situation and of any possible condition.68-77
Sometimes, anatomic and functional defects One or more of these questions can be flagged,
become clinically evident with a corollary of depending on the number and type of patient con-
symptoms and signs that are defined by the term ditions and on how aware patients are of their TMD
TMD. condition. This may define the gravity of its path-
The American Academy of Orofacial Pain ology. As there are a limited number of profession-
(AAOP) has defined some guidelines to assess pos- als who are able to solve TMD problems, patients
sible TMDs, and has made available a questionnaire sometimes wander from one dental office to another
that can be used during the physical investigation in search of treatment to solve their problems or at
and examination.71 least alleviate some of their symptoms. These pa-
21

tients sometimes describe their symptoms well be- Radiographically, signs of periodontal issues such
cause they have been described previously by other as the widening of the periodontal ligament (PDL)
professionals. However, during any clinical exam- may be helpful in the overall assessment of the
ination, symptoms such as pain in specific areas TMJs.
cannot be falsified, as the body naturally reacts to
it in ways that are usually similar. Prosthodontists
are experts in occlusion as well as TMJ conditions
associated with the occlusion.65,68,69,77
Lymphatic system
TMD signs and symptoms usually found during The lymph nodes are very important as their in-
the extraoral examination of the TMJs are: 68-77 flammation or infection is a warning sign of ill
1. TMJ pain at rest. health. Detecting these signs during the first head
2. Muscle pain at rest. and neck inspection alerts us not only to oral but
3. Laterodeviation on opening. also to possible general health problems in the
4. Limited excursive movements on opening (re- patient.
stricted opening = 4 mm). Lymph nodes are extremely specialized oval-
5. Abnormal sounds on opening and/or closing or bean-shaped tissue structures of the lymphatic
such as: system that drain the extracellular interstitial fluid
a. Clicking. of the body. They have different dimensions, oc-
b. Popping. cur isolated or in cluster groups, and are spread
c. Crepitus. throughout the central nervous system (CNS).
6. TMJ and masticatory muscle pain. There is an average of 800 lymph nodes through-
7. TMJ pain upon mandibular manipulation. out the body, about 300 of which occur in the head
8. Preauricular tenderness or pain on palpation. and neck.65,68
9. External acoustic meatus tenderness or pain on
palpation.
The lymph nodes and their
importance
TMD signs and symptoms usually found during the
intraoral examination of the TMJs are: The lymph nodes are the first line of defense for
1. Severe occlusal wear. our immune system, helping to defend the body
2. Acute malocclusion. against all types of infections, including cancerous
3. Excessive tooth mobility. cells. They contain nodules which house immune
4. Lateral tongue scalloping. cells such as lymphocytes (B cells and T cells). They
5. Buccal mucosal ridging. also house white blood cells called macrophages. If
there is an infection, the lymphocytes activate and
TMD trigger points on muscle areas you may want to produce specific antibodies, also poured into the
examine by palpation during a clinical examination blood stream, to kill the pathogen. The lymphocytes
to establish tenderness or pain include:65,68,69,77,79 create a domino effect, spreading the alert to all the
1. Extraoral point: other immune cells around the body, which also
a. Masseter muscle. activate to pursue and destroy the detected path-
b. Temporalis muscle. ogen. Macrophages also wipe out what remains of
2. Extraoral and intraoral points: the dead pathogens and are therefore considered to
a. Inferior lateral pterygoid muscle. be the scavengers of the immune system.65,68 The
b. Superior lateral pterygoid muscle. functions of the lymph nodes are summarized in
c. Medial pterygoid muscle. Table 7-7.
3. Lymph nodes.
22

Lymphatic system
Table 7-7 Functions of the lymph nodes The head lymph nodes drain the entire oral cav-
Lymph nodes have four important functions: ity assembly, tonsils, tongue, pharynx, and larynx,
●● Regulate the amount of liquid in the tissues and end up draining to the superior deep cervical
●● Regulate the amount of blood and its pressure in nodes (SDCNs).
the body As swollen lymph nodes inform us of possible
●● Filter the liquids coming from the tissues oral or extraoral infections, knowing their exact
●● Protect the body against pathogens like bacteria location in the head and neck and how to palpate
and viruses them is very important for detecting local and gen-
eral systemic pathologies, clarifying problems, ar-
riving at a correct diagnosis, and treating the pa-
tient. At times, such detection can even save a life
During this sentinel immune reaction, the lymph (Figs 7-15 and 7-16). The head and neck lymphatic
nodes usually swell to produce more lymphocytes. system is summarized in Tables 7-8 and 7-9.72
Those located just under the skin can be seen as
lumps, while deeper ones can be identified during
palpation. Very deep lymph nodes cannot be de-
tected during a routine clinical examination.
Once the infection has been eliminated and the
productive activity of the lymph nodes has slowed
down, they regain their original dimension and re- Table 7-9 Lymph nodes of the neck and their drainage
areas
sume a normal pace of activity.65
A. Lateral neck area (lower part of the ears, parotid
node):
1. Superficial cervical nodes drain to the SDCNs
B. Mandible area:
1. Submandibular nodes (posterolateral) drain to the
Table 7-8 Lymph nodes of the head and their drainage SDCNs
areas 2. Submental nodes (anterolateral) drain to the
A. Posterior head area: submandibular nodes, which then drain to the
1. Occipital nodes drain to the superior deep cervical SDCNs
C. Anterior neck area:
nodes (SDCNs)
1. Anterior (scalene) cervical nodes drain to the SDCNs
B. Lateral head area:
2. Deep cervical nodes, divided into two different
1. Posterior auricular nodes drain to the SDCNs
systems:
2. Anterior auricular nodes drain to the SDCNs
a. SDCNs, which receive the lymph from most of the
3. Parotid nodes drain to the SDCNs
nodes draining the head areas such as the scalp
C. Facial area:
parts, ears, posterior neck areas, nasopharynx,
1. Infraorbital nodes drain to the submandibular
nasal cavities, palate, larynx, trachea, tongue parts,
nodes and then to the SDCNs esophagus, and thyroid, and send part of their
2. Buccal nodes drain to the submandibular nodes lymph to the inferior deep cervical nodes (IDCNs),
and then to the SDCNs which then go to the jugular trunks, and finally
3. Mandibular nodes drain to the submandibular into the thoracic duct
nodes and then to the SDCNs b. IDCNs, which receive the lymph from the neck
4. Deep facial nodes drain directly to the SDCNs areas such as scalp parts, neck, superficial pectoral
D. Mouth: region, and proximal part of the arm; they have
1. Tongue, a limited portion of the lingual lymphatic afferents from the SDCNs and their efferent form
system the next jugular trunks and then the thoracic duct;
2. Retropharyngeal nodes drain to the SDCNs finally, the lymph returns to the blood circulation
23

Occipital
Preauricular
Retroauricular
Tonsillar (jugulodiagastric)
Parotid
Superficial anterior cervical
Superior deep cervical
Posterior cervical
Submental
Submandibular
Inferior deep cervical
Anterior scalene Supraclavicular
Fig 7-15 Location of lymph nodes in the head and neck.
PAN ON
RAN
PN
TN
SACN
SMN
SMeN SDCN
PCN
IDCN SCN
ASN
Fig 7-16 Direction of flow of the lymphatic system. [PAN: Preauricular node; PN: Parotid node; SMeN: Submental
node; SMN: Submandibular node; SDCN: Superior deep cervical node; IDCN: Inferior deep cervical node; ASN: Anterior
scalene node; ON: Occipital node; RAN: Retroauricular node; TN: Tonsillar node; SACN: Superficial anterior cervical
node; PCN: Posterior cervical node; SCN: Supraclavicular node]
24

Lymphatic system
Waldeyer’s tonsillar ring the two palatoglossal and glossopharyngeal

It is important in prosthodontics to be aware of arches, forming both lateral sides of the ring.
this lymphatic tissue assembly of four sentinel im- They can be seen when the patient raises the
mune centers surrounding the superior pharynx chin and opens the mouth wide, pronouncing a
(Fig 7-17). The function of the Waldeyer’s tonsillar long ‘Aaaaahhh’ sound. A tongue depressor is
ring is to deal with all viruses and bacteria that are used to view the tonsils. The tip of the tongue
inhaled or ingested through the nose and mouth.68 can be held with a 2 x 2 gauze, if necessary.
These immune control centers are located as fol- 2. Pharyngeal tonsils (adenoids): This is the most
lows (PPTL): superior mass of lymphatic tissue posterior to
1. Palatine tonsils (the true tonsils): The largest of the nasal cavity, in the nasopharynx just behind
the four groups, often visible when looking into the uvula. They are considered the postero-
the mouth, these tonsils form part of the oro- superior part of the ring and are not of clinical
pharynx. They are located bilaterally between interest to prosthodontic specialists. They can
Pharyngeal tonsils (adenoids)
Tubal tonsils
Lingual tonsils
Palatine tonsils
Fig 7-17 Waldeyer’s tonsillar ring, the lymphatic sentinels.
25

only be inspected with a long-handled oral fingertips into the skin over the anatomical areas
mirror and a tongue depressor. related to the nodes, looking for their presence.
3. Tubal tonsils: Lateral to the adenoids, these While the superficial nodes are easier to palpate,
tonsils are located on both sides of the naso- the deeper nodes can be palpated relatively easily
pharynx at the opening of the eustachian tubes. only in case of lymphadenopathies.7,8,64,65,68
They form the lateral part of the ring. They Your position: Again, to palpate the head and
are difficult to inspect unless one is clinically neck nodes you must put the patient at ease, with
trained and equipped. They are not of clinical all head and neck muscles relaxed. You can palpate
interest to prosthodontic specialists. from the front or the back of the seated patient,
4. Lingual tonsils: Located posteriorly on the with the chair at 90 degrees, if possible. A bimanual
tongue, at the sulcus terminalis, which ends palpation will give you the chance to compare and
at the foramen cecum. These tonsils have a appreciate any bilateral differences.
characteristic V configuration and constitute Patient’s head: This should be positioned on
the anteroinferior part of the ring. It is some- the headrest, if possible, with the chin relaxed and
times possible to inspect them by pinching the down. Otherwise, the head should be relaxed and
tongue with a 2 × 2 gauze and delicately pulling slightly anteriorly reclined.
the tongue out of the oral cavity. They may Characteristics of nodes: When palpating the head
appear when checking the tongue for cancer or and neck nodes, the following characteristics of the
other lesions during the intraoral examination. nodes you are examining are relevant for your as-
sessment, diagnosis or differential diagnosis:65
Physical examination of lymph nodes of A. Volume: Variable (5 to 12 mm each); it is a
the head and neck single node or a group of nodes fused in a
lymph node cluster.
Inspecting the nodes B. Shape: Nodes are usually ovoid in shape, like
Sometimes it is possible to see a lump or even a an almond. This shape may change in case of
swelling of one or more clustered nodes in the ana- lymphadenitis and abscesses involving the
tomical areas where they are lodged, and/or redness surrounding tissue.
of the skin on the overlying area. C. Pain: If nodes are infected they are swollen,
If an infection is already at the pus stage, a fistulous and palpation may elicit achiness or pain. In
tract could open up externally through the skin over the case of other type of infections such as
the node/s with a visible scar at the opening, which metastatic cancer, lymphoid leukemia, and
are signs of a progressively more serious underlying malignant lymphogranuloma, the nodes are
inflammatory and infectious process of those nodes. also swollen, but are usually said to be ‘silent
Remember that a lymphadenitis may be local to palpation’ because their palpation no longer
(adenopathy) as well as generalized (polyadeno elicits sensitivity, discomfort or pain due to the
pathy) such as in the case of a tuberculous cervi- deep damage to their structure. In this case,
cal lymphadenitis, in which cervical nodes up to a advise patients to see their physicians for fur-
diameter of 1 cm are often visible and palpable in ther examination. If you are in a university or
children up to 12 years of age.7,8,64,65,68 hospital environment, you may want to ask for
an immediate consultation with an oral pathol-
Palpating the nodes ogist or otorhinolaryngologist.
The patient should be relaxed. Palpate with one or D. Mobility: The mobility of both superficial and
two fingers, very gently pressing over the area of deep nodes needs to be differentiated from the
the nodes so there will be no defense reaction from mobility of the skin and of deep anatomical
the patient. When necessary, gently deepen the areas and facial plans.
26

Lymphatic system
1. I n case of healthy or slightly inflamed nodes, diagnosis, if necessary, after inspecting and palpat-
the nodes will be mobile. ing the nodes:70
2. In case of severe inflammatory and infec- 1. If the patient is healthy, the nodes will be
tious illnesses due to luetic lymphadenitis, small, barely palpable, of a regular ovoid shape,
Hodgkin disease, metastatic cancer, lympho- unnoticed by the patient, show no pain or sen-
sarcoma, and lymphatic leukemia, the nodes sitivity on palpation, be normally mobile and
will be less mobile. free, and of a soft consistency.
3. In case of tuberculous lymphadenitis and in 2. If the patient has inflammation due to perio-
advanced cancer metastatic lymphadenitis dontitis, tooth abscesses or a slight inflamma-
or lymphosarcomatous adenopathies, the tion of the oral mucosa due to a minor infec-
nodes will not move at all due to periodon- tion, the nodes will be of a normal shape but
topathic processes causing them to adhere slightly swollen with normal node mobility,
to the surrounding tissue. free of pain, and of an elastic consistency.
E. Consistency: 3. If the patient has periodontal disease, acute ne-
1. In case of fluidification processes, the nodes crotizing ulcerative gingivitis (ANUG) or severe
will be soft. oral and oropharynx abscesses and infections,
2. In case of simple inflammation, they will be the nodes will be severely inflamed and visibly
elastic. swollen, with a loss of their normal shape and
3. In case of severe, acute or chronic perio- mobility. They will have a hard-elastic consist-
dontal abscesses and local oral and ency and be sensitive to palpation and when
oropharynx infectious diseases such as swallowing.
tonsillitis, pharyngitis, lymphosarcoma, 4. If the patient has tuberculous lymphadenitis or
lymphogranuloma, and luetic adenopathies advanced cancer metastatic lymphadenitis or
they will be hard but elastic. lymphosarcomatous adenopathies, the nodes
4. In case of tuberculous lymphadenitis, and in will be extremely inflamed and very visibly
advanced cancer metastatic lymphadenitis swollen, with a loss of their normal shape and
and lymphosarcomatous adenopathies, they mobility. They will have a hard-wood consist-
will be hard as wood. ency, be asymptomatic, and silent to palpation.
The condition of the nodes: differential Figures 7-18 to 7-23 show the palpation of the most
diagnosis accessible lymph nodes that may reveal evident
The following points summarize the discussion on signs of pathology occurring in the oral cavity and
lymph nodes and assist with making a differential oropharynx anatomical areas.
a b
Fig 7-18 a Palpation of the parotid nodes (PN) and b preauricular nodes (PAN).
27

a b
Fig 7-19 a Palpation of the submandibular nodes (SMN) and b submental nodes (SMeN).
a b
Fig 7-20 a Palpation of the tonsillar nodes (TN) and b superficial anterior cervical nodes (SACN).
a b
Fig 7-21 Palpation of the superior deep cervical nodes (SDCN) under the sternocleidomastoid muscle:
a anterior and b posterior accesses.
28

Lymphatic system
a b
Fig 7-22 Palpation of the inferior deep cervical nodes (IDCN) under the sternocleidomastoid muscle:
a anterior and b posterior accesses.
a b
Fig 7-23 a Palpation of the supraclavicular nodes (SCN) and b anterior scalene nodes (ASN).
Lymphatic system of the tongue tongue.64 Examination of the tongue is described in

Palpation of the nodes that drain the tongue should detail in Chapter 8 (intraoral examination).
be performed according to the anatomy of their
drainage system (Table 7-10). Table 7-10 Lymphatic system of the tongue
The tongue has an extremely complex arterial The lymphatic system of the tongue is divided
and venous system as well as filigreed ramifications into four parts according to its drainage areas:
of its lymphatic drainage system.64,65,68 ●● Apical, the anterior tip of the tongue, drains to the
During the first visit and every subsequent ex- submental nodes
amination of a patient it is advisable to pay care- ●● Central, the central body of the tongue, drains to
ful attention to the tongue as it is a very sensitive the SDCNs
organ. It may be a first indicator of cancer in the ●● Marginal, the lateral sides of the tongue, drains to
mouth, especially among smokers because tobacco the submandibular nodes
is a major cause of inflammation and of further neo- ●● Basal, the posterior pharyngeal portion, drains to
the SDCNs
plastic lesions that occur mainly on the border of the
29

Salivary glands Table 7-11 Salivary glands
A. Major glands (extrinsic)

The salivary glands are three pairs of extrinsic 1. Parotid gland
glands that pour mainly liquid saliva and a small 2. Submandibular glands
amount of mucous saliva into the mouth as well as 3. Sublingual glands
a large number of intrinsic glands, which produce B. Minor glands (intrinsic)
less liquid saliva but a larger amount of mucous 1. Mucous glands (buccal, palatine, labial, and
lingual)
saliva (Fig 7-24). The salivary glands are commonly
C. Von Ebner’s glands (tongue)
divided into major glands and minor/mucosa-lining
glands (Table 7-11).59,67
intraorally. Palpation of the salivary glands is de-

How to palpate the salivary glands
scribed in detail in Chapter 8 (intraoral examina-
While the parotid and submandibular glands can be tion), where special attention is given to the parotid
palpated both extraorally and intraorally, the palpa- glands due to their volume and physiologic impor-
tion of the sublingual glands can only be performed tance (Figs 7-25 and 7-26).59,65,68
Stensen’s duct
and output
Rivinus’s duct
and output
Wharton’s duct Parotid gland
Bartholin’s duct
Sublingual caruncle
and output
Sublingual gland Submandibular gland
Fig 7-24 The major salivary glands, their ducts, and their outputs.
30

Salivary glands
a b
c d
Fig 7-25 a to d Extraoral palpation of the parotid gland in a patient with recurrent painful sialadenitis. Palpation
objectives are the delimitation of the body of the gland and the assessment of its shape and various consisten-
cies. In this case, the gland showed areas of swelling, while other areas were less tense and of a softer consist-
ency. The patient reported increased swelling before and during meals.
a b
Fig 7-26 a and b Extraoral palpation of the submandibular glands. An intraoral approach can complete the
examination of their supramylohyoid portion. Instead, any extraoral palpation of the sublingual glands is in-
effective due to the impossibility of reaching these salivary structures that are positioned more anteriorly and
elevated just below the floor of the mouth. The correct palpation procedure is illustrated in Chapter 8 (Fig 8-21).
31

Thyroid gland Inspection
The thyroid is the only gland that can be reached from The thyroid can be physically inspected by asking
the outside. For clinical reasons (explained below) it the patient to sip some water, slightly raise the head,
is important to know how to inspect and assess it. then swallow the water slowly. If you know where
the gland is attached to the trachea (just below the
Adam’s apple), you will notice when its shape be-
Shape
comes more visible and easier to detect as the pa-
The thyroid gland is butterfly shaped, with one right tient swallows the water. Sometimes it may be seen
and one left lobe joined by a narrow isthmus. It is while it moves up with the trachea. If the gland is
located over the trachea, lateral to the thyroid car- unhealthy, this will be evident due to it being swol-
tilage (Adam’s apple). The isthmus is usually below len. In the case of thyroiditis, some redness of the
the cricoid cartilage. Each lobe is about 5 cm long overlying skin might be visible.65-67
and 3 cm wide, with a thickness of 2 cm (Fig 7-27).72
Thyrohyoid membrane
Hyoid bone
Thyroid cartilage
(Adam’s apple)
Cricothyroid muscle
and ligament
Thyroid wing
Cricoid cartilage
Thyroid isthmus
Trachea
Fig 7-27 Thyroid gland and surrounding anatomical structures.
32

Thyroid gland
a b
Fig 7-28 a and b Basic bimanual palpation, in a posterior position at chairside. Locating the thyroid wings (right)
and isthmus (left) (left index finger).
Palpation
4. Slide over the trachea to the center and feel
To palpate the thyroid, follow the steps outlined for the superior part of the isthmus.
below: 5. Ask the patient to raise the head and
A. One-hand palpation: position yourself in front swallow slowly. As the trachea moves up,
or to the side of the patient and palpate with the thyroid gland will do so too because it is
a circular motion using the second and third closely connected to the trachea on its sides
finger, searching for the left and then the right as well as to the thyroid cartilage. This will
lobes of the gland. Palpate the isthmus by force it to slide up and down under your
descending with the index and middle finger fingertips, and in the case of swelling you
vertically along the trachea, immediately below might be able to feel it.
the cricoid cartilage.
B. Two-hand (bimanual) palpation: position your- The presence of the long vertical bodies of the ster-
self behind the patient. Evaluate both sides by nothyroid and sternohyoid muscles over and lateral
observing the shape and size of the two lobes of to the thyroid gland might impede an immediate
the gland and comparing them. identification of a normal-sized gland. Therefore, it
1. With both index fingers, first palpate the is necessary for these muscles to be relaxed, with
cricoid cartilage below the lower margin of the patient’s head on the headrest or slightly tilted
the thyroid cartilage so that the fingers are forward at rest, if seated. Then, move these two
positioned right over the thyroid gland. muscles slightly laterally with your fingers in order
2. Both index and third fingers must be posed to better uncover and reach the two lateral bodies
medially to the anterior margins of both the of the gland (Fig 7-28).
sternocleidomastoid muscles.
3. Then, ask the patient to raise the head, and
palpate the anterosuperior part of both
lobes.
33

Health status hyperthyroidism include anxiety, exophthalmos

(protrusion of the eyeballs), nervousness, palpi-
If the patient is in normal good health, you will tations, tremor, insomnia, weight loss, contin-
not usually be able to detect the thyroid gland uous hunger, chest pain if overexcited, muscle
under your fingertips due to its softish and flat weakness, and diarrhea.
body. It is easier to detect in a thin patient and is
more likely to be located and correctly palpated
Clinical relevance
by an experienced clinician.70,71 When gently pal-
pating over the thyroid gland, if you feel small It is the medical duty of the prosthodontist to be
nodules over its body or if there is pain on palpa- aware of the patient’s health status. If you know
tion, advise the patient to see an otolaryngologist the signs and symptoms of hypo- or hyperthyroid-
or endocrinologist to investigate for any possible ism, you are in a position to make a correct diag-
problems. nosis and report this on the patient’s chart. In case
of both hypo- and hyperthyroidism, it is important
to know whether patients are controlling their dis-
Function
ease. If you detect any swelling of the gland or the
The clinical importance of the thyroid gland is due presence of nodules, refer them to their physician.
to its possible abnormal functionality. The thy- Note that it might be a problem to treat patients
roid gland produces thyroid stimulating hormone affected by these disorders because prosthodon-
(TSH), which is a pituitary hormone that stim- tic treatments can be stressful and at times very
ulates the gland to produce thyroxine, and then lengthy. It is better if the patient is being medicated
triiodothyronine, which stimulates the metabo- for the disorder. Furthermore, thyroid nodules may
lism of almost every tissue in the body. Patients sometimes degenerate in certain malignant cancers
may suffer from hypo or hyper functionality of such as carcinomas, mostly in women (2:1).66 It is
the gland due to autoimmune diseases and other therefore important to know how to palpate the
causes. Since its hormones may affect the metab- thyroid, which is relatively easy and may be use-
olism, cardiovascular system, normal brain devel- ful during the pretreatment physical examination
opment, thought and sleep patterns, the menstrual planning phase.
cycle, and the sexual function, the function of this
gland is of paramount importance. Therefore, it is Absence
important that you know how to inspect and pal-
pate it. Sometimes, the thyroid gland has been surgically
Clinically, the thyroid gland’s functionality is removed, and with it, occasionally, the four para-
important in dental medicine in cases of:65,66,72 thyroid glands. These are located on the internal
1. Hypothyroidism (underactive thyroid), the most surface of both wings. In these cases, report this
common cause of which is the autoimmune information on the patient’s chart and verify the
disorder called Hashimoto’s disease. The symp- daily therapy with the patient to avoid unpleasant
toms of hypothyroidism include weight gain, situations such as seizures, dizziness, and possible
loss of hair, intolerance to colds, a slow heart fainting. The use of appropriate medications will
rate, and constant tiredness. replace the absence of hormones that can occur
2. Hyperthyroidism (overactive thyroid), the most with the loss of the thyroid gland. These medi-
common cause of which is the autoimmune cations also very importantly regulate calcium
disorder called Grave’s disease. Another cause metabolism, so taking them helps to avoid these
could be the use of amiodarone, which is an possible problems and their unpleasant signs and
antiarrhythmic medication. The symptoms of symptoms.66
34

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36

CHAPTER EIGHT
Physical examination
Part II: intraoral examination
Calvani_Ch_8 SUe.indd 1 6/1/20 3:51 PM

8 Physical examination | Part II: intraoral examination
The aim of the intraoral examination is to use all Table 8-1 Basic prosthodontic examination tools
existing semiotic means at your disposal to assess
●● Face mask
the oral health status and possible presence of ab-
●● Protective eyewear
normal morphologies or signs of inflammation of ●● Two pair of gloves (one for the extraoral and one
relevant clinical significance in all the intraoral ana- for the intraoral examinations)
tomical structures.1-7 ●● Photographic mirror
For the intraoral examination, you will now use ●● Mouth mirror
all the examining instruments shown on the tray ●● Explorer
in Figure 7-1 in the previous chapter. Open the ●● Cotton rolls
sealed instruments in front of patients for their ●● Pliers
peace of mind regarding contamination. Further ●● Periodontal probe
tools may be necessary to examine the oral cavity ●● 2 x 2-inch gauze squares
●● Miller pliers for articulating ribbon
(Table 8-1).8-11
●● Tongue depressor
It is extremely important and medically correct
to use a new pair of gloves when switching from
the extraoral to the intraoral examination. This is
strongly advised due to pathogens that can be intro- examination checklist. It is based on a practical, ex-
duced into the patient’s mouth if gloves are used in- perienced dental medical working rationale. It is
traorally that have previously been in contact with advisable to use this checklist as you carry out the
the patient’s head, neck, and face.8-12 intraoral inspection, palpation, percussion, auscul-
tation, and odor examination (IPPAO) of the vari-
ous anatomical areas.
Intraoral examination
procedure Intraoral examination checklist
A. Vestibular area:
Since you are evaluating anatomical structures that 1. Lips.
occur on both sides of the face and mouth (also in- B. Vestibules:
traorally), a better perception of possible differences 1. Cheeks.
is achieved if you match the right side with the left 2. Parotid (salivary) glands.
side during the examination. 3. Floor of the vestibules.
When performing a physical oral cavity exami- C. Oral cavity:
nation, it may be a good idea to proceed following 1. Palate:
a. Hard palate.
the logical order of outside to inside, dividing the
b. Soft palate.
mouth into two different areas. The following pro-
D. Oropharynx and isthmus of fauces:
cedure is advised: 1. Pharyngeal tonsils.
●● Examine the outer part of the oral cavity or E. Tongue.
vestibular area. F. Floor of the mouth.
●● Examine the inner part of the oral cavity, which G. Salivary glands:
contains important anatomical structures. 1. Parotid glands.
2. Submandibular salivary glands.
3. Sublingual salivary glands.
4. Minor mucous salivary glands.
Intraoral examination checklist 5. Von Ebner’s glands.
H. Alveolar arches and teeth.
In Chapter 7, a checklist for the extraoral examina-
1. Occlusion.
tion was presented. What follows is the intraoral

Vestibular area
Vestibular area ●● from a prosthodontic point of view, the need for

fuller lips is due to the lack of posterior support
Lips caused by malpositioned teeth and arches;
●● loss of vertical dimension of occlusion (VDO);
The examination of the lips may seem simple and ●● erroneous maxillomandibular position, which
obvious, but anatomically and functionally the lips then creates an esthetic demand that is often
are connected to and integrated with many struc- (erroneously) met by the immediate filling of
tures of the mouth and face, so their careful assess- the lips and face.
ment is important and should form part of the in-
traoral examination. Problems arise because many patients are unhappy
The lips constitute the initial orifice of the gastro- with how their lips look, and because for years it
enteric system and the main entrance of the respira- has been very difficult to find balanced answers to
tory system. They are one of the many organs that the questions of how one can look ‘better’ or ‘more
assist in the processes of breathing, eating (chewing attractive’ or have lips that are an esthetically pleas-
and swallowing), drinking, and speaking. They are ing size. To these questions, there are no right or
also important in terms of communicating expres- wrong answers.
sion and therefore have social as well as an esthetic Unfortunately, many patients are advised or
relevance. Any problem concerning the lips may af- persuaded by (often) non-professional, unethical,
fect any one of these important functions.13-18 economically driven interests to spend money to en-
large their lips for cosmetic ‘improvement.’ Further-
Anatomy more, very few of these patients realize that chang-
The lips are strongly vascularized by the superior ing the shape and therefore the esthetics of their lips
and inferior labial arteries, which are branches of will very likely affect their speech and pronuncia-
the facial artery. In terms of their lymphatic sys- tion. This is due to the strong relationship that exists
tem, the upper lip drains to the submandibular node between form and function; between the shape and
(SMN), while the lower lip drains to the submental volume of the lips and their mobility and activity.
node (SMeN). The nerve supply of the lips is the Also, since the lips also have contraction and
facial nerve (CN VII) for the upper lip and the vesti- prehensile muscular capabilities, these so-called
bulocochlear nerve (CN VIII) for the lower lip. ‘improvements’ might compromise functionality
The orbicularis oris muscle assists to close the lips, and esthetics to the point where some patients are
while the two modioli at the corners of the lips are a unable to properly close their mouths while chew-
crossway of tendons that receive insertion by a num- ing and swallowing.
ber of facial muscles. They developed for the purpose According to the American Society of Plastic Sur-
of changing the position and shape of the lips, pull- geons (ASPS), there were 17.5 million known mini-
ing them in all directions to allow for better chewing, mally invasive cosmetic and plastic surgery proce-
speaking, and adjustment of facial expression.13,14 dures performed in the USA in 2017. This represents
a 2% increase over 2016. In 2018, the astronomical
Esthetics and function sum of more than 16.5 billion dollars was spent on
The demand by patients for lip fillers and botuli- cosmetic plastic surgery procedures in the USA.19
num toxin (BTX) (brand name: Botox) has increased Prosthodontists need to be aware of these reali-
dramatically in the past decade. The anatomical and ties concerning plastic surgery when they tackle the
physiologic reasons for this demand are usually rehabilitation of a patient’s dentition and mouth,
aging or genetic disharmonies in the skeletal sys- especially when functional limitations are appar-
tem or the soft tissue and lip formation. ent from the start. Therefore, if the initial exami-
The dental reasons are: nation reveals that a patient’s lips may have un-

Fig 8-1 Lips of different shapes. No one is identical Fig 8-2 An example of the excessive use of lip fillers
and specific attention should be paid when examining (before and after). Such patients may have unrealis-
a patient’s mouth and smile – both at rest and during tic esthetic expectations. Furthermore, the excessive
function – for the purposes of prosthodontic rehabili- use of fillers and facial surgery may be a sign that the
tations. patient has a low self-esteem, with possible related
psychologic behavioral issues. Hence, during the initial
examination and treatment planning, it is wise to delve
more deeply into these aspects if you perceive them
to be problematic so as to avoid unpleasant misunder-
standings later on.
a b
Fig 8-3 Medication angular cheilitis due to systemic Fig 8-4 Two images showing lip pathologies. a Herpes
corticosteroid use. Often, the causes of this pathol- simplex types 1 and 2. This virus is very contagious,
ogy are not well investigated and the condition is not mostly at the blister stage, and shows an in situ neo-
treated appropriately. plastic lesion at the initial stage. b This patient, a heavy
smoker, attempted to cover a lesion with lipstick.
dergone changes, ask in a sensitive and respectful diagnosed, refer the patient for an immediate con-
way whether any previous lip modifications have sultation with an oral pathologist, dermatologist,
been carried out. Inform such patients about all the otolaryngologist or oral surgeon (Figs 8-1 and 8-2).
related functional and esthetic possibilities and/or
limitations of lip modifications. If a patient is deter- Pathology
mined to undergo plastic surgery, it is wise to main- The lips may suffer from various overlapping local
tain contact with the plastic surgeon in order to find metabolic, viral, and bacterial pathologies, which
a satisfactory solution. There is also well-known lit- need to be diagnosed as soon as possible to avoid
erature in this regard that can be consulted.20 modification and interruption of important lip func-
Inspection of the vermillion border of the lips tions.13,14,21 If a patient has angular cheilitis (Fig
may reveal local color changes, the presence of in- 8-3), this may be due to a loss of VDO, or it may be
flammation, lumps, swellings, and bleeding. These because of medications the patient is taking. Alter-
may be due to reasons such as a harsh climate, the natively, this condition could be due to nutritional
use of cosmetics, fillers, dental materials, and aller- or exfoliative causes, glandularis, Miescher’s cheili-
gens, among others. tis, and amyloidosis, among others.13,14,21
Palpation should be done with care, using an in- Lip lesions may also be caused by generalized
traoral mirror and a 2 x 2-inch gauze to hold the lips. diseases such as herpes, psoriasis, candidiasis,
In the case of lumps or lesions that are not easily pemphigus vulgaris, Osler-Weber-Rendu disease

Vestibular area
a b
Fig 8-5 Lip pathologies. a For the patient, a little mole. b For the clinician, a melanoma in situ in a very sensitive
place, to be removed as soon as possible.
Fig 8-6 Intraoral inspection of the external a upper and b lower lip and labial vestibule.
(OWRD), Stevens-Johnson syndrome, Behçet’s dis- visit is important, as it is crucial to be aware of the
ease, Crohn’s disease, acrodermatitis enteropathica, general health of our patients.13,14,21
systemic lupus erythematosus (SLE), scleroderma, In light of their extremely important anatom-
and syphilis (Fig 8-4). They may also be caused by ical position, multiple functionality, esthetic impor-
cancerous lesions such as leucoplakia, papillomato- tance (especially in our modern world), and possible
sis, basal-cell carcinoma (BCC), keratoacanthoma, pathologies to which they are susceptible, the lips
carcinoma, and melanoma. In such cases, the sooner should be given the appropriate amount of atten-
the lesions are identified and treated, the better (Fig tion during the first and subsequent visits (Fig 8-6).
8-5). Recognizing lip pathologies during the first

Vestibules 3. Slightly posterior to that, you may see and

palpate the Stensen’s duct and its output. You
Cheeks may perceive nodulated calcifications engaging
or obstructing the end part of the canal and its
The cheeks are composed of important anatomical outputting orifice.13
structures such as the skin, the complex and layered 4. In case of doubt, it is always advisable to com-
muscles of facial expression, the two parotid glands, pare the right and left sides of the face to better
and connective and fat tissue. They also comprise perceive any macroscopic differences.
the buccal branches of the facial nerve (CN VII) and
the buccal branches of the mandibular division of
Parotid (salivary) glands
the trigeminal nerve (CN V3), the facial arteries, the
veins with all their subtle ramifications, the lym- Please note that even though these are salivary
phatic system, and the largest part of the oral mu- glands, the others of which are described later in
cosa (the mucous membrane that lines the inside of the chapter, the parotid glands are discussed here
the mouth).1-7,13-18 as they form part of the examination of the cheeks.
Inspection of the oral mucosa of the cheeks can According to the type and quantity of saliva they
be easily performed by introducing the tip of one produce, the overall salivary gland assembly is di-
finger on both sides and then delicately pinching vided into major and minor salivary glands and the
the border of the lips with the thumbs from the out- Von Ebner’s glands (Table 8-2).13
side in order to move the lips aside and see the areas The two parotid glands are the largest of the sal-
you need to examine without a mirror (Figs 8-7 to ivary glands. Their shape is slightly irregular, and
8-9). sometimes they can be slightly different in shape
Palpation of the cheeks can be delicately per- (mainly anteriorly) even in the same person. Never-
formed using two to three opposing fingers outside theless, they fit into the area delimited by the sur-
and inside the mouth, feeling with the fingertips rounding anatomical structures. It is important to
through the inner structure of the cheek to per- locate their position on both sides of the face, which
ceive, differentiate, and examine. is usually:
1. Posteriorly, you should be able to perceive part ●● right in front of the ears;
of the most anterior extension of the parotid ●● below the posterior part of the zygomatic
gland, especially if it is slightly swollen or there processes;
has been a change in its shape, consistency, ●● over the masseter muscles and slightly anterior
and/or sensitivity to palpation.22,23 to them.
2. In the same area, you may sometimes perceive
a swelling of an accessory parotid gland (10.2% Intraoral palpation of normal healthy parotid glands
clinical evidence and 7.7% incidence of all pa- usually does not reveal their location and does not
rotid gland cancer).24,25 allow you to distinguish their body from the overall
muscle, subcutaneous buccal pad fat, buccopharyn-
geal fascia, and arterial-venous-lymphatic assembly.
Table 8-2 Salivary glands You may feel the heartbeat when you palpate in
the area of these glands if you are pressing over the
●● Major salivary glands: parotid, submandibular, transverse facial artery and the superficial temporal
and sublingual and maxillary arteries, branches of the external ca-
●● Minor salivary glands: oral mucosa mucous
rotid artery.3-5,7,14
glands
In the case of swelling of the parotid glands due
●● Von Ebner’s glands
to mumps, or obstruction due to stones (sialoliths)

Vestibules
Pterygomandibular raphe mandibular area Tongue sublingual area
Retromolar pad area
Lingual frenum
Masseter muscle and its

lower internal insertion
area (masseteric notch)
Floor of the mouth area
Buccal vestibule area

Buccal shelf area
Fig 8-7 Inspection of the right internal cheek, buccal vestibules, retromolar pad, and floor of the mouth areas.
and further saliva accumulation into its glandular

parenchyma or its internal or Stensen’s ducts, the
internal hydraulic pressure increases and the swol-
len body of these glands may become very easy to
detect, and their borders easier to delimitate.14,21
Furthermore, in many cases they also become
sensitive to palpation, which is easy to note as the
patient usually grimaces in discomfort or pain.
Comparing the right and left parotid glands may
allow you to perceive differences in volume and
consistency due to possible inflammatory condi-
tions that need to be differentially diagnosed. These
Fig 8-8 Inspection of the left internal cheek, buccal symptoms and signs, including the presence of var-
vestibules, retromolar pad, and floor of the mouth iously swollen lymph nodes, may help you to diag-
areas. nose any current condition.

Maxillary buccal vestibule:

• Zygomatic process
• Retrozygomatic fossa
Stensen’s duct orifice: pierces Internal aspects of the cheeks

the buccinator muscle and out- Mucosa lining: non-keratinized
puts at the second molar area stratified squamous epithelium
Fig 8-9 Extra- and intraoral palpation of the cheek by means of touching, locating, and gently pinching the
anatomical structures inside it.
Floor of the vestibules Oral cavity

The deep concavities of the maxillary and man-
Palate
dibular labial and buccal vestibule floors must be
investigated for possible lesions and lumps of the Examine the two main component parts of the pal-
mucosa or for remaining food, signs of poor oral ate: hard and soft.
hygiene, and/or limited cheek mobility.13,14,17,18
Palpation will determine or verify any perceiva- Hard palate
ble swelling under the mucosa. See whether this is The hard palate is composed of the two palatine
mobile or firm, whether it is a simple inflammation processes of the maxillary bones posteriorly, and of
of the mucous glandular tissue or whether it is due the larger horizontal portions of the palatine bones
to any pathologic lesion.13,14 anteriorly. The mucosa may be lightly and variously
The maxillary and mandibular labial and buccal raised over the midpalatal suture if torus palatinus
frenula must be investigated. Gently pull the lips is present. Anteriorly, the palatine rugae area does
forward or laterally to examine these mucosa folds, not usually show signs of specific pathologies un-
which may also contain muscle insertions that con- less traumatic chewing lesions exist.13,17
tain fibers of the buccinator, levator anguli oris, and
depressor anguli oris muscles. This is of paramount Soft palate
importance when assessing them for the purposes Posteriorly, the soft palate is composed of the two
of a rehabilitation involving removable partial den- pharyngeal walls on both sides that are made up of
ture (RPD) prostheses (Fig 8-10).13,16,21 the palatoglossal folds (anteriorly) and the palato-

Oropharynx and isthmus of fauces
Labial frenum Buccal frenum
Retrozygomatic
fossa
Labial vestibules Labial and buccal vestibules Zygomatic process

a b
Fig 8-10 Examination of the a thin labial and b wide buccal frenum of an edentulous mouth.
pharyngeal folds (posteriorly). The palatine tonsils of complete denture (CD) prostheses. The presence
occur between these folds (Table 8-3).13,17 of a torus palatinus may indicate that the compres-
For anatomic and prosthodontic reasons, the sion in that area needs to be relieved.13,17,18,26-32
hard and soft palate must be clinically inspected and
investigated:13,17,18
Clinically: for possible mucosal lesions, which
may vary from a slight to a more serious pathologic
Oropharynx and isthmus of
inflammation.14,21 fauces
Prosthodontically: a structural evaluation of the The oropharynx is divided into the:
surface of the hard and soft palate should be per- ● nasopharynx;
formed. In addition, the anteroposterior extensions ● oropharynx;
should be examined in the case of RDPs, since the ● hypopharynx.
hard palate is the primary maxillary bearing area
for the major connectors of RDPs, and for the bases The oropharynx is relevant to prosthodontics and
is important to assess. Clinically, it comprises the
wide posterior area of the oral cavity, the central
Table 8-3 Muscles of the soft palate
and lower opening of which is smaller and sur-
The soft palate contains four muscles: rounded by walls that move according to their
● Palatoglossal: the main component of the functions. It is the most posterior part of the oral
palatoglossal arch, anteriorly cavity and is immediately visible when you inspect
● Palatopharyngeal: the main component of the the most posterior part of the palate and the tongue
palatopharyngeal arch, posteriorly (Figs 8-11 and 8-12).13,18
● Levator veli palatini: elevates the soft palate The anatomical composition of the oropharynx
when speaking comprises the soft palate, the posterior third of the
● Tensor veli palatini: tenses the palate when
tongue, the pharyngeal walls, and the pharyngeal
swallowing
tonsils (Table 8-4).

Table 8-4 Anatomical composition and functions of

the oropharynx
● Soft palate and its important and complex

muscles that are active in swallowing, breathing,
and the emission of sounds
● Posterior third of the tongue has the same
anatomical and physiologic functions as the soft
palate
● Pharyngeal walls on both sides – anterior and
posterior pillars, which have the same anatomical
and physiologic functions as the soft palate and
the posterior third of the tongue
● Pharyngeal tonsils are lodged between and are
Fig 8-11 The use of a photographic mirror may partially protected by the anterior and posterior
improve the view of the maxillary arch, palate, and pillars and have an important immunologic
related anatomical structures and therefore speed up
function
the intraoral examination.
Palatine tonsils
Anterior palatine pillars
Pterygomandibular raphe area Hard–soft palate border area
Fig 8-12 Oropharynx area being inspected with the use of a tongue depressor.
10

Oropharynx and isthmus of fauces
It is possible to inspect but not palpate the oro- is often carried out together with the removal of the
pharynx. When swallowing, food and liquid are adenoids.14,33
forced to pass through the ad hoc small-diameter
oropharyngeal transits, to be canalized either into Oropharyngeal cancer
the most posterior smaller esophagus or into the Despite the important role played by the tonsils and
larger-diameter anterior trachea tube, which is then adenoids in protecting our bodies from infection,
immediately closed and sealed off by the epiglottis continuous inflammation of the oropharynx due
valve, as air passes through this way.13,14 to the inhalation of harmful substances, smoking,
For these anatomical and functional reasons, the heavy alcohol use, or infection by the human pap-
oropharynx is continually moving and undergoing illomavirus (HPV) – especially HPV type 16 – may
direct physical stresses.33 In fact, physical stress lead to oropharyngeal cancer, the occurrence of
arises due to the constant temperature changes of which is unfortunately increasing.14,33,34
its superficial mucosa induced by contact with hot According to the March 2018 report of the Na-
and cold food and liquid, which makes this area tional Institutes of Health, National Cancer Institute
more susceptible to acute and chronic inflamma- (NCI),34 the following signs and symptoms are in-
tion. Also, wounds such as scratches or impact indicative of possible oropharyngeal cancer, although
juries expose it to pathogens that may cause local they are similar and often overlap with those of
areas of inflammation, leading to infection and even other types of oral malignancies such as soft palate
precancerous changes.14,33 cancer and tongue cancer:
Medical and dental signs and symptoms: sore
throat that does not go away, trouble swallowing,
Pharyngeal tonsils
ear pain, coughing blood.
It is not by chance that human evolution has de- Extraoral examination: swelling of the SDCN and
veloped the two pharyngeal tonsils and the overall IDCN, which can be ipsilateral or bilateral depend-
Waldeyer’s ring components right at the isthmus of ing on the position and extent of the lesion.
fauces.14,33 Intraoral examination: trouble opening the
Tonsils are immune pillars – two powerful sen- mouth fully, difficulty moving the tongue, a lump
tinels of our immune system. They are the first part in the back of the throat, presence of a white
of the defense barrier against possible pathogens patch on the tongue or lining of the mouth that
that cause general, respiratory, and gastrointesti- does not go away, and evidence of some localized
nal infections. The tonsils induce a cell-mediated bleeding.
immunologic response with B-cells, and a humoral If oropharyngeal lesions are present and can-
immunologic response with antibodies against po- cer is suspected, refer patients immediately to
lio, streptococcus pneumonia, influenza, and a wide their physician, an oral pathologist or an otorhino
range of infectious diseases.14,33 laryngologist. In these cases, the patient should im-
Any inflammation and further possible infection mediately undergo a head and neck computed tom-
of the tonsils (tonsillitis) may result in symptoms ography (CT) scan or magnetic resonance imaging
such as fever, difficulty in swallowing, stinging pain (MRI) to evaluate the extent of the invasiveness of
when swallowing, sore throat, ear pain, voice loss, this pathology as well as a positron emission tomo
and throat tenderness. Also, signs may be seen such graphy (PET) scan to reveal any possible presence
as swelling of the tonsils and of the white mucous and diffusion of malignant cells throughout the
that covers them, swelling of the superior and in- body.
ferior deep cervical nodes (SDCN and IDCN), and From a prosthodontic perspective, any inflam-
their possible bleeding. If the infection becomes mation of the oropharynx may also cause inflam-
chronic, surgical removal is often indicated, which mation and possible swelling of the bordering
11

Anatomy
The anatomy of the tongue is divided into an ante-

rior (oral) and posterior (pharyngeal) portion, sep-
arated by the terminal sulcus of the tongue, ending
at the foramen cecum. The latter is characterized
superficially by the lymphoid follicles that consti-
Lingual tute the so-called lingual tonsils (Fig 8-13).13 It is
tonsils important for immune, digestive, and gustatory rea-
sons to examine this area carefully.
Tongue muscles: The muscles shown in Table 8-5
are used to perform all the movement necessary for
the tongue to assist in chewing, swallowing, and
Fig 8-13 Clinical image of the V-shaped lingual ton- speaking. During any physical examination, the
sils achieved with a long tilted otorhinolaryngologist tongue should be evaluated both at rest and in ac-
mirror, which should be part of your armamentarium.
tion.13,33
Gently hold the tip of the tongue with a 2 × 2-inch
gauze. It is not possible or necessary to palpate the mus-
cles of the tongue; in any case, palpating them indi-
vidually and properly cannot be achieved. Instead,
what is of paramount interest for prosthodontists is
mucosa that lines the anterior pillars of the ptery- to evaluate the working of the tongue and whether
gomandibular raphe, and of the posterior palatal there are any functional deficits present in one or
seal (PPS) area. This may affect the stability and re- more of the muscles.14,17,18,30-32
tention of CD prostheses, and of some types of RPD The blood supply to the tongue arises from the
prostheses, due to an increased local sensitivity and lingual artery, a branch of the external carotid artery.
possible swallowing or speaking difficulties. As the tongue is at high risk of oral cancer, the initial
extraoral examination of its draining nodes is very
important, together with a very attentive intraoral
examination of all the tongue tissue. Any evidence
Tongue of even small swollen nodes (submental, submandi-
It is very important to investigate this organ for the bular or SDCNs) should be further investigated.35
following clinical and prosthodontic reasons: Signs and symptoms of tongue cancer: Further-
1. Due to its sensitivity and the many motor more, if the patient reports symptoms such as a lack
functions it performs, the tongue is clinically of sensitivity or of taste, or signs such as reduced
important. Look for possible inflammatory and/ mobility, this clinical evidence may also be related
or pathologic lesions affecting its functionality to neoplastic lesions, which might in some way af-
and health.13,21 fect the nerve supply of the tongue (see red box on
2. The tongue, together with the lips, is a major the next page).
site of oral cancer.13,21
3. Prosthetically and biomechanically, any ab- Table 8-5 Muscles of the tongue
normal alteration of the shape, condition, and/
● Extrinsic tongue muscles: hyoglossus,
or functioning of the tongue may significantly
genioglossus, styloglossus, palatoglossus
affect the stability of any RPD or CD prosthe-
● Intrinsic tongue muscles: superior and inferior
sis.26-29 longitudinal, transverse lingual, vertical
12

Tongue
2. Check its dimensions, as they may destabilize

Tongue nerve supply
A. Motor: hypoglossal nerve (CN XII). any CD prosthesis. An unusually large tongue
B. Taste: epiglottic part, the superior laryngeal branch (macroglossia) may barely fit into the availa-
of the vagus nerve (CN X). ble space once an implant or CD restoration
1. Posterior third: glossopharyngeal nerve (CN IX). has been delivered, and may cause further CD
2. Anterior two-thirds: chorda tympani, a branch instability and/or lateral tongue biting. An unu-
of the facial nerve (CN VII). sually small tongue (microglossia) can result in
C. Sensitivity: epiglottic part, the superior laryngeal the tongue not being able to properly stabilize a
branch of the vagus nerve (CN X). mandibular CD, with all the related biomechan-
1. Posterior third, glossopharyngeal nerve (CN IX). ical problems during chewing and speaking, as
2. Anterior two-thirds: lingual nerve, from the
it might not be able to assist well during these
mandibular trigeminal nerve (CN V).
functions.
3. Using a 2 x 2-inch gauze, gently and firmly
grasp the tip of the tongue and pull it slightly.
Examination of the tongue Then move the tongue sideways in both direc-
tions to check the anatomy of its lateral bor-
The clinical intraoral examination of the tongue can ders. Look for possible changes in the color of
be easily performed following four main steps: the mucosa as well as scars, inflammation, and/
1. Gently ask the patient to open the mouth and or pathologic lesions.
protrude the tongue. Inspect its dimensions and 4. Ask the patient to open the mouth wide and
mobility, being alert to any possible tremor or raise the tip of the tongue toward the palate
deviation from the midline. This information so that you can check the lingual frenum. Also
will tell you immediately whether there are check if there are one or more mucosal folds,
functional problems of any extrinsic or intrin- the level of their insertion at the alveolar ridge
sic tongue muscles. Also, this may show if the and under the tongue base, and their dimen-
tongue is a so-called ‘shy little tongue,’ often sions, as this may also be important in terms
accompanied by a short lingual frenum, which of RPD prostheses due to prosthetic structural
might be a serious problem for the stability of configurations and for biomechanical stability
CD prostheses. and retention (Figs 8-14 to 8-17).
a b
Fig 8-14 Tongue with a a wide multifolded frenum and b a small short lingual frenum preventing and limiting
the normal range of tongue movement.
13

a b
Fig 8-15 Both macroglossia and microglossia are major problems for the stability and retention of CD pros-
theses and of Kennedy Class I and II RPD prostheses. a In this case of macroglossia, the tongue was so volumi-
nous that it affected the interarch distance. b In this case of microglossia, the patient had a very short frenum
that reduced the mobility of the tongue.
a b
Fig 8-16 a and b Inspection of the borders of the tongue, the site of possible masticatory and cancerous lesions.
Fig 8-17 Tongue verrucous lesion that

may degenerate and should be surgi-
cally removed. Postoperative histologic
examinations showed how, deep inside
these lesions, degenerative changes may
develop. Therefore, their removal is usu-
ally strongly suggested and performed
to avoid more serious invasive problems
developing.
14

Floor of the mouth
Floor of the mouth porting and peripheral seal tissues for retention and
stability purposes.14,17,18,31-33
Ask the patient to raise the tongue so you can care- Always follow the same method to check the
fully check the floor of the mouth for possible mu- floor of the mouth so you can easily memorize the
cosal lesions (Figs 8-18 and 8-19).13,14,33 procedure and will be able to inspect the anatomical
The inspection and palpation of this anatomic features step by step (see red box on the next page).
structure may be of clinical interest. If a specific
lump or swelling is present, check its consistency
and whether it is movable or painful.13,14,33,35
Besides the clinical interest and search for possi-
ble pathologies, the shape and position of the floor
of the mouth is relevant to the prosthodontist in
terms of the dimensions of the lingual flanges of
the resin bases for the stability and support of RPD
and CD prostheses. Also thoroughly check the sup-
Mylohyoid muscle
Anterior insertion areas
Submandibular
gland area
Sublingual gland area and

the ducts of Rivinus
Caruncles: two submandibular

and two sublingual Warthon’s
Premylohyoid fossae
and Bartholin’s ducts
Fig 8-18 Floor of the mouth. The severely resorbed mandibular edentulous alveolar ridge allows for an excellent
panoramic view of many important anatomical and prosthodontic landmarks that are otherwise impossible to
see as clearly.
15

Premylohyoid fossae Outputs of two caruncles: Warthon’s

and Bartholin’s salivary ducts
Superior genial tubercles area
Fig 8-19 Extreme resorption and destruction of an edentulous mandibular alveolar ridge, and exceptional visi-
bility of the superior part of the genii tubercles touched gently with a T burnisher.
Floor of the mouth inspection guidelines

A. Lateral part of the floor: move the tongue medially with a mirror and gently and inspect the:
1. Premylohyoid fossae: dimensions, mucosa, color, and depth.
2. Mylohyoid ridges: the entire insertion of the anteroposterior mylohyoid muscle, its position, depth,
color, and the overlying mucosa.
3. Retromylohyoid fossae: its dimensions, depth, color of the mucosa, and possible inflammations and
pathologies. Remember that the rounded posterior vertical wall of this fossa (the retromylohyoid
curtain) is very important in CD prosthesis rehabilitations. It contains three important muscles:
a. Superior pharyngeal constrictor (posterolateral).
b. Palatoglossus (posteromedial).
c. Mylohyoid (medial).
B. Central part of the floor: ask the patient to raise the tongue so you can gently inspect the:
1. Sublingual caruncles: dimensions, mobility, mucosa, color, and ability to secrete saliva. Any swelling
or obstruction present is sometimes due to little whitish cysts called ranulas (sublingual glands).
2. Lingual frenum (one or more): length, width, color, insertion width, and distance from the adherent
gingiva.
3. Genial tubercles: visibility, and relationship to the dentulous or edentulous ridge.
16

Salivary glands
Salivary glands posterior lateral insertions and the posterior border

of the mylohyoid muscle that divides a superficial
The two parotid glands have been previously de- larger portion or lobe that lies over it, and a smaller
scribed in this chapter as a part of the examination deep portion that lies under it.
of the cheeks. Their position is limited: laterally by the body of
Both the inspection and the palpation of the the mandible, medially by the upper portion of the
submandibular and sublingual glands are briefly de- trachea, anteriorly by the mylohyoid muscle, and
scribed below for semiotic purposes. For anatomical inferiorly by the connective tissues and the sub-
reasons, only the inspection of the minor salivary mandibular skin layers.13,14,33
glands and the Von Ebner’s (gustatory) glands is Palpation: The submandibular salivary glands
described.13,14,33 can be partially palpated extraorally and intraorally
because on both sides they embrace the posterior
border of the mylohyoid muscle. Extraorally, only
Submandibular salivary glands
their lower surface can be perceived, and then with
The submandibular salivary glands are the smallest some difficulty (unless they are swollen due to an
of the major salivary glands, with two large excre- inflammatory process). Intraorally, they can be pal-
tory ducts as well as a few smaller ones. They occur pated by inserting the fingertips on both sides of the
anteriorly and on both sides of the lingual frenum, tongue at the level of the mandibular molars. Then,
posterior to the two Wharton’s ducts (submandib- follow the floor of the mouth posteriorly over the
ular), that then continue anteriorly into the two mylohyoid muscle until you feel their upper lobes.
Bartholin’s ducts (sublingual), and finally drain into Practice and experience are necessary in order to
the two final outputs of the sublingual c aruncles perform this procedure successfully.13,14,33
(Fig 8-20).13,33 Pathology: Apart from producing the most saliva,
These glands are located under the floor of the the submandibular salivary glands are extremely
mouth, in front of two slight concavities or depres- vulnerable to the pathology of sialoliths (stones) –
sions on the right and left (anteroposterior) internal the highest percentage (about 80%) of all sialoliths
sides of the body of the mandible, called the sub- produced in the salivary glands are found in the
mandibular gland fossae. Their body hooks the most submandibular salivary glands.13,14,33
Sublingual salivary glands

These are located anteriorly in the two sublingual
fossae, in front of the submandibular glands, just
below the two mandibular canines/first premolar
area, over and in front of the anterior end of the
mylohyoid muscle. They are the smallest of the ma-
jor salivary glands with two large ducts, the Bartho-
lin’s sublingual ducts, and a few other small excre-
tory ducts, the ducts of Rivinus, that instead open
directly into the oral cavity, on both sides of the
lingual frenum in the floor of the mouth.
The other two Bartholin’s sublingual ducts and
their mucous saliva join the two submandibular
Fig 8-20 Gentle intraoral palpation of the area of the Warthon’s ducts that come from the submandibular
superior part of the submandibular salivary gland. glands, with their more liquid saliva, more anteri-
17

orly and medially in the floor of the mouth. Finally, Usually, these salivary stones are composed of
they both drain into the oral cavity, with their mixed calcium phosphates and carbonates. Patients af-
type of saliva flowing out into the two right and left fected by sialolithiasis may then suffer from vari-
outputs, called the sublingual caruncles.17,18,37 ous pathologies such as salivary cramping that can
Palpation: The sublingual glands can be palpated occur when eating. This is when the production of
from the front or the side of the patient. Introduce saliva increases and may elicit sudden painful sen-
the tip of an index finger just behind each man- sations and swelling of the gland. Usually, these
dibular canine, in front of the mylohyoid muscle on episodes tend to regress spontaneously during the
both sides, into the sublingual fossa (premylohyoid following hours, and if the stone is small enough it
fossa), gently pressing downward. At the same time, can be excreted immediately during an episode or
gently press extraorally with another finger upward later after other episodes. Failing this, minor sur-
over the skin of the corresponding area, under the gery can be performed depending on the position of
mandible and behind the mental protuberance. In the stone. If the stone is deeply lodged, it is strongly
this way, it is possible to feel the dimensions of the advised to refer the patient to an experienced oral
glands that will now be delicately pinched between surgeon or otolaryngologist to avoid further severe
the internal and external fingertips (Fig 8-21).4,7,14,33 iatrogenic postsurgical lesions.36,37
Pathology: The most common clinical problem
relating to these little salivary ducts are ranulas,
Minor mucous salivary glands
which are whitish concretions that may obstruct
the ducts of (usually) one of the two caruncles, thus These glands (there can be up to 1000 of them) are
inducing a mucous reflux that may enlarge the cor- located all over the oral cavity within the submu-
responding ipsilateral gland. cosa. They are surrounded by connective tissue and
have dimensions not exceeding 2 mm. They are
mainly mucous glands that excrete mucous onto the
overlying oral mucosa by means of a single or dou-
ble excretory duct in common with another gland.
Clinically, they are not affected by major patholo-
gies, but their mucous production may be signifi-
cantly affected by age, drugs or medications that the
patient may be taking, and by any problem affecting
the functioning of the facial nerve (CN VII) that in-
nervates them.13,14,33
Dryness: A reduction of the mucous in these minor
salivary glands may create problems of oral dryness,
which results in a reduction of the amount of mu-
cous film under the RPD prosthesis base and, in turn,
a reduction of the interfacial surface tension that the
base helps to create. This may dramatically reduce
the retention and stability of CD prostheses.31,32
An inspection of the oral mucosa will immedi-
Fig 8-21 Intraoral palpation of the sublingual salivary ately show if it is dry. In this case, questions about
gland. Gentle vertical exploration using the index fin-
patients’ age and possible drugs or medications
ger over the right part of the floor of the mouth and in
the right premylohyoid fossa, while the thumb, or the they may be taking are relevant in order to establish
index finger of the other hand, holds and (if necessary) the reason for these glands not producing enough
pinches the opposite external submental skin area. mucous (Table 8-6).38-41
18

Salivary glands
Table 8-6 Saliva production Signs: In most cases they swell and become more
visible and palpable.
●● The submandibular salivary glands are the
Symptoms and pathologies: Patients often com-
primary producers of the saliva that is excreted
into the oral cavity, producing about 55% to 65% of plain about a range of symptoms, from fever to
both the mucous and serous saliva swelling to a sense of tension and pain similar to
●● The two serous parotid glands are the secondary that experienced with mumps. Mild or more extreme
producers of saliva, producing about 25% to 35% of xerostomia may occur in cases of different types of
the saliva produced acute obstructive sialadenitis, while xerostomia and
●● The two mucous sublingual glands produce pain may occur in chronic sialadenitis pathologies
some 3% to 5% of the remaining amount of such as Godwin’s syndrome, Mikulicz syndrome,
saliva17,37 and Sjögren’s (autoimmune) syndrome.14,38-41
The salivary glands may also be afflicted by be-
nign or malignant neoplastic lesions. This is rare,
occurring in three cases out of 100,000 per year. The
malignancy represents 3% to 5% of head and neck
cancers and usually affects people of 60 to 70 years
of age.14,33,36
Von Ebner’s glands In the case of cancer, surgery is usually pre-
ferred although it is extremely difficult to perform
Also called the Ebner’s glands or the gustatory successfully as it takes a great deal of experience,
glands, these are serous glands located near the ter- skill, and knowledge of that anatomic region. Often,
minal sulcus of the tongue, in the moats around the residual lesions may occur on the facial nerve (pa-
eight to ten circumvallate papillae and the numer- rotid glands), lingual nerve, and hypoglossal nerve
ous foliate papillae.13 (submandibular and sublingual glands), with their
related negative clinical consequences and func-
Function tional limitations.
The function of the serous produced by the Von Eb-
ner’s glands is related to lipid hydrolysis that plays
a role in the initial perception of taste by means of
digestive enzymes such as lingual lipase and pro-
teins. Their action occurs around the circumval-
late papillae, where a large number of taste buds
are located and where they excrete their enzymes
to dissolve food. They are innervated by the glos-
sopharyngeal nerve (CN IX).14,33 Prosthetic implications of salivary gland
Clinically, their serous production can be af- pathologies
fected by drugs or medications, while prosthetically Depending on whether they are temporary or
their activity has a limited value due to their posi- permanent as well as their symptoms and course
tion far back on the tongue.38-41 of development, most salivary gland pathologies
affect a patient’s ability to successfully wear RPD
and CD prostheses in terms of fit, stability, and
Clinical conditions of salivary retention. Apart from various degrees of xeros-
glands tomia, there is always the possibility of the post-
Clinically, a number of conditions may affect the surgical outcome being invalidated or of compli-
salivary glands. cations arising.
19

Alveolar arches and teeth Occlusal treatment planning is based on an eval-

uation of existing conditions and the potential for
All periodontal and dental anatomical, functional, treatment as well as a knowledge of certain physical
and clinical information necessary to describe how laws and biologic principles governing the control
to plan a treatment is presented in Chapter 15 in of stress on the stomatognathic system.44,45,48
each of the reported case presentations. The intraoral occlusal examination should aim
to:
●● give you information about the medical,
dental, and prosthodontic history of the
Occlusion patient;
The description of the vast topic of the occlusal ●● evaluate a number of anatomical factors based
intraoral examination is limited here to the syn- on objective physical, biologic, and biome-
thesis of those concepts that should not be over- chanic findings, and any further clinical evi-
looked during prosthodontic treatment planning. dence encountered in the examination;
As mentioned previously, the aim of describing ●● analyze the radiographic examination per-
the intraoral examination in this chapter is to me- formed during or after the clinical examination
thodically evaluate the most important features that to better understand and assess the limitations
should be taken into consideration during the first of the patient’s system;
visit and in later examinations. ●● try to eliminate occlusal, muscular, and/or TMJ
Occlusion has been defined as “part of a dynamic stress by achieving a more correct and even
system that changes all the time,” and also “the re- distribution of occlusal loads.
lationship that exists between the maxillary and
mandibular dental arches.” 43-47 The occlusal system Inspection and palpation: At chairside, begin by
is composed of three interrelated anatomical and reviewing with the patient the evaluation ques-
functional determinants that work together in har- tionnaire that has been completed. Discuss any
mony as part of the same dynamic system called the occlusal problems that have been mentioned, de-
occlusion (Table 8-7). scribed, and recorded in the patient history data.
During the first visit, the components of the Therefore, during the extraoral and intraoral oc-
occlusal system should be evaluated. Be alert to clusal examinations, you have an opportunity to
possible pathologies and functional disharmonies verify and clinically assess any pathology or dys-
in order to fulfill the aims of restorative treatment function by assessing any clinical evidence of pos-
planning.42,43 sible occlusal conditions (see the numbered points
below).49-82
When you formulate the treatment plan you
should already have answers to questions about the
patient’s occlusion in terms of:
Table 8-7 Components of the occlusal system
A. With the mandible at rest:
●● Anterior determinant: namely, the position of 1. Whether the patient has been or is
the maxillary and mandibular dentition and the suffering head, neck or shoulder pain or
way the jaws meet and articulate one another discomfort.
●● Posterior determinant: the form and functioning 2. Whether there is any degree of clenching
of the two temporomandibular joints (TMJs)
or bruxing or any other parafunctional
●● Neuromuscular determinant: all the muscles
occlusal habit.
involved in the movement of the mandible and in
the chewing function
3. State of the upper and lower lip
posture.
20

Occlusion
4. Whether there is TMJ pain or discomfort at (CR) (use of a thin articulating ribbon/
rest, and, if so, its specific location. paper).
5. Evidence of normal trophism or hyper- 7. Assessment of the direction of the applied
throphism of some or all of the masticatory occlusal forces on the mobile teeth when
muscles. closing and biting.11
6. Skeletal class of the patient (Angle’s classi- 8. Type of anterior guidance in protrusion
fication). (one or more teeth and their timing order).
7. Characteristics of the curves of Spee and 9. Type of lateral guidance on the working
Wilson. side (canine, group function).
8. Number of missing teeth and their strategic 10. Disclusion or lateral interferences on the
position on the arch. nonworking, balancing side, and which
9. Presence or absence of tooth migration. teeth are involved.
10. Presence or absence and degree of tooth
mobility.
Radiographic examination
11. Presence or absence of proper occlusal
surfaces of faulty restorations. How can we know, if we can’t see? This could be the
12. Presence or absence and number of wear motto of radiologists. But it is true – the dental ra-
facets. diographic examination allows us to see, analyze,
13. Presence or absence of broken or cracked measure, highlight, integrate, and understand what
teeth. cannot be seen clinically.
14. Presence or absence of interproximal The radiographic examination has to be con-
contact areas. ducted methodically, evaluating step by step the
15. Presence or absence of any periodontal several features you need to investigate to confirm
disease (which may create loss of the or modify what you have found during the clinical
alveolar bone and therefore loss of tooth examination. Although the advances in technol-
stability and support). ogy have resulted in the most sophisticated three-
B. With the mandible in motion, and then while dimensional (3D) radiographic tools being available
occluding and discluding: to us today, such as cone beam computed tomo
1. Presence of any TMJ, skeletal, and/ graphy (CBCT), basic guidelines are useful and
or neuromuscular problem limiting the helpful for this diagnostic and treatment planning
range and freedom of any mandibular endeavor.
movement. The American Dental Association (ADA) has
2. Presence or absence and location of TMJ or set such guidlines.83,84 In its 2012 report, Dental
dental pain or discomfort during function. Radiographic Examinations: Recommendations for
3. Presence or absence of abnormal occlusal Patient Selection and Limiting Radiation Exposure,85
sounds when opening or closing and/or the ADA stated that the use of radiographs is rec-
when biting. ommended in a number of cases in which possible
4. Presence or absence of any occlusal insta- ongoing conditions or infectious processes need to
bility. be understood. Therefore, clinical prosthodontic
5. Presence or absence of concomitant con- situations for which radiographs may be indicated
tacts and their value while occluding. include but are not limited to:
6. Where the tooth and cusp incline is first A. Positive historical findings:
perceivable (by the patient) and visible 1. Previous periodontal or endodontic
(to you) while occluding in maximum treatment.
intercuspation (MIP) and centric relation 2. History of pain or trauma.
21

3. Familial history of dental anomalies. In addition, these radiographs may be used

4. Postoperative evaluation of healing. to achieve diagnostic and therapeutic goals. Par-
5. Remineralization monitoring. ticularly in dental implant therapy for edentulous
6. Presence of implants, previous implant- patients, radiographs are an important aid to di-
related pathosis or evaluation for implant agnostics, prognostics, and the determination of
placement. treatment complexity.86,87 Therefore, an individu-
B. Positive clinical signs/symptoms: alized radiographic examination based on clinical
1. Clinical evidence of periodontal disease. signs, symptoms, and the treatment plan is recom-
2. Large or deep restorations. mended.
3. Deep carious lesions. Therefore, apart from the abovementioned rea-
4. Malpositioned or clinically impacted sons, in the case assessment of a prosthodontic case,
teeth. radiographs are useful to evaluate the presence or
5. Swelling. absence of the following features:
6. Evidence of dental/facial trauma. A. Skeletal features to be considered during the
7. Mobility of teeth. assessment and planning:
8. Sinus tract (fistula). 1. Abnormal development of the maxilla and
9. Clinically suspected sinus pathosis. mandible.
10. Growth abnormalities. 2. Intraosseous tumors.
11. Oral involvement in known or suspected 3. Systemic conditions affecting bone metab-
systemic disease. olism.
12. Positive neurologic findings in the head and 4. TMJ anatomical abnormalities.
neck. 5. Elongation of the styloid process (Eagle’s
13. Evidence of foreign objects. syndrome).
14. Pain and/or dysfunction of the TMJs. 6. Orbital floor.
15. Facial asymmetry. 7. Nasal floor.
16. Abutment teeth for fixed dental prostheses 8. Infraorbital foramens.
(FDPs) or RPD prostheses. 9. Maxillary tuberosity.
17. Unexplained bleeding. 10. Pterygoid plates.
18. Unexplained sensitivity of teeth. 11. Nasopalatine canal.
19. Unusual eruption, spacing or migration of 12. Zygomatic bones.
teeth. 13. Anterior superior alveolar canals.
20. Unusual morphology, calcification or color 14. Posterior superior alveolar canals.
of teeth. 15. Lingual foramens.
21. Unexplained absence of teeth. 16. Incisive canals.
22. Clinical erosion of teeth. 17. Genial tubercles.
23. Periimplantitis. 18. Mylohyoid undercuts.
19. Inferior alveolar nerve canals.
In the case of clinical examination for the possible 20. Mental foramens.
prosthodontic care of a dentate or partially den- 21. Retromolar foramens.
tate adult, the ADA has approved bitewing and/ 22. Sublingual fossae.
or a full-mouth series of periapical and/or panorex 23. Lingula of ascending ramus.
radiographs. Together with other extraoral radio- B. Dental arch features to consider during the
graphs, the possible and eventual presence of dental assessment and planning:
diseases and periodontal conditions may need to be 1. Missing teeth (presence of edentulous
confirmed or assessed. areas).
22

Occlusion
2. Bony spicules along the edentulous alveolar ning as it relates to the occlusion:
ridge. 1. Lateral cephalometric hard tissue cranial
3. Cysts. landmark assessment (Fig 8-22).
4. Pneumatization of the sinuses. 2. Lateral cephalometric soft tissue cranial
5. Maxillary sinus and its proximity. landmark assessment (Fig 8-23).
6. Root proximity. 3. Lateral cephalometric cranial planes
7. Root proximity with mandibular canal. assessment (Fig 8-24).
8. Fused roots. 4. Lateral cephalometric cranial angles
9. Root hemisections. measurement (Fig 8-25).
10. Implants. 5. Lateral cephalometric soft tissue assessment
11. Salivary calculus. (Steiner’s S-line) (Fig 8-26).
12. Abnormal tooth positioning (mesialization, B. Growth and development of occlusion.
distalization, infrarotation). C. Missing teeth, and healing bone situation.
13. Tooth supraeruption, infraeruption. D. Teeth with periodontal problems.
14. Widened periodontal ligament (PDL). E. Teeth tilting, infrarotation, abnormal
15. Bone loss (horizontal, vertical, pattern). positions.
16. Absence of lamina dura. F. Teeth supraeruption.
17. Attachment loss. G. Interproximal cortical bone loss.
18. Caries. H. Amount of bone loss.
19. Calculus. I. Crown-to-root ratio of all teeth, specifically of
20. Periodontal pocketing. the mobile teeth.
21. Angular bony defects. J. Widening of PDL and its degree.
22. Furcation involvement. K. Presence or absence of interproximal
23. Residual cysts. contacts.
24. Possible root fractures (presumed, and to L. Curve of Spee variations.
assess). M. Overjet, overbite.
25. Endodontic filling.
26. Periapical radiolucency. The presence of all these radiographic features, if
27. Possible fistulous tract (gutta-percha they exist, may be clinically assessed. Such an as-
cone). sessment will certainly influence the choices made
28. Apical granuloma. and direction decided upon for the treatment plan-
29. Residual infections. ning. It will also allow for better customization of
30. Residual roots. the treatment according to the patient’s needs and
31. Defective amalgam or composite restora- the clinical possibilities of the case. The lateral
tions. cephalometric soft tissue evaluation (see Figs 8-22
32. Crown-to-root ratio. to 8-25) may allow you to assess and define the po-
33. Defective FDPs. sition of the upper and lower lips as they relate to
34. Post and cores. the lower profile of the nose and the profile of the
35. Open contacts. chin. Balanced faces show that the labrale superior
(Ls) and labrale inferior (Li) points of the upper
During treatment planning, the radiographic ex- and lower lips should touch the Steiner’s S-line
amination with regard to the occlusion may be use- (Fig 8-26), otherwise they may fall into the catego-
ful and helpful in the assessment of the following ries of lips that are too recessive or too retrusive.
examinations and clinical evidence:61-63,65-70,88-96
A. Cephalometry of prosthodontic treatment plan-
23

Po
ANS
Ba
PTM A
PNS
Pr
Is
Go
Ir
Pog
Gn
M
Fig 8-22 Traditional lateral cephalometric hard tissue cranial landmarks according to Steiner’s analysis.
[G: Glabella; N: Nasion; S: Sella; Po: Porion; O: Orbitale; ANS: Anterior nasal spine; PNS: Posterior nasal spine;
PTM: Pterygomaxillary fissure, pterygomaxillare; A: Point A, subspinale; Pr: Prosthion, superior prosthion, supradentale;
Is: Incision superius; Ir: Infradentale; B: Point B, supramentale; Pog: Pogonion; Gn: Soft tissue gnathion; M: Soft tissue
menton; Go: Gonion; Ba: Basion]
24

Occlusion
Tr
Pn
Sn
Sls
Ls
St
Li
Ils
Pog
Gn
Me
Fig 8-23 Traditional lateral cephalometric soft tissue cranial landmarks according to Steiner’s analysis.
[Tr: Trichion; G: Soft tissue glabella; N: Nasion; Pn: Pronasale; Sn: Subnasale; Sls: Superior labial sulcus; Ls: Labrale
superior; St: Stomion; Li: Labrale inferior; Ils: Inferior labial sulcus; Pog: Pogonion; Gn: Soft tissue gnathion;
Me: Soft tissue menton; C: Cervical point]
25

N
e
l bas
r cr ania
Anterio
S
Po Frankfurt horizontal
Palatal ANS
PNS
Occlusal
Go
Man
dibu
lar
Gn
Fig 8-24 Traditional lateral cephalometric cranial planes according to Steiner’s analysis. A mean difference
of 2 degrees angulation between angle SNA (average measurement 82 degrees) and angle SNB (average
measurements 80 degrees) should be considered for a normal occlusion. [N: Soft tissue nasion; S: Sella; Po: Porion;
O: Orbitale; ANS: Anterior nasal spine; PNS: Posterior nasal spine; Go: Gonion; Gn: Gnathion]
26

Occlusion
75°
S
77°
SNA
SNB
Fig 8-25 Lateral cephalometric SNA/SNB angles to study the facial profile and facial support.
[N: Soft tissue nasion; S: Sella; A: Point A, subspinale; B: Point B, supramentale]
27

Lips too
recessive
Lips too
protrusive
Steiner’s S-line
Lips balanced
Fig 8-26 Lateral cephalometric Steiner’s S-line.
28

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31

CHAPTER NINE
Main clinical examination
assessment questions
153
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9 Main clinical examination assessment questions
Proper planning, evaluation forms, strict protocols, During the extraoral and intraoral examinations
and working guidelines have always been the key to and the overall evaluation of the case, a number
success in all human activities, procedures, and op- of questions arise that require answers. It is ne-
erations. An example of a questionnaire in the med- cessary to take systematic notes, which can be
ical field is the Cornell Medical Index (CMI).1 Since more effectively done using lists of organized
the development of the CMI, many others have been questions. The lists below summarize the con-
developed and used, including in the dental medical tent of the previous chapters in terms of evalu-
field.2-16 These questionnaires, with their specially ation and treatment planning. With the answers
formulated questions, are designed to help clinicians to these questions in hand, the prosthodontist
to investigate a number of topics and to gather all has a more objective and comprehensive pic-
the relevant personal and medical information from ture of the details of the case. The prosthodontist
the patient. This is necessary in order to: can then assess the issues and limitations of the
● assess the current health status of the patient; case, rationalize a list of priorities that can solve
● make a proper diagnosis; the patient’s problem/s step by step, and write a
● plan the treatment to solve the patient’s prob- treatment plan with the aim of rehabilitating the
lem/s and rehabilitate the patient. patient.
Clinical extraoral examination
A. Clinical extraoral head and face examination form (inspection)

1. Head form: ( ) rounded ( ) oblong ( ) flattened ( ) oval
2. Head posture: ( ) upright ( ) tilted
3. Head symmetry: ( ) symmetric ( ) asymmetric
4. Facial type: ( ) round ( ) oval ( ) square ( ) triangular
5. Facial symmetry: ( ) symmetric ( ) asymmetric
6. Facial profile (Rickett’s plane): ( ) convex ( ) normal–straight ( ) concave
7. Lower to upper facial height: ( ) short ( ) equal ( ) long
8. Nose size: ( ) small ( ) medium ( ) large
9. Nose symmetry: ( ) symmetric ( ) asymmetric
10. Breathing: ( ) mouth ( ) nose ( ) both
Additional esthetic facial analysis assessment questions

1. Lips – symmetry to midline: ( ) symmetric ( ) right _________ mm ( ) left _________ mm
2. Lips – action: ( ) competent ( ) potentially competent ( ) incompetent
3. Upper lip dimensions: ( ) full ( ) adequate for face ( ) thin
4. Lower lip dimensions: ( ) full ( ) adequate for face ( ) thin
5. Upper lip shape: ( ) curved ( ) straight ( ) short ( ) medium ( ) long
6. Lower lip shape: ( ) thin ( ) normal ( ) thick ( ) everted ( ) behind upper lip ( ) in front of upper lip
7. Mental sulcus: ( ) shallow ( ) normal ( ) deep
8. Nasolabial angle: ( ) < 90 degrees ( ) 90 degrees ( ) > 90 degrees
9. Presence of fillers: last time _________; amount ( ) optimal ( ) not acceptable
10. Tooth exposure at rest: maxillary _________ mm; mandibular _________ mm
11. Tooth display: ( ) natural ( ) prosthetic
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Clinical extraoral examination
12. Tooth length: ( ) adequate ( ) short ( ) long

13. Tooth color (use your personal shade guide for the assessment): _________
14. Maxillary diastema: ( ) none ( ) yes Where? _________
15. Mandibular diastema: ( ) none ( ) yes Where? _________
16. Interpupillary line vs maxillary occlusal plane: ( ) parallel ( ) canted: right ( ) canted: left
17. Interlabial space at rest: _________ mm
18. Lips – smile line: ( ) high ( ) medium ( ) low
19. Maxillary split philtrum groove (SPG): ( ) present ( ) light ( ) absent
20. Maxillary gingival display on smiling: _________ mm
21. Mandibular gingival display on smiling: _________ mm
22. Maxillary midline: ( ) correct ( ) right _________ mm ( ) left _________ mm
23. Mandibular midline: ( ) correct ( ) right _________ mm ( ) left _________ mm
24. Buccal corridor at smile: ( ) absent ( ) bilateral present: ( ) right ( ) left
25. Maxillary labial frenum: ( ) visible ( ) not visible
B. Clinical extraoral temporomandibular joint (TMJ) examination form

(inspection + palpation)
A. Muscles
1. Muscle trophism: Masseter – hyper: ( ) right ( ) left; hypo: ( ) right ( ) left
Temporalis – hyper: ( ) right ( ) left; hypo: ( ) right ( ) left
2. Muscle tenderness at rest: Masseter ( ) right ( ) left Temporalis ( ) right ( ) left
3. Muscle tenderness on palpation: Masseter ( ) right ( ) left Temporalis ( ) right ( ) left
4. Muscle soreness on palpation: Masseter ( ) right ( ) left Temporalis ( ) right ( ) left
Joint ( ); trigger point? _________
5. Muscle pain on palpation: Masseter ( ) right ( ) left Temporalis ( ) right ( ) left
Joint ( ); trigger point? _________
B. TMJ
1. TMJ palpation: Tenderness ( ) right ( ) left Soreness ( ) right ( ) left
Pain ( ) right ( ) left; trigger point? _________
2. TMJ direction on opening: ( ) Normal Deviated ( ) right ( ) left _________ mm
Deflected: ( ) right ( ) left _________ mm
3. TMJ direction on closing: ( ) Normal Deviated ( ) right ( ) left _________ mm
Deflected: ( ) right ( ) left _________ mm
4. TMJ limited excursive movement: ( ) Opening _________ mm ( ) Protrusion
Lateral ( ) right ( ) left
5. TMJ sensitivity at rest: ( ) Normal Tenderness ( ) right ( ) left Soreness ( ) right ( ) left
Pain ( ) right ( ) left
6. TMJ sensitivity on mouth opening: Tenderness ( ) right ( ) left Soreness ( ) right ( ) left
7. TMJ sensitivity on mouth closing: Tenderness ( ) right ( ) left Soreness ( ) right ( ) left
8. TMJ sounds on mouth opening: Click on ( ) right ( ) left Crepitus on ( ) right ( ) left
Pain on ( ) right ( ) left
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9. T MJ sounds on mouth closing: Click on ( ) right ( ) left Crepitus on ( ) right ( ) left

Pain on ( ) right ( ) left
10. Masticatory pain: Bite in maximum intercuspation position (MIP) ( ) right ( ) left
Bite on a cotton roll ( ) right ( ) left
The functional evaluation of muscle pain for the c linicians to become experts at TMJ examination, a
superior, inferior, and lateral pterygoid muscles can- number of important TMJ and occlusal references
not be done properly by simply palpating them. For are discussed in this book.
this reason, and due to the significant difficulties for
Clinical intraoral examination
Oral mucosa evaluation
This evaluation of the oral soft tissues is especially examination for prosthetic rehabilitation. Never-
requested for cancer examination as well as for theless, it should always be performed before any
complete denture and removable partial denture dental examination.
A. Oral and pharyngeal cancer evaluation
History
Usually, these patients may describe:
1. the sensation that something is stuck in their throat when swallowing or other difficulty in
swallowing;
2. ear pain that occurs on one side only;
3. unexplained numbness of the mouth or lips;
4. hoarseness or a sore throat that does not resolve within a few weeks.
Clinically
A. Characteristics of long-lasting signs and symptoms.
1. Color:
a. Red, white, brown or black discoloration of the soft tissues of the mouth.
2. Shape:
a. A lump or thickening that develops in the mouth.
b. A lump or hard spot in the tissue, usually on the borders of the tongue (induration).
c. A painless, firm lump on the outside of the neck that has existed for at least 2 weeks.
d. A growth (tissue raised above the tissue surrounding it) (exophytic).
Activity:
1. Any abnormal bleeding on touching.
2. Any sore or ulceration that does not heal within 14 days.
3. Any sore under a denture that does not heal even after adjustments have been performed.
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B. Lips evaluation
1. Presence of scars: ( ) upper ( ) lower ( ); wounds: ( ) upper ( ) lower ( ) Type: _________
2. Presence of moles between the vermillion border and the skin: ( ) upper ( ) lower
3. Upper lip vermillion border: ( ) normal ( ) inflamed ( ) indentations ( ) pathology
4. Upper lip internal mucosa: ( ) normal ( ) inflamed ( ) indentations ( ) pathology
5. Upper labial vestibule mucosa: ( ) normal ( ) inflamed ( ) pathology
6. Upper buccal vestibule mucosa: ( ) normal ( ) inflamed ( ) pathology
7. Lower lip vermillion border: ( ) normal ( ) inflamed ( ) indentations ( ) pathology
8. Lower lip internal mucosa: ( ) normal ( ) inflamed ( ) indentations ( ) pathology
9. Lower labial vestibule mucosa: ( ) normal ( ) inflamed ( ) pathology
10. Lower buccal vestibule mucosa: ( ) normal ( ) inflamed ( ) pathology
C. Maxillary vestibule evaluation

1. Gingiva: ( ) normal ( ) inflammation: ( ) generalized ( ) localized
2. Mucogingival defects: ( ) absent ( ) present
3. Maxillary labial frenum attachment: ( ) upper ( ) lower ( ) normal ( ) high ( ) fibrotic
4. Maxillary labial frenum length: ( ) long ( ) short ( ) normal ( ) two- or three-fold
5. Maxillary right buccal frenum attachment: ( ) upper ( ) lower ( ) normal ( ) high ( ) fibrotic
6. Maxillary right buccal frenum length: ( ) long ( ) short ( ) normal ( ) two- or three-fold
7. Maxillary left buccal frenum attachment: ( ) upper ( ) lower ( ) normal ( ) high ( ) fibrotic
8. Maxillary left buccal frenum length: ( ) long ( ) short ( ) normal ( ) two- or three-fold
D. Mandibular vestibule evaluation

1. Gingiva: ( ) normal ( ) inflammation: ( ) generalized ( ) localized
2. Mucogingival defects: ( ) absent ( ) present
3. Mandibular labial frenum attachment: ( ) upper ( ) lower ( ) normal ( ) high ( ) fibrotic
4. Mandibular labial frenum length: ( ) long ( ) short ( ) normal ( ) two- or three-fold
5. Mandibular right buccal frenum attachment: ( ) upper ( ) lower ( ) normal ( ) high ( ) fibrotic
6. Mandibular right buccal frenum length: ( ) long ( ) short ( ) normal ( ) two- or three-fold
7. Right buccal shelf: ( ) narrow ( ) wide ( ) long ( ) short
8. Right retromolar pad: ( ) present ( ) absent
9. Mandibular left buccal frenum attachment: ( ) upper ( ) lower ( ) normal ( ) high ( ) fibrotic
10. Mandibular left buccal frenum length: ( ) long ( ) short ( ) normal ( ) two- or three-fold
11. Left buccal shelf: ( ) narrow ( ) wide ( ) long ( ) short
12. Left retromolar pad: ( ) present ( ) absent
E. Tongue and floor of the mouth evaluation

1. Tongue: ( ) normal ( ) small ( ) large ( ) inflamed ( ) indentations
2. Tongue mobility: ( ) normal ( ) trembling ( ) ankyloglossia ( ) side tilted
3. Lingual frenum attachment: ( ) high ( ) low ( ) normal ( ) two- or three-fold
4. Lingual frenum length: ( ) long ( ) normal ( ) short ( ) two- or three-fold
5. Floor of the mouth mucosa: ( ) normal ( ) inflamed ( ) pathology
6. Sublingual excretory duct: ( ) normal ( ) inflamed ( ) sialolith ( ) pathology
7. Right premylohyoid fossa: ( ) narrow ( ) wide ( ) deep ( ) shallow ( ) inflamed
8. Right mylohyoid area: ( ) narrow ( ) wide ( ) deep ( ) high ( ) inflamed
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9. Right retromylohyoid fossa: ( ) narrow ( ) wide ( ) deep ( ) shallow ( ) inflamed

10. Left premylohyoid fossa: ( ) narrow ( ) wide ( ) deep ( ) shallow ( ) inflamed
11. Left mylohyoid area: ( ) narrow ( ) wide ( ) deep ( ) high ( ) inflamed
12. Left retromylohyoid fossa: ( ) narrow ( ) wide ( ) deep ( ) shallow ( ) inflamed
Case assessment occlusal evaluation
A. Static analysis of occlusion

1. Angle classification: ( ) Class I ( ) Class II (div I) ( ) Class II (division II) ( ) Class III
2. Molar occlusion: ( ) right ( ) left
3. Canine occlusion: ( ) right ( ) left
4. Arch form: ( ) maxillary ( ) mandibular
5. Inverted occlusion (cross bite): ( ) absent ( ) anterior ( ) posterior
B. Dynamic analysis of occlusion

1. Right anterior guidance: ( ) canine ( ) anterior group function
( ) (lateral) (canine) (1 bicuspid) (2 bicuspids) (1 molar)
2. Left anterior guidance: ( ) canine ( ) anterior group function
( ) (lateral) (canine) (1 bicuspid) (2 bicuspids) (1 molar)
3. Mandibular shift: ( ) absent ( ) right _________ mm ( ) left _________ mm
4. Mandibular opening: (max: average of 53 to 58 mm; restricted: 40 mm) _________ mm
5. Interarch space at rest: _________ mm
6. Curve of Spee: _________ mm
7. Curve of Wilson: ( ) normal ( ) altered
8. Maxilla: ( ) retrognathic ( ) orthognathic ( ) prognathic
9. Mandible: ( ) retrognathic ( ) orthognathic ( ) prognathic
10. Maxillary interdental space: _________ mm ( ) crowding ( ) spacing
11. Mandibular interdental space: _________ mm ( ) crowding ( ) spacing
12. Mandibular incisors: ( ) retroclined ( ) normoinclined ( ) proclined
Table 9-1 Prosthodontic questions that require answers for treatment planning
A. Is it possible to manipulate the mandible in centric relation? ( ) yes ( ) no
B. Is there any loss of vertical dimension? ( ) yes __________ mm ( ) no
C. Is there enough space for restorative material? ( ) yes ( ) no
D. Is there enough posterior support? ( ) yes ( ) no
E. Is there enough interocclusal space at rest? ( ) yes __________ mm ( ) no
1. How is the occlusal plane? Curve of Spee ( ) yes ( ) no; Curve of Wilson ( ) yes ( ) no
2. How can we rehabilitate the anterior guidance? ( ) canine ( ) group function
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Clinical oral and tooth assessment questions

The information gained from asking the questions The answers to these questions may be a useful aid
on page 160 should be carefully indicated on the when examining and analyzing, both clinically and
following periodontal-prosthodontic chart (Fig 9-1). radiographically .
Fig 9-1 Periodontal-prosthodontic sample chart.
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1. Mucosal lesions: Chemical? Physical? Infectious? Immunologic? Premalignant? Malignant? Lumps?

Bumps? Swellings? Bleeding areas? (inspection)
2. Salivary glands: Conditions: Premalignant? Malignant? (inspection and radiographs)
3. Tongue conditions: Malformations? Macroglossia? Microglossia? Short lingual frenum? Tremors?
Scars?
4. Tooth conditions: Hereditary? (inspection and radiographs)
5. Missing teeth: Where? How many? (inspection and radiographs)
6. Impacted teeth: Pericoronitis? Pain? (probing and radiographs)
7. Individual tooth position: Infrarotated? Mesially/distally/buccally/palatally/lingually inclined?
Mesialized? Distalized? Supraerupted? (inspection and radiographs)
8. Interproximal open contacts: Where? Type?
9. Caries: Where? (explorer and radiographs)
10. Defective restorations: Where? Type? Marginal ditching? Over- or undercontoured? Voids?
(inspection and explorer and radiographs)
11. Amalgam tattoos: Where? How many?
12. Tooth sensitivity: Caries? Cervical abrasions? Fractures? Periodontal problems? Occlusal contacts?
Bruxing habits? Bleaching? Steroid therapy? Anxiety? (touch and blow air/water and marking ribbons)
13. Pain: Anxiety? Pulpitis/periradicular lesions: Continuous? Provocated? (tapping and radiographs)
14. Physical/chemical dental lesions: Abrasions (brushing)? Attrition (occlusal wear facets)?
Erosion (chemical)? (inspection)
15. Possible pulpitis (gentle tapping)
16. Fractured/cracked teeth (gentle tapping and explorer and ink and radiographs)
17. Periodontal conditions: Gingivitis? Periodontitis? (probing and radiographs)
18. Bleeding: Where? Spontaneous? On Probing?
19. Pus: Where? Spontaneous? On Probing?
20. Fistulous tracts: Where? Swelling? Bleeding? Pus? (probing and gutta try-in and radiographs)
21. Presence of plaque and calculus: Where? Amount? (explorer and probing)
22. Periodontal probing: Pocket depth? Bleeding? Furcations? (probing and radiographs)
23. Angular bony defects: Where? Depth? Bleeding? (probing and radiographs)
24. Furcation involvement: Where? Degree? Bleeding? (probing and radiographs)
25. Bone loss: Where? How Much? Vertical? Horizontal? Pattern? (probing and radiographs)
26. Attachment loss: Where? How much (mm)? (probing and radiographs)
27. Tooth mobility: Grade I/II/III? (mirror and pressure from the explorer handles)
28. Periodontal ligament (PDL) widening: Trauma from occlusion? Where? (probing and radiographs)
29. Crown-to-root ratio: Where? Bone loss? Extrusion? Natural tooth? Fixed prosthesis? (probing and
radiographs)
30. Parafunctional habits: Bruxing? Clenching? Gnashing? (inspection)
31. Root evaluation: Hemisections? Root resorption? Fused? (probing and radiographs)
32. Presence of residual roots: Where? Bleeding? Mobility? (probing)
33. Presence of implants: How many? Where? Function? (inspection and radiographs)
34. Periimplant conditions: Inflammation? Infections? Pus? (probing and radiographs)
35. Fixed prostheses: Type? Movable? (inspection and radiographs)
36. Post and cores: Type? Dimensions? (inspection and radiographs)
37. Removable partial dentures: Type? Conditions? (inspection)
38. Complete dentures: Tissue bearing? Implant-supported? (inspection)
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References
rology and Psychiatry, Cornell University Medical Col-

References lege, 1949, revised edition, 1956.
1. Boucher CO. Full dentures. J Am Dent Assoc 1950;40: 7. Krol AJ, Jacobson TE, Finzen FC. Removable Partial
676–677. Denture Design, ed 4. San Raphael, CA: Indent, 1990.
2. Bresciano M, De Maria A, Morello M, Poglio E, Auden- 8. Lynn BD. The significance of anatomic landmarks in com-
ino G. Efficacy of a checklist, for office-laboratory complete denture service. J Prosthet Dent 1964;14:456–459.
munication: a clinical study on quality outcomes for 9. Carr A, Brown D. McCracken’s Removable Partial
single crowns. Int J Prosthodont 2017;30:160–162. Prosthodontics, ed 12. Mosby, 2011.
3. Burnstone CJ. Lip posture and its significance in treat- 10. Nassif J. Examination forms for edentulous patients – A
ment planning. Am J orthod 1967;53:262–284. survey. J Prosthet Dent 1976;35:222–227.
4. Calvani L, Michalakis K, Hirayama H. The Influence 11. Rosenstiel SF, Land MF, Fujimoto J. Contemporary
of full-arch implant-retained fixed dental prostheses Fixed Prosthodontics. Mosby Elsevier, 2001.
on upper lip support and lower facial esthetics: pre- 12. Shillingburg HT, Hobo S, Whitsett LD. Fundamentals of
liminary clinical observations. Eur J Esthet Dent Fixed Prosthodontics, ed 2. Quintessence, 1981.
2007;2:420–428. 13. Shoji N, Endo Y, Iikubo M, et al. Dentin hypersensitivity-
5. Calvani L, Calvani L, Hirayama H, Pissiotis, Micha- like tooth pain seen in patients receiving steroid therapy:
lakis K. Association between increased concavity of An exploratory study. J Pharmacol Sci 2016;132:187–191.
maxillary labial alveolar bone and decreased labial 14. Stratton RJ, Wiebelt FJ. An Atlas of Removable Partial
cortical bone thickness: a cone beam computed tomog- Denture Design. Quintessence, 1988.
raphy aided retrospective cohort study. J Prosthodont 15. Stewart KL, Rudd KD, Kuebker WA. Clinical Removable
2019;28:244–251. Prosthodontics. Ishiyaku EuroAmerica, 1988.
6. Cornell Medical Index – Health Questionnaire, (CMI). 16. Malone WFP, Tylman SD. Tylman’s Theory and Prac-
New York Hospital and Department of Medicine, Neu- tice of Fixed Prosthodontics, ed 7. Mosby, 1978.
161
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v
CHAPTER TEN
The type and structure
of prosthodontic treatments
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10 The type and structure of prosthodontic treatments
“Simpler solutions are more likely to be cor- Treatment planning and

rect than complex ones.”
predictable results
William of Ockham (c. 1287–1347)
All therapeutic possibilities should be clear in the
“Keep it simple and stupid… sometimes.” clinician’s mind before writing the treatment out-
Lloyd L. Miller Jr. (1930–2007) line.
Some readers may feel that this statement is
redundant, but often students and clinicians ap-
Serious endeavors are never easy, and planning proach treatment planning with too much ease
prosthodontic treatments is definitely a serious en- and casualness, while instead it should be a mo-
deavor. ment of reflection and a chance for continuous
The aim of this chapter is to review and organize, learning, as many procedures and treatments
in a simple way for learning and practical planning change with time due to the clinical and technical
purposes, a classification of the prosthodontic treat- progress that is continually being made in dental
ment types in accordance with their biological and medical science.
procedural clinical rationale and in the light of the The soundest premise to conceive an appropri-
author’s medical, dental medical, dental technician, ate and rigorous treatment plan for each patient is
and prosthodontic clinical experience. the meticulous understanding of the case details. This
This chapter also presents a short explanation will make the rehabilitation and the end result more
and discussion of the main phases and treatment al- predictable and enduring. Therefore, the search for
gorithms necessary to plan a clinical case. predictable results is one of the most important
treatment planning endeavors. Predictable results
can safely guide both the clinician and the patient
through a properly organized and well-engineered
Prosthodontic treatment treatment to rehabilitate, improve, and maintain
algorithms both the oral health, functionality, and esthetics of
The Merriam-Webster Dictionary defines the word the patient’s mouth.
‘algorithm’ as: a procedure for solving a mathemat- There are a number of important and condition-
ical problem … in a finite number of steps that fre- ing factors to take into account when planning a
quently involves repetition of an operation; broadly, treatment. Four of these are elaborated upon in the
a step-by-step procedure for solving a problem or following section:
accomplishing some end.1 Algorithms are used in 1. Clinical priorities.
many fields, including mathematics, computer sci- 2. Presence of an infectious disease and its healing
ence, medical science, and engineering. Practically, time.
an algorithm is any procedure or formula or list of 3. Need for additional clinical collaborators.
specific steps created for solving a problem. 4. Consequentiality of procedures.
In the case of prosthodontic treatment planning,
the knowledge of prosthodontic treatment algo-
Clinical priorities
rithms, namely the proper set of a certain number
of basic procedures to accomplish the prosthodontic The chief complaint is the main clinical priority,
task, is necessary in order to plan and work safely which is sometimes also a clinical emergency, in
during the development of the entire clinical ther- which case it is obviously urgent to attend to the
apy, from the first visit through the treatment phase problem. The primary needs of the patient only
and into the posttreatment care and follow-up/ sometimes coincide with the chief complaint,
maintenance. which may be symptomatic or asymptomatic.
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Treatment planning of complex cases
If the chief complaint is symptomatic, that is an of this concept would be that, within the limita-
undoubtable medical reason to give it priority of tions of each specific case, it is usually better to
investigation and plan for an immediate clinical perform an endodontic treatment after and not
solution. before a periodontal one, as this specific sequence
has been shown to be more successful. Therefore,
treatment procedures should be planned accord-
Presence of an infectious disease
ing to scientific evidence of positive consequen-
and its healing time
tiality.
The presence of an infectious disease usually has
an impact on the health status of the patient, and
consequently also on the restorative aims and on all
the phases of the treatment plan. The healing time
Treatment planning of
of an infectious disease has relevance for the timing complex cases
of the treatment because final restorative proced- The prosthodontic treatment planning for complex
ures need to be postponed until there is sufficient cases demands considerable time and effort and re-
evidence that the disease has completely healed and quires professional knowledge, experience, skills,
the local health status is stable. These timeframes commitment, availability, patience, and passion.
need to be taken into consideration when planning When planning a treatment, prosthodontists
a treatment. need to take into account the following points:
1. Consider and analyze all the procedures
that must be performed according to their
Need for additional clinical
individual and general rationale and sequential
collaborators
order.
There are several instances when collaborators or 2. Bear in mind that for complex prosthodontic
specialists from another field of medicine or den- cases, the overall treatment planning effort is
tal medicine are required to assist in a patient case. also complex because all the clinical, laboratory,
One instance is when there is the presence of any and surgical steps need to be multiplied by
disease. Another is when there is a need for surgery. the number of procedures that are required to
Sometimes other specialists are required to assist rehabilitate the patient successfully.
in the clinical treatment for a simple improvement 3. Consider that often they have to elaborate
of the functional and/or esthetic situation, for in- more treatment options for each clinical case,
stance, an orthodontist or a periodontist. In these depending on factors that must be assessed
and various other situations, one or more specialists beforehand such as the chief complaint; the
need to be consulted to discuss their cooperation time and financial limitations; and the patient’s
and involvement in the patient case. This consulta- will, levels of understanding and commitment,
tion should take place before or during the restora- personality, and expectations.
tive planning phase and again, where necessary,
during the development of the treatment. Therefore, before any prosthodontic endeavor, it
is advisable to get into the ‘treatment planning
mood,’ in other words, spending time researching,
Consequentiality of procedures
conceiving, revising, and organizing the treatment
All the restorative procedures must follow a plan step by step. In this way, the predictability will
well-conceived, pre-established clinical and tech- be enhanced, the delivery of the treatment will go
nical order that is dictated by scientifically proven more smoothly, the patient will be satisfied, and
restorative rationale. One simple clinical example your professional life will be made easier.
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Concept of the ‘initial phase’ Expectations: a danger zone

The most important moment of the entire prostho- Expectations are beliefs about the future and are a
dontic treatment is the initial diagnostic planning reflection of people’s desires, needs, and hopes.
phase. This is because it is the moment that defines In the context of our profession, patients’ ex-
the path and development of the entire rehabilita- pectations relate to the consequences that may lead
tion. to the individual’s psychologic and physiologic
After years of specialty training, prosthodon- change. Health expectations have been defined as
tists are prepared for the restoration of the most cyclical and longitudinal processes, together with
complex of dental cases. Our main effort starts in an accelerating final phenomenon preceded by the
this first phase, when we take stock of the clinical understanding, the expectancy formulation, the out-
situation and start to understand how to customize come, and the post-outcome cognitive processing.2
each therapy. Often this is a difficult task. In some As regards expectations, from the patient’s point
complex cases, a large amount of data and clinical of view, the reconstruction of a single anterior tooth
findings need to be carefully collected, collated, and can often be equally significant and have the same
studied. emotional impact as a full-mouth rehabilitation.
Only once the past and current clinical health In some instances, this situation may become
conditions and the restorative limitations and pos- very dangerous for us. Therefore, it is mandatory to
sibilities have been assessed can we come up with a be aware of this and take care to address it firmly
correct diagnosis and pretreatment prognosis. but kindly. Be gentle and empathetic but careful
when it comes to patients’ needs, desires, and will.
Always try to make patients aware of the reality
Concept of customization
of their problems and the limitations imposed by the
Only with a correct diagnosis and pretreatment clinical situation as well as the financial and/or time
prognosis it is possible to elaborate one or more constraints. Indeed, it is worthwhile and wise to
treatment plans. Each one of these possible plans carefully and sensitively explain to patients the clin-
must be customized and tailored for each patient ical meaning and objective signs of their subjective
and must be explained carefully to patients. symptoms, always being careful not to offend them.
If possible, the treatment plan should contain In this way, you can help to ‘resize’ their expec-
step-by-step lists of treatment details that outline the tations so that they are as realistic as possible. In
specific clinical and technical procedures in their fact, too often patients’ wishes and the objective
chronologic order. clinical reality are in sharp contrast with one an-
It is the rule to incorporate into the treatment other. It may take time, but it is much better to ex-
plan the level of commitment expected from the pa- plain to patients in detail from the beginning the
tient, how long the treatment is going to last, and fundamental structure of the customized treatment
as detailed a description of the schedule of proced- plan and how you foresee it developing in reality.
ures as possible. This then serves as a useful and
necessary written reminder that the patient can go
back to and consult again and again. In this way, Patient collaboration
patients forgetting appointments or remembering It is our duty as well as in our interests to main-
procedure details inaccurately can be prevented. It tain active patient collaboration to avoid mis-
is also a way of protecting yourself and your prac- understandings. In the dental medical field, the
tice because sometimes patients blame the clinician patient’s life is mostly not threatened, so there
or other members of the dental office team when are no excuses for not accurately informing the
they forget or misunderstand something. patient, also in the case of emergencies.
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Treatment planning of complex cases
‘Not enough time’ Patients need to understand that the posttreat-

ment care is a well-established and necessary part
Many professionals say that they ‘have no time’ and of all prosthetic treatments. What also needs to be
therefore do not dedicate sufficient time to the cru- made clear is that, since all patients are different
cial first visit and related treatment explanations. and their individual needs vary, maintenance is
This can turn out to be a huge mistake that may have usually customized to suit each patient.
to be paid for in some way later on.
Depending on the likely duration and the known
The clinical result should not be
complexity of the prosthodontic treatment, you
equal to or worse than the problem
should always be ready to spend a good amount of
time initially, and perhaps again further along in
itself
the treatment. The ethical standard of care and the clinician’s good
It is important to listen carefully to patients’ con- sense determine that in medicine and dental medi-
cerns and questions and to explain the whys and cine, the clinical result should not be equal to or worse
wherefores of present and future procedures, includ- than the problem itself, otherwise the treatment can
ing why in some phases procedures may get more (or be seen as useless or a failure.
less) complicated and may speed up or slow down. Our treatment should always improve the pa-
tient’s situation. If it appears to you in your profes-
sional capacity that this will not be the case, then
Balance of time commitment
the no-treatment option should be considered. This
It should not be forgotten that the clinician’s and means that you need to propose to the patient that
patient’s time commitment should balance because instead of a restorative treatment, no treatment is
the chairtime availability of both parties is identical. carried out because the treatment may end up either
Therefore, it is important to discuss this equation not improving the situation or making it worse or
thoroughly during the first visit and again at the more problematic than it currently is. This situation
start of treatment, during the rehabilitation, when may arise for a number of reasons, including psy-
the healing phase begins, and during the mainten- chologic, physical, clinical, and prosthodontic ones.
ance phase (see below). As every patient case is dif- Furthermore, within the limitations of scientific
ferent, it is crucial to be clear with patients about research, many clinical studies have shown that in
exactly how much mutual time will have to be com- some cases the non-replacement of missing teeth
mitted to ensuring continuity of care in their par- leads to no future problems, and that patients man-
ticular case. age quite well without them.
Nothing happens by itself or by chance in our
specialty and profession. No-treatment option
Therefore, in those cases in which there is sufficient
doubt or uncertainty about the treatment outcome,
Posttreatment care commitment and where the facts and our ethical consciousness
This is an important factor that is unfortunately often are causing alarm bells to ring, it is in the best in-
overlooked. No professional should forget to make terests of our patients, ourselves, and our entire
the patient aware that after the final delivery there practice to propose a no-treatment option.
will be a first trial stage, followed by the maintenance Make it clear to the patient that this is not a
posttreatment care, which involves following up decision that is arrived at lightly, but as an experi-
with the patient to make sure everything is working enced and knowledgeable professional you think
well and both the patient and the clinician are happy it is best due to medical, ethical, and (where rele-
and satisfied with the outcome of the rehabilitation. vant) economic realities.
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Classification of prosthodontic istical data relating to the percentage of cases that

fall into each of these categories.
treatments
Apart from some minor possible variables,
With each case, three basic prosthodontic clinical mostly one sees evidence of only these three types
situations and treatment possibilities will present of cases, so it seems reasonable to give them a name
themselves (Tables 10-1 and 10-2). The prosthodon- and to classify them.
tic situations should be critically analyzed, bearing Also, it can happen that complications occur
in mind the following simple and important para during the clinical treatment that change the initial
meters: clinical evaluation. Nevertheless, each case should
1. Disease: the presence or absence of one or more be defined at the start during the treatment plan-
oral infectious diseases. The presence of disease ning phase according to the initial clinical situation
will delay or limit the prosthodontic treatment at the time.
because the disease will need to be resolved Therefore, in accordance with these three types
before the rehabilitation can be finalized. of prosthodontic clinical cases, three different pros
2. Collaborations: the possible intervention during thodontic rehabilitative possibilities are postulated
the prosthodontic rehabilitation of other spe- (Table 10-2):
cialists with whom you will need to collaborate
in order to improve the clinical situation and/
Class I: Prosthodontic treatments –
or solve one or more pathologic clinical condi-
full reconstructive rehabilitations
tions.
(FRR)
These two crucial variables allow for only three No disease, only prosthodontics (pure prosthodontic
mathematical possibilities of prosthodontic treat- cases): Simple prosthodontic restorations and/or re-
ment types. Therefore, according to academic and storative improvements of problematic teeth or of
clinical experience, a classification can be made in- old prostheses are performed in these cases. Into
volving the three main possible prosthodontic reha- this first category fall all straightforward prosthetic
bilitative scenarios shown in Table 10-1. rehabilitations of healthy mouths where no infec-
Within the limitations of the author’s research tious bacterial and/or viral oral disease is present
investigations, there appears to be nothing in the and in which there is no need for any type of other
literature to date defining and classifying these clinical improvement but the prosthodontic one.
three categories. Therefore, there is no current stat- There is therefore no need to collaborate with other
specialists.
Table 10-1 Possible clinical prosthodontic cases Table 10-2 Classification of prosthodontic treatment

according to the presence of disease and need for possibilities
collaboration
1. Prosthodontic cases with no disease and no Class I Prosthodontic treatments – full

need for other specialist collaboration reconstructive rehabilitations (FRR)
2. Prosthodontic cases with no disease and the Class II Prosthodontic treatments – inter
need for other specialist collaboration disciplinary improving rehabilitations (IIR)
3. Prosthodontic cases with disease and the need Class III Prosthodontic treatments – inter
for other specialist collaboration disciplinary healing rehabilitations (IHR)
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Prosthodontic treatment phases and their algorithms
Class II: Prosthodontic treatments – Complex cases mostly involve the collaboration

interdisciplinary improving of various specialist partners. This intelligent work-
rehabilitations (IIR) ing trend is well structured and becoming increas-
ingly common in dental medicine in the USA.
No disease, interdisciplinary: Into this second cat- The classification outlined above should also be
egory fall all prosthetic rehabilitations of healthy seen in light of the increasing clinical challenges
mouths where no infectious bacterial and/or viral and organizational complexity that each clinical
oral disease is present, but where other periodon- case and prosthodontic treatment presents.
tic, orthodontic, oral surgery, and/or maxillofacial The art of prosthodontic treatment planning is to
therapies are necessary. There is therefore a need highlight all the clinical and technical variables and
to collaborate with one or more specialists who will limitations, then organize lists and the right sequence
contribute to the restoration to achieve the best of interventions and relevant clinical treatments re-
function and esthetics possible and a better chance quired from start to finish to rehabilitate the patient.
of a more predictable and stable outcome. Thorough treatment planning therefore shows
respect for the professionalism of our specialty,
while not planning properly has the opposite effect.
Class III: Prosthodontic treat-
ments – interdisciplinary healing
rehabilitations (IHR)
Disease, interdisciplinary: Into this third category
Prosthodontic treatment
fall all prosthetic rehabilitations of mouths where phases and their algorithms
one or more bacterial and/or viral oral diseases are The three types of prosthodontic treatments out-
present. In these cases, there is a need to collaborate lined above usually involve a specific pattern of
with one or more other specialists who will con- working phases. They may be simplified into two
tribute to heal, save, and restore the dental and oral step-by-step algorithms or procedures (Fig 10-1).
structures with periodontic, endodontic, oral sur- 1. Class I: Prosthodontic treatments – full recon-
gery, and maxillofacial therapies. structive rehabilitations: In these rehabilitative cases,
after the initial diagnostic phase that incorporates
the treatment planning (Phase I), there is a purely
Clinical challenges
restorative phase (Phase II), which involves the en-
As prosthodontists, we know that in reality there tire prosthetic treatment from start to finalization.
are a large number and variety of clinical challenges Then follows the final phase (Phase III), which in-
that fall within these three categories. We also know volves the mandatory posttreatment care and main-
that the number of tasks that demand our attention tenance (Table 10-3).
usually increases with the complexity of the pros-
thodontic treatment. Table 10-3 Class I: Prosthodontic treatments – full
Therefore, corresponding to the increase in treat- reconstructive rehabilitations
ment planning challenges is an increase in know-
ledge, technology, understanding, commitment, ex- Phase I Diagnostics, consultations, and
perience, and the involvement of other specialists to treatment planning
better solve the challenges of each case.
There is an increasing number of sophisticated Phase II Purely restorative, prosthodontic
clinical therapies evolving in the various specializa-
Phase III Posttreatment care and
tions of dental medicine that work together to heal
maintenance
and restore patients.
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Phase I: Diagnostics Emergencies and priorities
+
1. Dental and medical history 1. Oral cancer control emergencies
2. Clinical and radiographical examinations 2. Maxillofacial emergencies
3. Diagnostic casts and photographs 3. Periodontal emergencies
4. Diagnostic wax-up 4. Endodontic emergencies
5. Esthetic evaluation 5. Tooth extraction emergencies
6. Consultations 6. Caries emergencies
7. Professional oral hygiene
TREATMENT PLANNING 8. Mock-up provisionals
CLINICAL TREATMENT RED LINE
Phase II: Improvement, disease, restorative

1. Removal of existing restorations
2. Post and cores, core buildup
3. Short-term provisionals
4. Orthodontic therapy
5. Maxillofacial therapy
6. Periodontal therapy
7. Endodontic therapy
8. Implant placement
9. Long-term provisionals
10. Final prostheses
Phase III: Maintenance

1. Recall after a few days
2. Recall after 1–4 weeks
3. Recall every 3–6 months
4. Fluoride (Cambra/Featherstone) protection
5. Reinforced oral hygiene
6. Improved diet
Fig 10-1 Prosthodontic treatment sequence and timing.
2. Class II: Prosthodontic treatments – interdis- tion of other specialists is often required. In fact,
ciplinary improving rehabilitations and Class III: in both classes, collaborations are often introduced
Prosthodontic treatments – interdisciplinary healing from Phase I.
rehabilitations: Due to their variable complexity The only difference between Class II (improving)
and large number of treatment planning possibil- and Class III (healing) treatments is the presence or
ities, these cases and their possible clinical treat- absence of any infectious and/or pathologic oral con-
ments have for years intrigued and challenged ditions. In both cases, they can be envisioned with
the curiosity, knowledge, experience, and intelli- a clinical and technical algorithm comprising the
gence of clinicians, university faculties, and study abovementioned three phases. However, in both
clubs to find proper clinical solutions. In the case cases, Phase II may be subdivided into two parts
of these two classes of treatments, the collabora- (Tables 10-4 and 10-5):
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Predictability, sequence of work, and consent
Table 10-4 Class II: Prosthodontic treatments – inter- remove that which cannot heal, and then to restore
disciplinary improving rehabilitations in the healthier oral environment the anatomy and
Phase I: Diagnostics, consultations, and functionality of any decayed and/or missing denti-
treatment planning tion.
Indeed, prosthodontists always require sound
Phase II: Part 1 – Collaboration for improving, soft and hard tissue as well as biomechanically
and initial prosthodontic therapy sound and reliable natural and/or artificial struc-
tures and abutments to support the prosthetic
Phase II: Part 2 – Restorative and structures and rehabilitative solutions. Only when
prosthodontic therapy any existing oral condition has been healed or elim-
inated can the final restorations be crafted and the
Phase III: Posttreatment care and overall rehabilitation predictably finalized.
maintenance
These three specific phases and their two se-
quential algorithms are therefore very important.
Table 10-5 Class III: Prosthodontic treatments – inter-

Predictability, sequence of
disciplinary healing rehabilitations work, and consent
Phase I: Diagnostics, consultations, and
treatment planning Predictability
Phase II: Part 1 – Collaboration for healing, As was previously mentioned, the objective of any
and initial prosthodontic therapy prosthodontic treatment is to work with predictable
premises; to foresee and then to achieve predictable
Phase II: Part 2 – Restorative and results.
prosthodontic therapy
Indeed, excellent healing necessarily and dra-
matically lowers the unpredictability of any prog-
Phase III: Posttreatment care and
nosis, reducing risk factors and the sequential and
maintenance
related chain of negative events that could follow.
Unfortunately, too often the concept of predict-
ability is forgotten in dental medicine and prostho-
dontics, which in the end can causes damage that
could have been avoided. In this regard, prostho-
According to this algorithm, the prosthetic work dontics always involves respect for clinical algo-
usually starts at the beginning of Phase II. It should rithms and precision.
be organized according to precise and well-planned Phase I (diagnostics, consultations, and treat-
rehabilitation objectives that follow the most ra- ment planning) and Phase III (posttreatment care
tional sequence of clinical and technical interven- and maintenance) are a constant in all medical and
tion. dental medical treatments.
The clinical timeline is dictated by reasonable
and well-established medical rules that strongly
‘Red line’ concept
suggest that in medicine, hence also in dental med-
icine and prosthodontics, it is clinically reasonable In all prosthodontic treatments, there is an imag-
and advisable to first heal that which is not well, or inary but solid ‘red line’ between Phases I and II.
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When this line has been reached, there is no going Always follow the diagnostic and consensus
back. The ‘red line’ at the end of Phase I is a precise procedure step by step. If you show too much com-
and predictable treatment boundary. Once this line passion or are too timid or yielding in your profes-
has been crossed (ie, once you start treating patients sional approach toward the patient, as opposed to
and changing their initial situation), the only way being rational, this might lead to problems.
is forward. This may expose you to possible legal It is important to retain control of the situation
consequences. to avoid certain treatment developments and out-
comes taking a negative or unpredictable course
where you could have had them under better con-
Emergencies and priorities
trol had you strictly followed the correct proced-
The Merriam Webster Dictionary defines a ‘med- ures.
ical emergency’ as “an unforeseen combination of
circumstances, or the resulting state that calls for
Sequence of work and patient consent
immediate action such as: a) a sudden bodily altera-
tion (eg, a ruptured appendix or surgical shock) that If we change the shape of the existing original nat-
is likely to require immediate medical attention, or ural or artificial dentition, we may expose ourselves
b) a usually distressing event or condition that can to legal risks. Therefore, in Phase I, long before the
often be anticipated or prepared for but seldom ex- start of Phase II when the clinical treatment begins,
actly foreseen.” it is wise to follow a sound informational procedure
The same dictionary defines a ‘priority’ as “some- that should always end with the patient’s handwrit-
thing given or meriting attention before competing ten and signed informed consent.
alternatives.”
During the first patient visit and examination, an
emergency or priority situation may be apparent. Signed written informed consent
This should be treated first from a therapeutic point In all cases, including in situations of emergency
of view. In other words, such a situation would need or priority, follow the step-by-step informed con-
to be clinically treated as soon as possible before the sent procedure, because if you adjust or modify
start of the prosthodontic treatment because it would something without the patient’s full signed agree-
be causing problems or could potentially cause fu- ment, you could face legal action being brought
ture problems for the patient’s oral (and possibly against you. It is not uncommon for a patient to
also general) health. verbally agree with a proposed procedure, then
As mentioned previously, in dental medicine later complain and start legal proceedings against
there are seldom, if ever, situations that are life the clinician, dental office, hospital, department
threatening to the patient. There may, of course, be or school.
situations where you notice something during the
examination that alerts you to a possible serious
situation, in which case the patient must be referred
as soon as possible to a relevant specialist.
However, on the whole, as patients are not ex- References
posed to a life-threatening degree of risk when they
1. Merriam-Webster Dictionary. https://www.merriam-
present for prosthodontic treatment, there is usu-
webster.com/dictionary/algorithm. Accessed 15 June
ally plenty of time to explain the treatment plan to 2019.
patients and obtain their written agreement. This 2. Janzen JA, Silius J, Jacobs S, et al. What is expectation?
should occur also in case of an evident emergency Developing a pragmatic conceptual model from psy-
or priority. chological theory. Health Expect 2006;9:37–48.
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CHAPTER ELEVEN
Treatment planning analysis
of complex rehabilitations
Phase I:
Diagnostics, consultations,
and emergencies
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11 Treatment planning analysis of complex rehabilitations
Brainstorming prosthodontic treatment planning or complicate the course of any prosthodontic

is a powerful and exciting exercise in understand- treatment. Even though you may finally establish a
ing. It trains prosthodontists to think strategically treatment plan, its sequence and development, ad-
while following the logical rationale of a variable ditions, subtractions, and shortcuts may alter and
number of clinical and technical care steps, with the vary as the clinical and technical work progresses.
aim of finding the best possible clinical and pros- Negative eventualities should never affect the
thetic solution to rehabilitate the patient’s mouth cost of the treatment, unless the patient is evidently
and dentition. responsible for these eventualities.
Despite recent technological advances, exten-
sive and complex rehabilitations are usually very
Time for communication and
time demanding. They are also difficult to study and
explanations
organize into well-planned and properly outlined
treatments after only one patient visit. Clinical experience shows that many patients have
Planning needs time, so if patients want an im- both limited health education and oral health edu-
mediate answer to their dental ailments, explain to cation, and those who are well informed often ne-
them that it is better to take time to avoid possible glect their oral health despite this awareness. This
future complications and problems. Usually time, occurs for various reasons, ranging from fear or in-
dedication, experience, and a humble approach re- attention to personal (especially preventive) health
sult in a speeding up of the procedure, lightening care to laziness and indolence. Some people under-
and shortening the clinician’s planning effort. estimate or ignore the issue of constant aggressive
It is not the aim of this book (or chapter) to de- microbiota in their oral cavity, and unfortunately
scribe all prosthodontic procedures in detail; intake little care of the health of their mouths and
stead, this is the first of three (Chapters 11, 12, and teeth.1,2
13) that present a brief and simple discussion of the When patients come to your office seeking a re-
three distinct working phases that must be taken into habilitation, if they have obviously taken little care
consideration when planning a treatment. For this of their oral health you should point out that dental
reason, some details of these phases described in health is not only a matter of teeth but is inextricably
Chapter 10 will be briefly revisited in this chapter, linked to overall health. This crucial understanding
while more details and further information is pre- is important because otherwise whatever you re-
sented in Chapter 15. habilitate is likely to have a poor prognosis.3,4
Health problems usually arise at the same time
in the body and in the mind, which is why it is im-
Some preliminary remarks portant for medical professionals to treat patients
with empathy and kindness. One sometimes meets
knowledgeable and skillful professionals who un-
Treatment variations and
derestimate (or do not possess) the quality of sen-
alterations
sitivity and are unable to deal with patients in an
It is important to remind patients in advance that empathetic manner, taking into account their psy-
clinical and technical procedures may undergo chologic and emotional health. These professionals
changes during the course of the treatment. This often fail because they are not able to meet both the
possibility is more likely with complex cases and patient’s heart and mind.
can happen for various reasons that usually cannot In complex prosthodontic treatments, proper
be predicted or avoided. and constant communication is mandatory due to
Changes depend on possible clinical successes the changes that may occur or the sudden surprises
(fortunate) or hiccups (unfortunate) that may ease and difficulties that may arise during the treatment.
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Diagnostics
Therefore, as has previously been suggested, it is to the clinician that may, in their opinion, have im-
advisable to spend more time during the diagnostic plications for the treatment planning.
Phase I to communicate and transfer information Then, once the initial questionnaire has been
to the patient. It is advisable to take time to under- completed, it is the responsibility of the prostho-
stand, plan, and explain so that the patient is clear dontist to conduct the initial interview and com-
about the rehabilitation about to be performed. plete all the other dental and periodontal charts that
As clinicians become more experienced, they are considered necessary. The clinical examinations
usually become more capable of understanding are then performed, at which time the intraoral and
what patients really want and need and how to extraoral clinical examination questionnaires are
transfer information clearly, concisely, and com- completed. (See Chapter 4, page 35, for an example
pletely. As communication skills improve, so the of an initial diagnostic screening questionnaire.)
communication procedure is shortened.
Second updating questionnaire
When patients have not visited the dental office for
Diagnostics some time or when they have missed both the clin-
In Phase I, the actual state of the patient’s oral ical examination and the professional hygiene ses-
conditions and prosthodontic problems (subjec- sion that form part of posttreatment care (Phase III
tive and objective) is assessed in detail in order to periodic appointments), ask them to complete a
understand it well enough to devise one or more new diagnostic questionnaire at their next visit. It
treatment solutions. At the end of this first phase, is a sound and appropriate professional habit to
the clinician presents the patient with a number update patients’ health records with information
of well-defined treatment plans, but only once all about their recent past and current health status.
clinical and prosthodontic questions have been ade- This new diagnostic questionnaire is completed as
quately answered. Then, once the patient has under- if they were new patients.
stood, accepted, and consciously signed the informed For this purpose, the dental office staff should al-
consent agreement, the rehabilitation can start to be ways check the patient’s chart and the last visit date
practically organized and executed. to establish whether there has been a significant
In Phase I, there are a number of reasonable and period of time since the last visit; if so, by default
important steps that are usually considered and
evaluated to arrive at the diagnosis. The proced-
ures observed during this important investigative Table 11-1 Phase I: procedural steps
phase usually respect a specific order according to
1. Initial diagnostic screening questionnaire
a well-established rationale (Table 11-1).
(patient)
2. Initial interview and first visit (clinician):
Initial diagnostic screening a. Chief complaint investigation
questionnaire b. Histories and data collection
c. Clinical examinations and collection of findings
This is the first and often the only questionnaire d. Radiographic and CBCT evaluation
that will be completed by the patient. It is the ne- e. Diagnostic photographs and films
cessary first step to collecting all the patient in- 3. Diagnostic analog/digital articulators and
formation. casts
During this process at the first visit, dental office 4. Diagnostic analog and digital casts and wax-ups
staff should pay close attention to the patient’s atti- 5. Mock-up provisionals (mock temps)
6. Consultations with other specialists
tude, manner, and personality and report anything
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and according to standard operating procedures, Histories and data collection: personal,
the patient should complete a new initial question- medical, dental, and prosthodontic
naire in case something medically relevant has oc- Briefly, these documents allow you to collect as
curred in that time which may have significance for much data (patient health information) as possible
the patient’s oral health status. This information is in order to begin to define and understand patients’
important for the patient data record; in fact, it is current general physical health as well as their oral
sometimes related to the reason why the patient has and dental health status. They are important in or-
not visited for such a long time. der for you to begin to assess and properly under-
stand what limitations you face as you begin to plan
the best treatment for that patient.
Initial interview and first visit
Clinical examinations and collection of
Chief complaint investigation findings
The patient–clinician relationship is based on mu- These steps begin the ‘hands-on’ investigation that
tual collaboration. Part of this collaboration is mak- will allow you to deepen your understanding of all
ing sure patients are at ease in order to communi- possible clinical problems and to understand the
cate openly with you. There are several ways you strength of the connection between what the pa-
can ask patients about their chief complaint in a tient has told you and what you are able to detect
way that is comforting and sincere, eg, ‘How can we for yourself. Practically, this is the attentive work
help you?’ or ‘What can we do for you?’ (see discus- where you examine and collect, in various ways, all
sion in Chapter 5). relevant findings; namely, the signs and symptoms
Experience shows that patients’ chief complaint patients tell you about in their own words and those
is usually the first thing they describe to you and you are able to detect for yourself. This is achieved
which obviously you need to know about in order by means of both a careful clinical examination and
to help them. However, although pain and discom- the related clinical questions you pose while inves-
fort are what usually motivates patients to visit a tigating.
dental office, there are sometimes even more serious
problems that the patient may not even be aware of Radiographic and cone beam computed
as they may be asymptomatic. You will have time to tomography (CBCT) evaluation
examine these aspects in depth when interviewing The topic of the radiographic examination was dealt
the patient. with in Chapter 3, in the section describing prostho-
dontic tools, and in Chapter 8, in the section describ-
ing radiographic examinations. Radiographs are usu-
ally taken at the beginning of the first visit or when
first needed. They should be ready for use during the
It is always worthwhile to remember never clinical examinations. At the first visit, the dental of-
to underestimate the chief complaint and fice staff should routinely ask whether the patient
certainly not miss it. It is very important not has had any radiographs taken in the past 6 months.
only because it may be an expression of a These can be very useful for the purposes of possible
prosthetic problem or of a symptomatology differential diagnosis and clinical follow-up. If the pa-
that is creating problems, but also because tient does not have radiographs, a new set should be
it may be a real emergency, and this makes requested and taken before or during the first visit.
it also very important from a legal point of Regarding the three-dimensional (3D) CBCT
view (see Chapter 2). examination, this is an excellent and increasingly
safer way to gain insight during analysis and di-
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Diagnostics
agnostics (see Chapters 2, 5, and 7). Based on pro- contain, they are still the only means to verify iden-
fessional and clinical judgement, it should only be tical clinical information for treatment planning
requested if necessary and according to true need purposes, including the shape, composition, and
for each clinical case, always following the ALARA function of the anterior and posterior components
(as low as reasonably achievable) principle. of occlusion and possible centric and eccentric oc-
clusal interferences and/or prematurities. The last
Diagnostic photographs and films can sometimes be seen for the first time on the
Prosthodontic diagnostic dental and facial photo- articulator and then be double-checked in the pa-
graphs and speaking films are useful to study the tient’s mouth.
clinical case and possibly explain the treatment Therefore, if casts are mounted with average
plan to the patient. Furthermore, like original casts, articulator settings, they may be useful during
they are important records of the initial situation treatment planning to verify any difference exist-
and pretreatment clinical references and should be ing within the natural dentition. Clinical evidence
taken and saved as such. Unfortunately, this opti- has demonstrated that this is important because,
mal procedure is still not widely utilized in dental if diagnostic casts and their precious CR occlusal
offices, despite its value for clinical and possible mounting information is ignored, further possible
legal reasons. occlusal problems might be introduced by the new
Prosthodontists are increasingly taking advan- prostheses crafted on the basis of preexisting and
tage of high-tech digital cameras and smartphones, therefore verifiable occlusal issues.10-16 However,
which simplify this task due to the ease at which soon prosthodontists will study clinical cases ex-
macro and real-size images and films can be down- clusively on virtual models and articulators. Indeed,
loaded in diagnostic digital programs and apps. not long from now we will all be planning, working,
These can be shown to patients on these devices or and crafting prosthetic manufacts by means of arti-
on larger office monitors for the purpose of demon- ficial narrow intelligence (ANI) software algorithms
strating virtual replicas of the original oral condi- and related working machines.
tions, and enabling patients to envisage future pos- A new class of digitally savvy medical dental la-
sible rehabilitations that you may foresee for them. boratory technicians is emerging and revolutioniz-
ing prosthodontic laboratories, making important
Diagnostic analog/digital articulators and contributions to prosthodontic science. Laboratory
casts technicians have always been the most powerful
Prior to 1908, Alfred Gysi introduced models of an prosthodontic technical resource and they will al-
‘adaptable’ articulator with an incisal pin and guide.5 ways be the clearest example in our field of how it
Since then, preliminary diagnostic casts have been is possible to combine the latest analog and digital
poured in Type III stone, then mounted both in cen- science with the best human art, heart, mind, and
tric relation (CR) and in maximum intercuspation hand qualities.
position (MIP) with fast-setting gypsum materials
on increasingly perfected arcon and non-arcon ar- Diagnostic analog and digital casts and
ticulators by means of facebow transfers and proper wax-ups
maxillomandibular occlusal registrations.6-8 For decades the diagnostic wax-up has been the
Nowadays, both analog casts and digital models most important means for foreseeing the possible
are used.9 However, analog casts remain the most prosthodontic solutions during treatment planning.
useful twin-copy physical representation of the pa- In fact, for a long time both the original diagnostic
tient’s original dentition that can be used to study analog casts and the wax-up casts have been used
the case if you are not with the patient. Thanks to as physical tools to explain the ‘before and after’ of
the very valuable concrete clinical information they the treatment plan to the patient. The analog and
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wax-up casts make it clear to the patient what the In this way, patients can go home with the mock
prosthodontist envisages, taking all the existing oc- temps in place for a brief functional and/or esthetic
clusal and/or esthetic realities into account. All the evaluation, armed with simple maintenance in-
physical information they contain can be used as an structions. The pros and cons of the mock temps
elaborate model, able to guide the creation of the can be discussed with the patient at the next visit,
first set of provisionals. and if they have been well accepted and the patient
Currently, however, the latest digital technol- is happy, the final treatment plan can be finalized
ogies have far exceeded these analog possibilities. and signed. The mock temps can be impressed
The constantly improving algorithms and hard- or scanned, and their shape can be used as a raw
ware/software advances today offer the chance of model to create, where possible, adhesive final fixed
studying the TMJ–occlusal dynamic relationship prostheses or more invasive provisional restorations.
three-dimensionally. Digital virtual wax-up substi- If the patient does not accept the mock temps
tutes are also useful for crafting milled or printed they are simply removed, bringing the denti-
restorations faster and achieving much improved tion back to its original condition. In these cases,
prosthetic results. However, it seems that virtual re- sometimes the sudden absence of the mock temps
ality is already starting to become obsolete in view is enough to convince patients that they felt and
of the power and possibilities of augmented reality looked much better with rather than without them.
in the digital workflow.
Mock-up provisionals (mock temps)

These are temporary prostheses that can be utilized
Consultations with other
in Phase I as excellent functional and esthetic tools specialists
for our treatment planning aims. Generally, they are In Class II and Class III interdisciplinary rehabilita-
neither an emergency nor a priority, but they are tions, consultations with other specialists are the basic
often a useful tool for gaining patient approval of and most important foundation on which prosthodon-
the prosthodontic prosthesis prior to the permanent tists build the treatment plan framework.
one being crafted. Mock temps can also be useful Therefore, it is important to be ready for these
for convincing patients and providing an impetus consultations. In fact, it is advisable to only set up
to their commitment to the treatment by showing consultations with specialists after all the diagnos-
them a good approximation of the final prosthodontic data and findings have been collected and prop-
tic rehabilitation envisaged for them. erly studied so that you can explain the case and
The concept of mock temps is also important be- its limitations in as much detail as possible to your
cause their use does not commit the clinician or the professional colleagues, who will then confirm your
patient to any active tooth shape change, as once they proposed clinical solutions and/or offer advice.
are removed the original tooth structure remains. In It is important to remember that any consultation
fact, mock temps do not involve any tooth prepar- with a specialist offers you the chance not only to
ation or any change to the patient’s original den- understand how better to treat and serve the patient,
tition. They are additive shells composed of com- but also to become more knowledgeable. In our pro-
posite resin and are temporarily cemented over the fession as clinicians, the learning curve is ongoing.
existing teeth for a functional and/or esthetic try-in. In the paragraphs below, a number of areas of
The missing parts that need to be implemented competence are outlined to which we can refer pa-
and reshaped are simply added on to those teeth. tients for professional consultations when neces-
Note that they can only be crafted once you have sary. These consultations develop and enhance our
explained their usefulness and cost to the patient, dental medical and prosthodontic professionalism
whose signed acceptance must be received. and help us to plan prosthodontic treatments.
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Consultations with other specialists
An excellent aspect of the curriculum of USA

Consultations and information
dental medical schools is that they teach ways of
It is pointless to discuss any clinical case and
creating more effective working teams for the ben-
treatment plan with other specialists before all
efit of both professionals and patients. This is highly
the necessary information is at your disposal.
educational and formative for any professional who
Without this information, you will not be able to
may want to serve with conscience, learn, and im-
assess and explain all the prosthodontic aspects of
prove. Also, it maintains at a high rate (and hope-
the case, nor will you be able to answer questions
fully this will increase with time) the number of
(or ask the right questions) that will arise during
the discussion. For many this may seem obvious, these areas of study that are outside the USA, teach-
and yet practically in the profession it often does ing graduate and postgraduate students the useful-
not seem to work this way. ness of consulting and sharing information from the
start to the end of the treatment process.
Therefore, when knowledge, experience, and/
or clinical judgement does not allow you to make
Dental specialties and other areas a clear diagnosis or formulate a treatment plan,
of consultation and you need to delegate a specific aspect of the
Consultations with specialists is of major importance patient’s care to another expert outside your field,
for treatment planning. In the USA, a number of take advantage of these experts. This is the ethically
specialties have been identified and formally recog- sound and logical thing to do and is a sign of your
nized by the American Dental Association (ADA). respect for your patients, your professionalism, and
Worldwide, Masters programs exist that teach the your specialty. It is a course of action that should
theory of specific dental specialties such as prostho- be mandatory for all medical professionals. Today,
dontics. In the USA, Canada, Australia, and a few many areas of specialized study are available in
other countries, specialties are instead clinical areas many USA schools and any professional may con-
comprised of well-trained experts in dental medi- sult with any one of them (Table 11-2).
cine that, according to the ADA, would “protect the To date, the wide choice of specific dental areas
public, nurture the art and science of dentistry, and of postgraduate studies shown in Table 11-2 is very
improve the quality of care.” 17 well organized and established in the USA dental
Dental specialties are recognized in those areas education system. In most other countries, for a
where advanced knowledge and skills are essential number of reasons, the speciality of prosthodon-
to maintain or restore oral health. The contribution tics either exists in a limited number of universi-
of this group of professionals has always been ac- ties or does not yet exist academically, or in some
knowledged by the profession at large, and their instances is still unknown among the dental medi-
collaboration is always encouraged. To be a dental cal profession, and especially among the public. In
specialist means to become an expert in a specific other instances, there are isolated attempts by cou-
branch of dental medicine, a professional whose rageous knowledgeable professionals to establish
specific and profound clinical preparation should this specialty.
go a long way beyond the education gained from a Until now in the USA, together with eight other
regular dental medical degree. ADA-recognized dental specialties (see Table 11-2),
It is important to take enthusiastic advantage of there are 57 Commission on Dental Accreditation
such specialists, especially when they are needed (CODA)-accredited Advanced Education programs in
during treatment planning, because they may help prosthodontics; these programs lead to a Certificate
you to define a more precise and better clinical as- of Achievement in Advanced Education. Their over-
sessment of the case as well as a more correct diag- all quality and scientific standards are evaluated each
nosis and treatment plan. year by the ADA-CODA, a governing body created
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Table 11-2 Examples of training areas in dental lives at an unprecedented rate. There have been
medicine in the USA three previous industrial revolutions; we are now
1. Accredited Advanced Education Programs living through the fourth, but change is happen-
● Dental Public Health* ing at a much faster speed and rate of exponen-
● Endodontics* tial growth than ever before. Medical science, and
● Oral and Maxillofacial Surgery* therefore also the specialty of prosthodontics, is
● Oral and Maxillofacial Pathology* constantly experiencing dramatic changes. To suc-
● Oral and Maxillofacial Radiology* ceed, we need to learn about what is available and
● Orthodontics and Dental-Facial Orthopedics* foresee what is to come, and rapidly adapt our way
● Pediatric Dentistry* of thinking and working accordingly.
● Periodontology* Nevertheless, there is still some resistance in
● Prosthodontics*
the profession to transition from analog to digital.
● Oral Medicine
This reluctance is constantly being analyzed; for in-
● Dental Research
● General Practice Residency stance, the study by a knowledgeable and dedicated
● Advanced Education in General Dentistry Commission of the American College of Prostho-
2. Certificate of Achievement Programs dontists, the results of which have been published
● Cranio-Mandibular Disorders and Orofacial Pain online in a digital white paper.19 The outcome of
● Advanced Dental Technology and Research this study indicates that soon our profession will be
Program very different. It is feasible that in the near future,
● Advanced Education in Esthetic and Operative all analog diagnostic examinations and instruments
Dentistry used today in the specialty will be like blurred tech-
● Implant Dentistry nological memories lost in the waste basket of an
3. Fellowship Certificate of Achievement
obsolete analog era. What is predicted in the near
Programs
future are robotized ANI-AGI (artificial narrow in-
● Advanced Digital Prosthodontics and Implant
Fellowship telligence-artificial general intelligence) in-office
● Dental Education Learning and Teaching dental office staff, dental chairs, handpiece arms, la-
Academy (DELTA) Fellowship boratories, etc, all integrated into the dental office.
● Dental Sleep Medicine Fellowship Currently in prosthodontic treatment planning,
diagnostics is constantly being improved by new,
* Recognized as a specialty.
sophisticated systems for digital treatment plan-
ning such as 3D:
ad hoc to “develop, establish, and verify with severe ● virtual digital articulators and facebows;
controls of the specialty, the respect of adequacy and ● virtual digital models;
efficacy of the educational requirements established.”18 ● virtual wax-ups;
● digital occlusal and TMJ evaluators and scan-
ners;
Diagnostic digital dental technology
● virtual augmented reality (AR) glasses and
The importance of technology in the development of wearable 3D screens;
dental medical science and practice has been touched ● implant surgical treatment planning and im-
on in many places in this book because the current proved CBCT technology.
progress in the field is largely brought about by dig-
ital developments and all that derives from them. All of the above will be animated and driven by ded-
Therefore, only a short note will be added here. icated ANI capability.
We live in an era in which new digital technol- This reality is already taking the place of analog
ogies are changing our personal and professional twin-copy articulators, diagnostic stone casts, max-
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Emergencies
illomandibular recording materials, articulating pa- Sometimes, it is difficult to convince patients of

pers, and diagnostic wax-ups; increasingly, reliable the presence of an emergency situation if they do not
substitutes are being developed that are able to help feel something or are not uncomfortable. The prob-
us study any clinical case and to plan on computer lem may be easier for them to understand and accept
screens digital and virtual prosthetic rehabilitations if pain or discomfort is the chief complaint. In any
of various extents and complexities. In the prostho- case, the situation needs to be assessed, and shown
dontic specialty, these advances are evident in al- to the patient in some way, if possible. Explain im-
most all of our clinics and laboratories. They are by mediately, clearly, and carefully to the patient why
no means perfect yet, but new diagnostic tools are and how the issue needs to be solved before any pos-
being made available every day, improving expo- sible prosthetic treatment can take place.
nentially in capability as well as increasing in num- Depending on the nature of the emergency, solv-
ber, quality, and precision. ing the emergency situation needs to take place in
The pace of this change is governed essentially Phase I, more often than not before any prosthodon-
by economic limitations and generational and cul- tic treatment plan can be put in place (refer also to
tural mindsets.20 this topic in Chapters 2, 5, and 10 [Fig 10-1]).
Preferential route medical

Emergencies priorities
Preprosthetic emergencies, These include, among others:

● oral cancer and biopsy investigations;
priority treatments, and initial
● caries removal;
disease control
● tooth extractions;
Sometimes, students and professionals are so fo- ● severe oral hygiene conditions;
cused on the search for prosthodontic rehabilitative ● periodontal and endodontic emergencies;
solutions that they forget to prioritize more im- ● surgical removal of cysts and other lesions.
portant issues that should be solved first.
An important medical rule is that evidence of Even though these oral conditions and/or patholo-
symptomatic or asymptomatic emergencies should gies are sometimes asymptomatic, they all require
always be given priority during treatment planning. immediate assessment and a solution.21,22
As was previously mentioned, patients seek our Indeed, these conditions may be profoundly af-
help for several reasons, unfortunately too often due fecting the patient’s physical health and will affect
to pain or discomfort, at which time it can be consid- the planning of any prosthodontic treatment.
ered ‘too late,’ as the treatment is frequently therefore
by nature an emergency that needs to be prioritized.
In other instances, while gathering patient his- Posttreatment care and asymptomatic
tories, data, and findings, the clinician may discover illnesses
an illness or disease that the patient does not know Always remind patients that many illnesses and
about because it cannot be seen, felt, or experienced diseases, even the most serious, can be asympto-
in any other way by the patient. This may be an matic. This means that they are often discovered
urgent medical emergency that must be dealt with be- by chance and/or at an advanced stage. This is one
fore any treatment plan can be made. The urgency of reason why posttreatment recall and maintenance
the attention it requires is dependent on the gravity (Phase III) is recommended and should be manda-
and/or presence of negative (symptomatic or asymp- tory for important disease prevention and techni-
tomatic) symptoms or signs. cal short- and long-term maintenance purposes.
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Also, severe oral and dental problems that are

Even though a patient may only complain of
immediately diagnosed should be treated before any
tooth pain or oral discomfort, make a habit
(small or large) prosthetic treatment plan has been
of checking the entire oral cavity for pos-
devised and agreed upon. In fact, when such prob-
sible lesions before you look for cavities or
lems are initially discovered and assessed, especially
other dental issues. A patient’s life is more
cancer, it is imperative that you explain the specific
important than anything else, and it usually
emergency treatment to patients so that they un-
takes only a few seconds to check and pos-
derstand that the problem will need to be treated as
sibly detect something that could be deadly
a matter of urgency before they agree to and sign an
serious.
informed consent for any prosthodontic treatment
(Table 11-3).
If the patient is a tobacco smoker, a smokeless

Table 11-3 Main priority emergencies that should be tobacco user, a habitual consumer of alcohol, has a
solved before the start of the prosthodontic rehabili- persistent oral infection such as human papilloma-
tation virus (HPV), and/or is frequently exposed to ultra-
violet radiation, cancer control should be performed
● Oral cancer control
immediately the first time, and then at follow-up
● Maxillofacial emergencies
appointments on a routine basis.23-29
● Periodontal emergencies
Worldwide, oral cancer comprises almost 85% of
● Endodontic emergencies
all head and neck neoplastic lesions. In the USA,
● Tooth extraction emergencies
some 49,750 new cases of oral cancer were diag-
● Caries emergencies
nosed in 2017, and about 27 people die of it every
● Professional oral hygiene emergencies
day (roughly one every hour). 57% of people will
● Relining and rebasing complete or partial
survive for 5 years. Also in the USA, oral and phar-
dentures
yngeal cancer together with laryngeal cancer affects
54,000 people every year, and of them 13,500 people
die every year (36.98 per day, 1.54 per hour). Be-
tween 1.6% to 3% of both males and females are af-
Oral cancer control
fected by these cancers among the overall percent-
Dental medical clinicians have the ideal opportu- age of cancers. The largest incidence of oral cancer
nity as well as the professional duty to check their is among people over the age of 40.30
patients’ oral cavity regularly. This is a privileged Lip and oral cavity cancer accounts for two-thirds
professional responsibility that allows you to detect of oral and pharyngeal malignant tumors, while the
any possible precancerous or cancerous lesion. There- remaining one-third are tongue cancers. The tongue
fore, it is crucial to know how to recognize the signs is the most common site of oral cancer.30 The sur-
and symptoms of precancer and cancer. If you know vival rate for oral and pharyngeal cancer is 50% af-
it, you see it! And if you see something that you do ter 5 years, which is dependent on race, sex, and
not immediately recognize, do not hesitate to con- the site of the cancer. So, while the survival rate of
sult with an oral pathologist. The easiest and most lip cancer is 90% after 5 years, the tongue cancer
obvious way to do this is to photograph it and im- survival rate ranges around 50%. This low survival
mediately send the image to the specialist, request- rate is because the tongue has a large amount of
ing a diagnosis. Cancer control is a priority when both blood and lymphatic drainage vessels that fa-
checking the oral cavity and mucosa of all – not vor the spread of metastatic cells. Afro-American
only new – patients. males have the worst prognosis.30
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Emergencies
In 2017, the Oral Cancer Foundation published your dental office has a proven record of success in
an online document listing the signs and symptoms this regard.31-36
of the disease. This is described in Chapter 9, to-
gether with other medical considerations that could
Periodontal emergencies
be helpful when making a diagnosis.30
There are different degrees of periodontal emergen-
cies, and whether or not they should be performed
Maxillofacial emergencies
before or during the prosthodontic treatment has
It may happen that patients suffering from maxillo- long been a subject of discussion. This obviously
facial conditions, with facial, clinical, and intraoral has implications for the planning of the prostho-
defects, arrive at your prosthodontic office for treat- dontic treatment.
ment that they consider to be an emergency. They Periodontal disease has been defined as “a group
may be experiencing a loss of comfort or looking of lesions affecting the support of the teeth in their
for possible pain relief, or for another reason such sockets,” and also as “the pathologic processes affect-
as technical prosthodontic assistance. ing the periodontium; most often gingivitis and peri-
In general, many of these patients are more odontitis.” 37,38
sensitive than most because they may have gone However, what is certain is that symptomatic
through a difficult or traumatic experience, eg, ex- periodontal disease is often the reason for the pa-
tensive surgical care, radiotherapy, or mutilations tient’s visit. If the disease is asymptomatic and you
that have left visible or invisible scars. Their defect discover it during the assessment, the patient needs
can be congenital, acquired, developmental, or due to know that it is considered an emergency and a
to trauma or disease. You should therefore ask them priority, to be treated as soon as possible.
in a professional and empathetic way to explain Signs such as bleeding on probing, probing
their chief complaint and needs, as usually they are depth > 4 mm, presence of a purulent exudate, and
expert at handling their condition and prostheses. loss of attachment level are clear indicators of on-
If your dental office does not have the expertise to going periodontal disease that should be considered
assist such patients clinically and/or technically, an emergency to be treated immediately.38
refer patients immediately to a maxillofacial pros-
thodontist who can help them, or consult with such
Signs of periodontal disease
a specialist yourself. If, on the other hand, you are
● Bleeding on probing
experienced enough in the field to be able to take
● Probing depth > 4 mm
on the emergency and solve it, go ahead and devise
● Presence of a purulent exudate
the rehabilitation treatment plan, always remaining
● Loss of attachment level
aware that creating maxillofacial prostheses is not
an easy task and that clinical and technical compro-
mises are usually necessary.
Indeed, the patient’s maxillofacial prostheses Both when it is evident and when it is doubtful,
may at times involve a large part of the oral cavity, you should consult immediately with a periodontist
the TMJ and masticatory muscles, and sometimes to confirm the presence of one or more of these
also the nasal, auricular, and orbital part of the face. signs and to discuss their gravity. Periodontal dis-
This makes the clinical and prosthetic emergency ease can be progressive and needs to be assessed
very delicate for the patient and for the prostho- and stopped as soon as possible.38,39
dontist. If confirmed, periodontal disease will usually
Therefore, never pass the ‘red line,’ unless the in- condition the timing and direction of the initial
formed consent has been signed by the patient and part of the prosthodontic rehabilitation and affect
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the treatment planning. If acute pain or infection should be saved until they can be evaluated for
are present due to the periodontal condition, it will prosthodontic treatment purposes.51-57
need to be solved immediately before continuing
with the prosthodontic treatment; however, if the
Caries emergencies
condition is not infectious and is not causing pain,
the healing or improving or bone/mucogingival Caries is one of the most common and serious dis-
enhancing periodontal procedure therapy can be eases in humans. It has been defined as a “patholog-
incorporated into the overall prosthodontic reha- ical process of localized destruction of tooth tissues by
bilitation.40-45 microorganisms.” 58,59
Caries is an immediate dental priority when it is
causing the patient pain and discomfort and if there
Endodontic emergencies
is evidence of a serious lesion capable of creating
Any type of acute endodontic infectious process further pathologic problems.
is a real emergency that needs to be solved imme- However, if the carious process affects those
diately. It should never be delayed because it may teeth that are to be involved in the prosthetic re-
jeopardize not only the involved teeth and the peri- habilitation but is imperceptible and painless for
odontium but also the overall physical health of the the patient (asymptomatic), is not deep, and poses
patient. The therapy should be advised and started no immediate risks to the tooth structure or sur-
before any prosthodontic treatment is performed or rounding periodontium, treating it can be delayed
informed consent is signed. On the other hand, usu- and performed as soon as possible as part of the
ally the treatment of a chronic endodontic condition overall prosthodontic treatment. This needs to be
can be delayed and included in the comprehensive explained to the patient. The assessment of the
prosthodontic treatment. Therefore, in these chronic gravity of caries and when to treat it is the subject
cases, after consultation with an endodontist, the of many questions during treatment planning ses-
endodontic therapy can be performed before or af- sions. 59-64
ter a first provisionalization stage, depending on the
clinical situation and the prosthodontic rehabilita-
Professional oral hygiene
tive plan.46-50
emergencies
Plaque and calculus are directly responsible for
Tooth extraction emergencies
many periodontal problems and sometimes their
When a patient is in severe pain or infection is excessive accumulation is related to serious oral and
present in a tooth that has a doubtful prognosis be- physical emergencies. In case of evident subgingival
cause of the type and amount of tooth destruction accumulation and related periodontal problems, the
or severe endodontic or periodontal conditions, for removal of plaque and calculus is an emergency and
instance, extraction may be the best and only way needs to be performed as a priority.65-70
to solve the situation. Some teeth are simply an op- Immediately tackling the issue of bacteria is al-
timal receptacle for bacteria and it is therefore best ways strongly advised and should be carried out prior
to remove them as soon as possible. Teeth, residual to and independent of any prosthodontic treatment.
roots, and root tips should be extracted following a This is not only because infections can affect the
preferential route. oral structures, but also because bacteria and vi-
On the other hand, if these types of teeth or ruses in the oral cavity are easily spread to the entire
roots are asymptomatic and are not spreading in- body. It is not by chance that mammalian evolution
fection, and furthermore have a strategic position developed to position the lymphatic sentinels (the
in the arch from a prosthodontic point of view, they Waldeyer’s ring; see Chapter 7) at the oropharynx
184
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v
CHAPTER TWELVE
Treatment planning analysis of
complex rehabilitations
Phase II:
Prosthetic and restorative treatment
Calvani_Ch_12_sue.indd 1 6/1/20 3:53 PM

This is the actual clinical prosthodontic working Some preliminary remarks

phase in which all improving, healing, and restor-
ative work is performed. Any old restorations that
General factors that may affect the
require removal are taken out; the teeth are re-
planned treatment sequence
paired, prepared, and any necessary post and cores
positioned (and sometimes re-prepared before and/ Evidence-based clinical experience teaches that de-
or after the periodontal therapy). spite our best intentions, analysis, and planning, a
All necessary temporary prostheses may be po- number of factors might occur that may affect the
sitioned and then modified, depending on the pro- course of treatment. It is wise and professional to
gression of the periodontal work, the tissue heal- consider these factors during your planning and to
ing, and the occlusal adjustments that are required, plan the treatment accordingly as far as possible be-
always taking the esthetics and phonetics into ac- cause they might profoundly affect the progression
count. of the prosthodontic care.
Implants may also be positioned in Phase II They can be briefly summarized as follows:
following proper preprogrammed planning and 1. The knowledge and dexterity of the prostho-
timing. They can be immediately loaded or their dontist.
loading may be delayed; the loading is followed by 2. The availability, knowledge, and dexterity of
customized implant abutment positioning as well one or more other specialists.
as customization for specific periodontal soft tissue 3. The availability as well as the personality of
shaping.1-3 the patient.
Prosthodontic treatment planning is influenced 4. The availability of the collaborating laborato-
by various therapies and stages of treatment. The ries.
main considerations for prosthodontic treatment 5. The number of prosthodontic clinical issues
planning for the following eleven specific areas are that may occur (this usually increases with
discussed in this chapter: Class III prosthodontic treatments).
1. Orthodontic therapy. 6. The clinical gravity and extent of any oral
2. Periodontal and oral surgery therapies. disease/s.
3. Endodontic therapies. 7. The number and type of clinical, endodontic or
4. Mutilated roots and teeth. orthodontic therapies, treatments, and inter-
5. Post and cores. ventions.
6. Provisional restorations. 8. The number of periodontal, endodontic, max-
7. Implant placement. illofacial, oral or other surgical interventions
8. Maxillomandibular registration. that may be required.
9. Final impressions. 9. The number of clinical specialist interventions
10. Final prosthesis try-in and delivery. that may be required by other specialists to
11. Bite guards. solve problems and/or heal disease/s.
10. The rational concatenation of the temporal
Before the discussion of each of the above points, sequence of all interventions.
the general factors as well as the complications that 11. The healing process, which not only differs
may affect the sequence of treatment are briefly con- for each patient, but which also depends on
sidered. the number, extent, and combination of the
various clinical factors. There might be sev-
eral clinical factors that may complicate the
treatment and therefore affect the duration and
progression of the healing process, including:

Orthodontic therapy
a. patient’s age; 4. Periodontal: poor oral hygiene access, incom-

b. general and local physical and mental health plete calculus removal in periodontal pockets,
conditions; gingival and osseous tissue defects, suture
c. type of medicines being taken; abscesses, root sensitivity, trauma, foreign body
d. drug addiction, use, and abuse; impaction, food impaction and accumulation,
e. oral hygiene habits; swelling, ecchymosis (mainly in elderly pa-
f. type of occlusion; tients), vascular impairment, clotting disorders,
g. parafunctional habits; infections.
h. type of existing (old or new) temporary 5. Implant: incorrect placement, lack of integra-
prosthesis; tion, surgical traumas, mental nerve damage,
i. psychologic conditions. sinus penetration, fistulas, thread exposure, ex-
12. Possible complications that already exist or cessive countersink, soft tissue defects, osseous
may occur during the treatment. This fac- and structural defects, early prosthesis loading,
tor needs consideration as there might be a loose cover screw, screw fracture.
number of complications that could completely 6. Impact accidents: prosthetic, coronal, root frac-
change the timeline and forecasts of Phase II, tures.
slowing down the resolution of any healing or 7. Laboratory: technical laboratory issues.
restorative procedure as well as the final pros-
thesis delivery.
Orthodontic therapy
Complications that may affect the
Any preprosthetic orthodontic therapy should al-
planned treatment sequence
ways be taken into consideration as one of the first
During prosthodontic seminars, the question of options during treatment planning. If the teeth need
‘complications’ always seems to be a difficult one to to and can be properly aligned to optimize the po-
answer. Complications can be unknown, preexisting, sition of the remaining dentition, this should be
occurring, unpredictable or foreseeable. This makes planned for first in order to help reduce the amount
the issue of complications a complex one in terms of prosthetic work required.7,8
of prosthodontic treatment planning because many Any realignment, uprighting, rotation, intru-
of them cannot be foreseen or predicted. sion, extrusion, lateralization, mesialization, distal-
All of the following complications should be ization, and tooth and prosthetic abutment move-
borne in mind when planning a prosthodontic ments should be evaluated during the orthodontic
treatment:4-6 consultation. If any of these treatments seem neces-
1. Patient: finances, expectations, esthetic needs, sary, they should be carefully planned to be part of
phonetics, and/or psychologic issues. any prosthetic treatment rehabilitation.9-11
2. Dental: abutment fractures, defective abutment If recommended and possible, any orthodontic
restoration, incorrect post and cores dimen- treatment should be well integrated into the prost-
sions, incorrect abutment preparation for re- hodontic rehabilitation timeline, together with all
sistance and form retention, fracture of acrylic the other possible clinical interventions.12,13
provisionals, decementation of provisionals and It is advisable to explain this aspect thoroughly
post and cores, caries, any type of sensitivity. to the patient to avoid any waste of time during
3. Endodontic: tooth perforations, abscesses, fistulas, the orthodontic treatment that may follow, which
excessive post space preparation, excessive gut- can take a few months or longer. Due to the time
ta-percha removal, partial or defective endodon- demands of many orthodontic treatments, it is im-
tic fillings due to lateral canals, root sensitivity. portant to take into account how they will affect the

treatment schedule as well as their possible implica- Regarding the timing of endodontic therapies,
tions for oral hygiene and the integrity and func- indications of several studies have shown that endo-
tionality of the positioned provisional prosthesis.14 dontic therapy is more predictable if performed before
periodontal therapy, and that it may also positively
influence the healing of the latter. However, in com-
bined endo-perio lesions and diseases, the prognosis
Periodontal and oral surgery of both, and mostly of the endodontic treatment at the
therapies end, depends on the success of the periodontal ther-
In Class II and III treatment plan categories, the time- apy. So, it might be advisable to plan these treatments
line of both prosthodontic and periodontal thera- according to scientific and clinical evidence.34-39
pies should be well planned in Phase I according to Hence, any asymptomatic chronic apical le-
the clinical needs of the overall rehabilitative plan. sion or retreatment of defective endodontic fillings
They should work synergically from the beginning should be planned according to the chief complaint,
to optimize the healing time of the soft and hard the clinical judgement of the specialist team, and the
tissue as well as the restorative aims. The objective needs of the overall prosthetic treatment plan.40-45
is to achieve an improved oral and physical health In this regard, there are important prosthodontic
status in the fastest timeframe possible.4,15,16 considerations in terms of the successful repair of
Often in demanding cases, a first provisional pros- nonvital teeth and how to use them that should be
thesis may be positioned either before or after any analyzed when planning the treatment.46
periodontal therapy, and often relined after extrac- However, all the possible questions that will
tions, crown lengthening, pocket elimination, root arise during the discussion of the treatment should
hemisections and reshaping procedures, osseous and consider the one main question: Will this nonvital
mucogingival surgery, bone and mucosa regener- tooth be a reliable supporting structure in the prost-
ation surgeries, free gingival grafts, bone grafts, facial hodontic treatment being formulated?
surgeries, removal of cysts, sinus lifting, mandibular
nerve transposition, and for other reasons.17-21 Main questions related to endodontically
Provisional prostheses may be both useful and treated teeth:
necessary to guide any periodontal therapy and 1. What are the current conditions of the tooth
possible surgeries,22 revealing important anatomical that has already been/is still to be treated?
tooth and periodontal information in the quest for 2. Is it a maxillary or a mandibular tooth?
more esthetic and physiologic rehabilitations.23-27 3. What is the position/function of the tooth in
the arch? (anterior, guiding, posterior, chew-
ing)
4. Is the tooth prosthetically covered?
Endodontic therapies 5. Is the tooth decayed?
Endodontic therapies are necessarily invasive pro- 6. How much tooth structure exists?
cedures because they change the structure of the 7. How much tooth/dentin structure will remain
tooth. after a possible endodontic treatment?
Therefore, unless the first examination reveals 8. How much tooth/dentin structure will remain
evidence of an endodontic or a perio-endo emer- after a possible retreatment?
gency and/or lesions with evident symptomatic 9. What is the condition of the adjacent teeth?
signs of acute disease that require priority treat- 10. What is the condition of the edentulous spaces
ment, endodontic therapies may be established in adjacent to the affected tooth?
the timeline of the foreseeable prosthodontic treat- 11. What is the root length of the tooth?
ment plan.28-33 12. What is the crown-to-root ratio?

Post and cores
13. What type of endodontic filling has been/will 9. Is the root or tooth worth saving?
be used? 10. In case of root/tooth extraction:
14. What type of material will be used to recon- a. How could the periodontium of the adjacent
struct its core? (cast post and core, amalgam teeth change?
post and core, composite resin core with a b. How could the edentulous ridge change?
prefabricated post) c. Are any ridge preservation procedures
15. What type of prosthesis will that tooth be part necessary?
of? (single, part of a larger prosthesis, terminal d. What type of ridge preservation procedures
for cantilever) can be performed?
16. What type of biomechanical forces will be
applied to the tooth? (on the long axis, lateral)
17. How much force will be applied to the tooth?
(bruxer, 25-year-old marine soldier, elderly
Post and cores
person) If necessary, the rehabilitation of old or recent en-
18. What is the long-term prognosis of this non dodontic therapies from before the first visit that
vital tooth? show no signs of pathology can usually be consid-
ered for direct or indirect post and cores built and/
or cemented to rehabilitate any remaining root with
a core-supporting abutment.47-65
Mutilated roots and teeth Regarding post and cores, there are important
Often, when considering how to restore a remaining considerations about the predictability of recon-
root or tooth structure in the planning phase, their structed teeth as abutments. To this end, further
value and position will raise questions about the pos- biomechanical aspects should be taken into consid-
sibility of their use in the context of the planned re- eration (see questions below).
habilitation. In such cases, a decision must be made
as to whether to restore or extract the root or tooth. Main questions related to post and cores:
1. What is the strategic position of the roots or
Main questions related to mutilated roots and tooth on the arch?
teeth: 2. What is the shape of the roots?
1. What is the position of the tooth on the arch? 3. How much post space exists?
2. What is the biomechanical engineering value 4. How thin are the root walls?
of the root? 5. How thin is the pulp chamber floor?
3. What is the esthetic value of the root or tooth? 6. How far from the apical seal does the post
4. What will the crown-to-root-ratio be after any space end?
reconstruction of the root or tooth? 7. How much remaining tooth structure exists?
5. If the questionable root or tooth is restored, (amount of dentin, number of dentin walls,
will the patient be able to maintain good oral thickness of dentin walls)
hygiene in that area? 8. Does the remaining tooth structure and the
6. Is the root or tooth reducing or compromising post and core reconstruction allow for a
the long-term prognosis of the possible resto- ‘ferrule effect’ for any future fixed prosthesis?
ration? How high and thin would this dentin collar
7. Can the root be used for ridge preservation? be?
8. Can the root be used for removable partial 9. Is any possible crown lengthening therapy
denture (RPD) or complete denture (CD) planned around this tooth?
support? 10. Is it or can it be a cast post and core?

11. Is it or can it be an amalgam post and core? will not suffice but will only serve as a means for tran-
12. Is it an amalgam reconstruction with a prefab- sitional testing. In fact, this first set is often adjusted,
ricated threaded metal post? modified, relined, or altered, and sometimes tested
13. Is it or can it be a composite core with a pre- multiple times after any periodontal procedure and
fabricated post? according to specific biologic, esthetic, functional,
14. Is it visibly a screwed-in prefabricated post? and rehabilitative needs.73-78 It is therefore often
15. What is the possible long-term prognosis of compromised due to the many corrections, which
this nonvital post and core rehabilitated tooth? may alter its structure esthetically and weaken it
16. Will this nonvital tooth be a reliable support mechanically beyond the acceptable capability to
structure in the planned prosthodontic treat- resist any vertical or lateral occlusal load.79
ment scheme? Alternatively, would it be better In these functionally and esthetically challeng-
to extract it and replace it with an implant? ing and/or demanding rehabilitations, it may be
17. What is the individual prognosis of the non necessary and worthwhile to plan for a second pro-
vital tooth? visional fixed prosthesis. This will mean that the lab-
oratory technician will not have to craft the final
prosthesis using approximation and intuition alone
because this second set of provisionals will afford
Provisional restorations the opportunity of acquiring refined and more pre-
As previously mentioned, provisional prostheses cise anatomical, functional, and esthetic informa-
are very important and sensitive rehabilitative tion than that obtained from the first set. This in-
structures. formation is important and necessary to construct
Depending on the complexity of the prostho- the final prosthesis.
dontic treatment, one or more sets of provisional
fixed restorations may be needed. Their use must be
Planning the lifespan of
carefully foreseen, they must be planned accord-
provisionals
ing to the challenges of the clinical case, and their
maintenance must be explained to the patient.4,66-72 Clinical evidence shows that regular resin-based,
In simple Class I full reconstructive rehabilita- laboratory processed temporary fixed prostheses
tions, where there is no disease and where a pure are structurally rather weak and are therefore more
prosthodontic restorative rehabilitation is planned, likely to flex, become uncemented, wear, and finally
clinical experience suggests that the restorative break.
treatment can usually be managed with one set of Therefore, simple provisional fixed restorations
provisionals, which will probably suffice to carry out should not be used for too long unless originally well
its functional and esthetic purpose and to obtain all planned, designed, and crafted with specific bio-
the information necessary to create the final pros- compatible materials that are able to last and be ce-
thesis and restorations. mented properly.80-84
Often it is different for Class II improving and In fact, any type of temporary prosthesis should
Class III healing rehabilitations, in which more spe- remain in the mouth for the least amount of time
cialists need to intervene to improve and/or heal the possible but for long enough to allow for the healing
existing conditions of the compromised case. of any disease, to verify its function and esthetics,
Therefore, depending on the clinical conditions and to allow for the crafting, trying-in, and delivery
of the case and the aims of the rehabilitation, the of its final definitive prosthetic twin.4,67-72
use of a first set of provisionals (either fixed or re- In this regard, you need to remember all the main
movable) can be foreseen and planned. This is done functions of provisional fixed restorations and how
with the knowledge that, very often, this first set to use them properly. Their functions should be ini-

Implant placement
tially evaluated during the planning phase, and the Table 12-1 Requirements of provisional restorations
characteristics that play the largest role in crafting 1. Biologic requirements such as:
them properly should be well known so that they a. Protect the nerve
are clinically checked and defined according to the b. Maintain periodontal health
individual patient’s esthetics, phonetics, and func- c. Provide occlusal compatibility
tional requirements. d. Maintain tooth position
These desired characteristics have been well or- e. Protect against fracture
ganized and listed by Rosenstiel et al1 (Table 12-1). 2. Mechanical requirements such as:
a. Resist functional loads
b. Resist removable forces
Long-term fixed provisionals c. Maintain inter-abutment alignment
3. Esthetic requirements such as:
These are planned when complex long-lasting treat-
a. Easily contourable
ments need to be carried out such as extensive com- b. Color compatibility
prehensive partial or full-mouth rehabilitations, or c. Translucency
when patients are predictably not going to be com- d. Color stability
ing into the dental office for a long time.
Long-term fixed provisionals can also be useful
when temporomandibular joint (TMJ) problems have
to be verified and possibly solved over time before a thesis may function and should be shaped in order
final prosthesis is to be crafted and delivered. They to achieve the proper fit. Computer-generated vir-
are necessary in all those demanding cases in which tual models still cannot replace the experience of the
the physical structure of the provisionals will be sig- patient actually wearing the provisional prosthesis for
nificantly challenged in some way.85,86 a period of time.
These prostheses must be more resistant and By actually testing the provisional, patients can
therefore often need to be crafted using a reinforcing supply important subjective information (both neg-
metal or with polytetrafluoroethylene (PTFE) scaf- ative and positive) about the functional and esthetic
folding substructures. They can also be reinforced realities such as fit, comfort, effect on phonetics,
with various other synthetic materials that may im- etc. This information is clinically very valuable and
prove their elastic and physical properties so that will invariably enhance the prosthodontist’s under-
they are better able to withstand long-term occlusal standing of what is required for the final prosthesis.
functional wear as well as to increase their fracture It is difficult to estimate for how much longer
resistance to loads and fatigue.87-90 prosthodontists will still be obliged to use analog
provisionals to obtain reliable clinical informa-
tion. What is evident, however, is that one cannot
Analog or digital provisionals?
achieve the same true and reliable results on a com-
Despite the current digital technological advances puter screen as one can by testing a provisional in
in diagnostics, clinical experience has shown that a patient’s mouth.
analog, clinically tried-in provisionals are the most
reliable and effective way to test the shape of the
final prosthesis directly in the patient’s mouth.
Most often, prosthodontists working on complex
Implant placement
rehabilitations still require their patients to wear a Plan for implants according to the envisioned clin-
provisional so that they have an actual (as opposed ical opportunities, taking into account patients’
to a virtual) example to refer to that can give them a economic situation and their need/desire for and
clear and practical indication of how the final pros- understanding of implant therapy.

Patients must be well informed about all the According to various well-known studies, a cer-
clinical implant phases as well as the benefits, func- tain amount and quality of bone allows one to choose
tional and esthetic limitations, and risks of implant and position tilted implants properly when rehabil-
treatment. Explaining one or more treatment plans itating edentulous areas. As a prosthodontist, you
is a good opportunity to do this properly before should know better than any dental medical profes-
starting the clinical process. This is best accom- sional all the information pertaining to implants and
plished through questions and answers that are able restorative procedures when planning rehabilitative
to clarify all aspects of the proposed therapy as well treatments, regardless of whether you use digital
as how to avoid possible complications.91-106 models or analog casts and wax-ups.108-111
Thanks to the commitment and achievement of
the American College of Prosthodontists with the Main questions related to implant treatment
American Dental Association’s Commission on Dental planning:
Accreditation (ADA-CODA), all USA postgraduate 1. Patient evaluation:
students who enroll in the 3-year program toward a a. What kind of personality does the patient
USA Certificate in Prosthodontics have the opportu- have?
nity at school to repeatedly practice clinical surgical b. What are the patient’s needs, desires, and
implant positioning. This helps not only to improve expectations in terms of implants?
their expertise and clinical dexterity skills, but also c. How much time does the patient have
to broaden and deepen their knowledge about the available for the treatment?
initial prosthodontic treatment planning phase. d. How much knowledge and awareness does
ADA-CODA’s Accreditation Standards for Ad- the patient have about implants?
vanced Specialty Education Programs in Prosthodon- e. How active, aware, and dexterous is the
tics 4-23 established that students/residents must be patient regarding oral hygiene?
competent in the placement and restoration of den- f. How compliant do you think the patient will
tal implants, including referral. be in terms of posttreatment care?
The intention of implants is the replacement of g. Can the patient afford the cost of the
missing teeth and the associated oral and maxillo- treatment?
facial tissue using biocompatible substitutes, which 2. Tissue evaluation:
is a core component of the definition and practice of a. What is the arch form?
prosthodontics. Students/residents should perform b. What is the interarch space?
the surgical placement of dental implants in healed c. What is the overall amount of ridge
edentulous sites with adequate vertical and horizon- resorption?
tal osseous tissue as a part of prosthodontic treatment. d. What are the dimensional characteristics of
These experiences should enhance the know-how of bone? (height, width)
students/residents in terms of the processes of assess- e. What is the quality of the bone?
ment, diagnostics, treatment planning, the implemen- f. What is the type and amount of remaining
tation of a prosthetic rehabilitation, and referral.107 gingiva?
For a prosthodontist today, planning the ideal g. What type of periimplant tissue is present?
placement of any dental implant is a straightfor- h. What type of periimplant tissue can be
ward task because their position becomes clearer achieved, or how can it be improved?
with the analog or digital planning of the crown/s. 3. Prosthesis-implant evaluation:
The position of the crown/s also makes it easier to a. What type of dental esthetics is needed and
carefully program the loading of the implants on may be achieved?
their long axis to better withstand the biomechani- b. What type of facial esthetics is needed and
cal masticatory forces. may be achieved?

Implant placement
c. What prosthetic facial support may be envisioned and programmed?

achieved and what are the foreseeable limita- 5. Prosthesis-implant maintenance:
tions? a. What type of maintenance and recall
d. What type of implant prosthesis can be schedule can be programmed?
planned? (fixed, removable)
e. What type of implant prosthesis biome- In preprosthetic implant cases, placement may cer-
chanics are relevant? (single, multiple, tainly be planned during Phase I (diagnostics); how-
splinted) ever, the timing and positioning of implants should
f. What is the best implant location for the be reevaluated once the oral healing has been
prosthetic solution? achieved and the situation in the mouth is clinically
g. How many implants should be placed? stable in time. The same applies to preprosthetic
h. What is the possible distribution and orthodontic treatment – a reevaluation is best made
position of the implants on the arch? once the repositioning of the remaining teeth has
i. Will there be prosthetic cantilevers, and if so, been achieved and the situation is clinically stable
where? in time.
j. What type of implant placement can be During the initial prosthodontic-implant evalu-
achieved? (vertical, tilted) ations, the timing of all implant and prosthodontic
k. What will the stress distribution be on and procedures should also be optimized, as the possi-
around the implants? ble differences in bone characteristics between the
l. What type of prosthetic retention can be two arches might affect the planning of implant
used? (cement-retained vs screw-retained) insertions. Indeed, the lower density of the max-
m. What type of implant platform can be used? illary bone compared with the mandibular bone
(internal hex vs external hex) sometimes does not allow for faster loading of the
n. What type of prosthetic structural materials implants.
can be used? (metal, plastic, ceramic)
o. What type of occlusal scheme can be made
Implants are a sensitive
or remade?
rehabilitation to plan
p. What type of opposite occlusal material
already exists and/or can be developed? Particular attention should always be given to im-
q. What type of occlusal material can be used? plant cases, starting at the planning stage and then
r. What type of implant/s can be positioned? through post-insertion healing to the development
s. What type of final impression can be made? of an immediate rather than a delayed prosthodon-
(analog, digital) tic treatment.
t. What type of interocclusal record can be Patients should be advised to be consistent in
used? their commitment, consistency, and availability with
4. Prosthesis-implant surgical evaluations: regard to the appointment schedule. They should be
a. What type of drilling would be necessary encouraged to carefully follow all postsurgical and
and performed? (preformed burs, maintenance suggestions and instructions.
osteotomes) Clinical experience shows that many patients
b. How much postsurgical healing time is do not follow these instructions carefully enough.
envisioned? Often, if they have no symptoms and feel well af-
c. Will there be periimplant tissue condi- ter the surgeries, there is a tendency for them to
tioning? underestimate the importance of the postinsertion
d. Will there be provisional restorations? maintenance procedures. Some may fall into the old
e. What type of postsurgical care can be bad habits and behavior patterns that brought them

care maintenance information in writing on the treat-

to the dental office in the first place. ment plan that patients will sign, a copy of which will
be given to them to refer to whenever necessary.
It is also advisable to ask patients to comment on
Implant postsurgery instructions
the treatment plan after they have read it carefully
for patients
with you and you have discussed it, because their
Clinical experience suggests that it is important that immediate comments will give you an opportunity
practical instructions are not only verbally commu- to understand and foresee the particular kinds of
nicated to patients but are also supplied in written problems or difficulties that may arise with individ-
form. It is suggested that you devise a leaflet or form ual patients after implant positioning. Make sure
with postsurgery instructions to be given to patients to carefully answer all the patient’s questions that
to take home after implant surgery. may arise during this process.
Always explain the homecare postsurgery expec- The most important implant postsurgery in-
tations when you are discussing the treatment plan structions are given in the box below. These are
with your patients. In that way, they will be informed useful in order to introduce patients to the commit-
in advance about the expectations and responsibili- ments expected of them during implant treatment
ties that will be required of them during the healing and to remind them of these during the different
phase. In fact, it may be useful to include this home- phases of the procedure.1
Postsurgery implant instructions for patients

1. Smoking: DO NOT SMOKE any type of tobacco for 4 weeks postsurgery.
2. Cold packs: Use only if advised, in which case gently position the cold pack on the cheek over the implant site
without pressing down on it. Hold it in place for 5 minutes, remove, then repeat after 5 minutes. Only use
cold packs for the first 24 hours postsurgery.
3. Rinsing: Do not rinse your mouth for 72 hours postsurgery. Rinsing may remove the blood clot from the
wound, slowing down and jeopardizing the healing. After 72 hours, gently rinse the mouth twice a day with
the prescribed mouthwash.
4. Diet: It is best to eat soft foods at body temperature for the first 4 days postsurgery. Avoid too hot and too
cold food and drinks for 1 week postsurgery. Do not use a drinking straw. Try to eat a balanced diet in order
to heal properly. Do not drink alcohol for 1 week postsurgery.
5. Tooth brushing: Avoid any brushing on the wounded area and the sutures. However, gentle and accurate
brushing is suggested over the adjacent tooth surfaces. Normal brushing should continue elsewhere in the
mouth. Carefully remove residual food debris to avoid postsurgery infections.
6. Medications: Carefully follow the prescription doses and avoid any alcohol use. Do not take medications on an
empty stomach. Do not take other medications unless discussed with your clinician and then prescribed.
7. Bleeding: Light bleeding of the wound area is normal for 48 hours postsurgery. If necessary, sleep on two
pillows to raise your head. Avoid physical stresses.
8. Pain: A slight pain is normal on and around the wound
area. Painkillers should be taken as advised, if necessary. WARNING: Please call the dental office
9. Swelling: A slight swelling of the wound area is normal. in case of:
The extent of the swelling may vary according to the ex- 1. Severe pain, also after taking painkillers.
tent of the surgery and the size of the wound area. The 2. Profuse bleeding that does not stop even
swelling usually increases for the first 3 to 4 days post- after pressure is applied to the area.
surgery, and then should decrease and in time disappear 3. If the swelling continues after 4 days.
completely. The swelling is controlled by the prescribed 4. If there is an increase in body temperature.
medications. 5. If there are any other problems that are not
10. Sutures: These will be removed 7 to 15 days postsurgery. mentioned here.
10

Final impressions
the periodontal hard and soft tissue and abut-

Pay special attention to the emergency situa- ments are healthy and sound. At that point, the
tions shown at the bottom of the box (in the white final impressions are ready to be finalized and re-
space). corded.4-6
Therefore, the timing of the final restorative part
of Phase II is determined by how well the patient has
healed and the point in time when the clinical situ-
Maxillomandibular ation shows itself to be sound and stable.
registration The clinical situation is at this point when:
This brief note highlights a number of important 1. The hard and soft periodontal tissue is com-
prosthodontic parameters and their registrations such pletely sound.
as the three-dimensional (3D) maxillomandibular 2. The endodontic radiographic and clinical find-
relationship, the vertical dimension of occlusion ings are positive.
(VDO), the anterior guidance, the speaking space 3. Any possible orthodontic treatment has been
and individual capabilities, the rest position, and completed successfully.
the accurate transfer of all information related to 4. All implants are osseointegrated.
the functionality of the temporary prosthesis to any 5. The prosthodontic work to reconstruct and
analog or virtual articulator as well as to the final customize all provisional customized support-
prosthesis. ing abutments has been performed. They are
All these anatomical and physiologic parameters screwed in on the implant platform for the
may challenge the prosthodontist in Phase II. They emergence profile gingival shaping. The peri
should always be preestablished or reestablished, implant tissue must be healthy.
verified, and evaluated both on the mounted casts 6. The existing provisional prosthetic restora-
and in the mouth during treatment planning, and tions guarantee sound and stable anterior and
then clinically maintained or modified according to posterior determinants of occlusion, together
the needs of the individual patient during and until with excellent esthetic and phonetic results. All
the end of Phase II treatment.4-6,112-114 clinical information is ready to be transferred
They should also be carefully controlled to avoid to the final restorations.
unwanted changes before prosthesis delivery be- 7. All necessary tooth preparations have been
cause they constitute individual anatomical, func- perfected and finalized.
tional, and esthetic values that characterize each
individual case. The extent of the possible changes
that might occur may variously affect the proce-
dures and the treatment outcome. If these param- Note about payment
eters are correct, there is a much better chance of a Usually (but not necessarily) dental medical pro-
predictably successful treatment outcome. fessionals tend to divide the overall treatment cost
into thirds, with the first payment due when the
patient signs the initial treatment plan, the second
at the time of the final impressions, and the third
Final impressions before the delivery of the final prosthesis.
In the prosthodontic clinical timeline, the final im- Patients should clearly understand this pay-
pressions usually mark the end of the tissue healing, ment schedule, which should be specified clearly
the final abutment preparation stage, and the begin- on the treatment plan that they will sign before
ning of the final restorative part of Phase II. treatment begins.
A final impression can only be made when
11

outcomes so that patient expectations are always re-

8. Once all these steps have been sucessfully alistic, and disappointments can be avoided.
achieved, analog or digital final impressions
must be made, which accurately reproduce all
Relining and rebasing of RPDs and
the abutments details in order to create the
CDs
final prosthesis according to the anatomical and
functional information from the temporary one. According to the Glossary of Prosthodontic Terms,
‘relining’ is “the procedure used to resurface the in-
taglio of a removable dental prosthesis with new base
material, thus producing an accurate adaptation to
Final prosthesis try-in and the denture foundation area,” while ‘rebasing’ is “the
delivery laboratory process of replacing the entire denture base
At the end of Phase II, the final prosthesis is crafted material on an existing prosthesis.” 115
in the laboratory and is clinically tried in. The final Statistics in the USA show that while there was
occlusal and esthetic adjustments then take place. a 10% decline in edentulism each decade for the past
It is strongly suggested that patients be involved 30 years, this is more than offset by the 71% aging
in any final esthetic, phonetic, and occlusal testing. It of the adult population older than 55 years.116 This
is important for patients to know and understand means that, in the USA, the amount of people in
what they can expect as well as the possible limi- need of RPDs and CDs is increasing.117
tations they might experience after the prosthesis A good understanding of the difference between
is delivered. If they are involved in this testing pro- relining and rebasing and when to perform them
cess, their needs can be met as far as possible and should be part of the prosthodontic armamentar-
misunderstandings and disappointments regarding ium. Both these procedures alter the basal surface of
the final prosthetic outcome can be avoided. As has an RPD and CD, but while relining may be revers-
been mentioned, the last treatment payment is usu- ible, rebasing is always irreversible.
ally due before the delivery of the prosthesis.4,6,114 The possibility of these procedures being ne-
Regardless of the type of prosthesis being deliv- cessary should be well understood and properly
ered, the actual delivery is often a sensitive moment. planned for during Phase I. However, relining and
This is ironic because, in fact, it should be a simple rebasing can also be performed in an emergency or
delivery procedure with no further doubts about a priority situation, whether it is symptomatic or
the end result in terms of shape, color, esthetics, and asymptomatic.
functionality. The choice of one of these two procedures de-
By this stage, everything should have been pends on the composition, number, and gravity of
clearly and carefully communicated and clarified the prosthetic problems of which the patient is com-
by the dental team at each step throughout the pro- plaining or that you see during the clinical exami-
cess. The patient’s questions and doubts about the nation such as:118-125
therapy and the future outcome should have been 1. Mucosal-bearing tissue inflammation.
thoroughly addressed. 2. Loss of retention and stability.
As a clinician, the last thing you want is for the 3. Loss of VDO.
entire weight of all the decisions to be on your shoul- 4. Loss of support of the facial tissue.
ders, without the patient’s participation, awareness, 5. Horizontal shift of the prosthesis.
and consent. It is crucial for everyone concerned 6. Incorrect occlusal relationship.
that the patient is fully informed and understands 7. Possible reorientation of the occlusal plane.
clearly – from the time of the initial treatment plan
discussions – all the possible therapy and treatment The relining procedure of the base/s of the RPD or
12

Bite guards
CD with a soft relining material may be performed Bite guards

as an emergency temporary additive procedure only
in cases where there is a need for conditioning and In patient cases in which parafunctional activities
healing of the inflamed tissue. This is because soft and/or bruxing habits have been initially diagnosed,
relining material can be added chairside and then an occlusal devise such as a bite guard or night
removed (with some difficulty at times), regaining guard should be planned for the end of the restora-
the original intaglio shape of the base.122,126-128 tive treatment.
The rebasing procedure, on the other hand, might The protective utility of bite guards should be
be considered an invasive procedure because it com- clearly elucidated to the patient as part of the treat-
pletely changes the original structural integrity of the ment explanation in Phase I.
RPD or CD. This may present a problem if patients In many extensive rehabilitations, bite guards
do not clearly understand that things are going to are a predictable mandatory means of protecting
change dramatically within the base of their current the new prosthesis and the remaining dentition
prosthesis. from further potential damage.
Therefore, sufficient planning should be under- Bite guards should be crafted immediately after
taken in Phase I if the shape of the base of an old the delivery of the final prosthesis and their fitting
or new RPD or CD needs to be altered as a priority, checked until they are stable on the retaining den-
an emergency, or where the chief complaint is the tal arch. They should then be adjusted in centric re-
search for a better solution. lation and their eccentric guidance verified. Finally,
Indeed, once the base has been modified, the ‘red they should be polished and delivered to the pa-
line’ has been crossed and you are in the ‘danger tient, together with comprehensive instructions for
zone.’ It is therefore always wiser to plan it before- home maintenance.
hand and make sure it is understood and accepted It is advisable to ask patients to bring their
by the patient (with a signature on the informed bite guard along when they come for follow-up
consent form) prior to tackling it.122,129-131 visits. At these maintenance appointments, make
sure that patients are wearing the bite guards cor-
rectly and that they still fit properly. If parafunc-
13

Fig 12-1 Case 1. Pretreatment frontal view in maximum intercuspation position (MIP).
Fig 12-2 Case 1. Posttreatment view. Note the presence of the bite guard, crafted to save the dentition from the
possible presence of parafunctional bruxing habits.
14

Final prosthesis try-in and delivery
Fig 12-3 Case 2. Pretreatment frontal view in MIP.
Fig 12-4 Case 2. Posttreatment view. Again, the bite guard was used to save the dentition from possible
parafunctional bruxing habits.
15

16

Final prosthesis try-in and delivery
17

Periodontal Therapy, ed 6. St. Louis: Mosby, 1980.

tional habits were present, verify whether these are 16. Nevins M, Mellonig JT. Periodontal Therapy. Clinical
Approaches and Evidence of Success. Vol 1. Quintes-
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sence, 1998:1–27.
working effectively to reduce the parafunctional
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load.132-134 tegrated approach to periodontics and restorative den-
The images on the following pages (Figs 12-1 to tistry. Dent Clin North Am 1980;24:285–303.
12-8) are courtesy of the author’s former students, 18. Beaudreau DE. Periodontal considerations in restora-
who graduated some time ago with high honors tive dentistry. In: Goldman HM, Cohen DW (eds). Peri-
in Prosthodontics from Tufts University School odontal Therapy, ed 6. St. Louis: Mosby, 1980:1116.
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the periodontium significant to the restorative den-
work Dr G. Paniz, A Waleed, and S Lim.
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100. Spear F. The challenges of presenting interdisciplinary 112. Passamonti G. Atlas of Complete Dentures. Chicago:
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102. Lutz R, Schmitt C, Buchbender M, Neukam FW. Diag- Louis: Mosby, 1997.
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103. Goodacre BJ, Goodacre SE, Goodacre CJ. Pros- March 2019.
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S27–S36. thet Dent 2002;87:5–8.
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1995.

v
CHAPTER THIRTEEN
Treatment planning analysis of
complex rehabilitations
Phase III:
Posttreatment care and recalls
Calvani_Ch_13_Sue.indd 1 6/1/20 3:54 PM

Planning for Phase III If patient compliance with maintenance is one of the
goals of Phase III treatment planning, the prosthodon-
Planning for posttreatment care and recalls is a vital tic dental office needs to be a reliable source of oral
part of the overall treatment planning work. and general health information, and a place where pa-
The posttreatment maintenance involved in tients can receive professional help and advice. This
Phase III needs to be initially defined and explained will enable patients to effectively take care of both the
to patients. It should be mandatory to mention it prosthetic rehabilitation that has just been delivered
in the written treatment plan that is signed by the and their general oral health. For these two aspects to
patient. This best practice should be taught from the work well together, both should be sound and healthy.
start of any prosthodontics specialty program. Prosthetically rehabilitated patients need to be
In order for patients to cooperate with you and carefully monitored, especially those who still have
to avoid problems later on, be sure to explain care- dental and/or implant-supporting components and
fully, kindly, precisely, and consistently what will be pontics in their mouths or soft tissue that should
required of them during Phase III. Explain from the not undergo overloads and inflammation. These
start that the maintenance of their new prosthesis patients should be followed up regularly, and any
as well as their general oral health is of paramount evident conditions such as infections or chemical or
importance for their positive oral health, both in physical damage should be treated in order to avoid
the present and in the future. For professionality, the loss of important supporting teeth.
this explanation should take place before a wit- The three objectives prosthodontists should pur-
ness.1-3 sue with patients in terms of Phase III are:
A reciprocal relationship exists between the pro- 1. Improvement of their oral health education.
fessional recall practices of the dental office, the good 2. Improvement of their awareness of their oral
will and commitment of the patient, and the dexter- health problems.
ity with which the patient carries out the prostho- 3. Improvement of their assumption of responsi-
dontist’s professional maintenance advice (Fig 13-1). bility for their oral health.
Patient education and professional commitment

It is vital to educate patients regarding posttreatment care and recall by explaining what these will mean
for them and why they are so important. This should be an ongoing conversation with patients through-
out their treatment. Work to try to change patients’ attitudes in the face of evidence.
It needs to be elucidated to patients in a gentle but persuasive manner that a preplanned schedule
of oral hygiene appointments and controls is logical, beneficial, and necessary. This schedule should be
agreed upon before the treatment plan is signed. Usually, if there is collaboration with a periodontal
dental office, which is very common in the USA and Canada, oral hygiene appointments usually take
place as a matter of course.
Try to avoid leaving patients with the negative feeling that you are invading their lives or dictating
their behavior and habits to them. Apply all your intelligence, skills of persuasion, and good sense
(often humor helps) to assure patients that the information you are imparting to them is in their own
best interests. Make it clear to patients that, as with many other things in life, their new prosthesis
and their oral health need to be checked and maintained for the purpose of their overall oral and
physical well-being.

Planning for Phase III
Patient’s commitment
Punctual office recall
Patient’s dexterity
Fig 13-1 Cycle of positive posttreatment maintenance.
Periodic recalls for maintenance Patient compliance and special

maintenance holding programs
In periodontics, recall for maintenance has been
described by Cohen4 as an extension of periodontal There is no scientific evidence regarding compli-
therapy. This description can be transposed exactly ance as it relates to a patient’s age, sex, ethnicity or
to prosthodontics because it is indeed the case for intelligence.1,2,6-9
all classes of prosthodontic treatment recalls (Class Clinical evidence shows that, unfortunately,
I, II, and III). Therefore, the author suggests that “the some patients are not as compliant as they ought
prosthodontic follow-up and periodic recall for main- to be, and many tend to skip the maintenance con-
tenance is the last necessary extension of the prostho- trols after their prosthodontic treatment. Very of-
dontic rehabilitative therapy, and the recall schedule ten, this lack of compliance is the reason for the
is its active agenda.” original problem/s that brought them to the dental
The primary objective of periodontal mainten- and prosthodontist office in the first place.
ance has been described as the continued disruption Therefore, there is a need for less-complaint pa-
of bacterial plaque through professional control and tients to be recalled and clinically checked more
possible subgingival instrumentation.5 Therefore, it often than usual by placing them on a so-called
can be said that besides the necessary control of the ‘holding program’ for educational and motivational
overall oral health status, prosthodontic mainten- reasons, and for you to try to improve their attitude
ance should have as its primary objective a list of to maintenance recalls. This needs to be done sensi-
the clinical and technical examinations that must be tively, and their written and signed consent on the
performed on a routine basis to maintain not only treatment plan should be gained.
the health of the remaining dentition, but also the It is very important to try to develop and im-
entire prosthetic integrity, functionality, and effi- prove your communication with your patients. Be
ciency. careful not to use statements, a tone of voice or
Patients therefore need to know and understand body language that might seem patronizing or pu-
that, together with the periodontal maintenance nitive to them. Be empathetic and sensitive at all
schedule, the prosthodontic maintenance schedule times, cite examples of problems that have arisen
should be devised and observed. To this end, it is for patients who have lost control of the health of
your duty to encourage your patients to maintain their mouths, and explain in a gentle and kind way
this regimen. that your purpose is to serve them as best you can.

It also helps to gain patients’ cooperation if your 4. The presence of caries at the margin of the
explanations are kept clear and simple. fixed prosthesis as well as root caries.
If you are willing to delegate others to do this 5. Any sign of decementation or screw loosening,
job, be sure that they are trained properly to com- including mobility of the prosthetic abutments.
municate efficiently with patients, otherwise you This mobility test should be performed in the
may end up with the opposite response to what you case of both cemented and screw-retained
hoped for. implant prostheses.
6. Any change in color of the outer porcelain
layer of the prosthesis.
7. Any change in color of any existing metal
Basic prosthodontic substructure.
maintenance checklists 8. Any change in color at the margin of full
During any first visit for treatment planning pur- ceramic prostheses.
poses, and whenever you recall patients who have 9. Any porcelain crack on the surfaces of
been previously prosthetically rehabilitated, you prosthetic manufacts.
need to have structured basic prosthodontic main- 10. Any metal crack in the interproximal
tenance checklists. Such lists will make the checking connections.
procedure easier and more precise. If patients have 11. Any change in occlusion or presence of any
been treated previously, it is advisable to have to occlusal dysfunction.
hand at the recall visits their original prosthodontic 12. Any wear facet on the lingual side of the six to
treatment plan to better check the prosthesis that eight maxillary anterior teeth.
was delivered. 13. Any wear facet on the incisal margin of the six
to eight mandibular anterior teeth.
14. Any occlusal wear on the prosthesis and/or on
Fixed prosthesis maintenance
the antagonist teeth on the opposite arch.
checklist
15. Any presence of tooth abrasions on the buccal
It is always advisable to check your patients in aspect of the abutments.
the days and weeks following prosthesis delivery 16. Any loss of interproximal contact.
to verify their level of oral hygiene and make sure 17. Other controls, depending on the individual
they are following the oral hygiene instructions case.
properly. You will also need to check whether the
recently delivered prosthesis looks and feels sound
Removable partial denture (RPD)
and stable and is functioning as it should be.
maintenance checklist
If patients are visiting after a few months for a
periodical examination, ask them before you be- RPDs can be tooth borne or tooth-to-mucosa
gin the inspection whether they have noticed any borne, hence their examination should follow a
perceivable changes in their fixed prostheses, abut- different (twofold) type of investigation. Since
ments, and/or remaining teeth.10-14 these prostheses are not cemented but achieve
Then check and inspect for: their support, stability, and retention only by
1. The presence of plaque and calculus around all means of major connectors, rests, clasps, prox-
teeth and fixed prostheses. imal plates, direct and indirect retainers, and
2. Any excessive probing depth around all abut- bases, their structural relationship with the re-
ments and remaining teeth. maining teeth and edentulous areas should be an
3. Any spontaneous bleeding or bleeding on integrated part of the previous fixed prosthetic
probing (BoP). evaluation.

Basic prosthodontic maintenance checklists
At the end of the treatment, it is advisable to Complete denture (CD)

check patients after 24 hours if it is a tooth-to- maintenance checklist
mucosa-borne prosthesis, then after a few days,
1 week, 2 weeks, and thereafter whenever necessary The evaluation for removable CD prostheses is dif-
and/or when requested by the patient. ferent and should be based on completely different
Always listen first to the feedback from the pa- checks that are designed to satisfy a number of
tient in terms of functionality and any possible ail- different clinical and technical requirements from
ments or complaints.15-17 those described for RPDs.
Then check and inspect for: What needs to be investigated is how any CD
1. Physical and facial assessment: prosthesis guarantees esthetics, phonetics, and
a. Facial appearance. function for the patient, and how the patient relies
b. Evidence of problems, and any complaints. on the support, stability, and retention of the CD
c. The way the patient holds the face while at based on a large number of general and oral phys-
rest. ical, anatomical, physiologic, and structural factors.
d. Possible parafunctional habits. However, local investigations should be carefully
e. Presence of gagging. performed on both the health status of the oral cav-
f. The way the patient speaks, and any ity and the prosthetic integrity and functionality.
phonetic problems and challenges. In case of final delivery, it is advisable to check
g. Upper and lower lip support. these edentulous patients after 24 hours, then after
h. Vertical dimension of occlusion (VDO), at a few days, 1 week, 2 weeks, and thereafter when-
rest and while occluding. ever necessary and/or requested by the patient.
2. Intraoral and prosthetic assessment: This specific timeline is particularly advisable
a. Maxillary and mandibular prosthetic and for checking elderly patients, in whom all oral tis-
tooth mobility. sues are subject to the well-known changes brought
b. Occlusal wear of denture teeth. about by aging. A careful investigation should be
c. Type of RPD. (Kennedy classification) performed because these changes usually weaken
d. Level of oral hygiene. the capability of the arches to hold the prostheses
3. Framework components: in place and to withstand the stresses caused by
a. Seating of the RPD framework. (complete, speaking and chewing.18-20
stable) Check and inspect:
b. Abutment–clasp adaptation. 1. Physical assessment:
c. Relief of major and minor connectors or a. Presence of any physical condition.
mucosal impingement. b. Possible weight loss.
d. Presence of entrapped food. c. Possible use of medicines and drugs.
e. Presence of any lesions on the abutment d. Possible ongoing dialysis therapy.
teeth. 2. Physical and facial assessment:
4. RPD bases: a. Evidence of complaints.
a. Mobility. b. Facial appearance.
b. Presence or lack of occlusal contacts, or c. Possible parafunctional habits.
complete disocclusion. d. Upper and lower lip support.
c. Presence of food or foreign bodies under the e. Amount of tooth display.
bases. f. Tooth color.
d. Soft tissue adaptation, impingement. g. The way the patient holds the face while at rest.
e. Lesions on the bearing areas. h. The way the patient speaks, including any
f. Lesions on the border tissue. phonetic problems/challenges.

i. Mandibular mobility, while speaking and at s. Support, stability, and retention.

rest. t. Occlusal stability.
j. The way the patient chews on a small u. Presence, lack of, flow, and quality of saliva.
cotton roll. (salivary gland issues, medications, drugs)
k. VDO, at rest and while occluding. v. Interridge distance at rest.
3. Intraoral and prosthetic assessment:
a. Presence of gagging.
b. Localized or diffuse areas of soreness.
c. Burning sensation. (palate)
Reinforcing oral hygiene at
d. Presence of bleeding areas. recall visits
e. Ill-fitting dentures. Recalls are optimal opportunities to assess to what
f. Evidence of denture and tooth wear. extent patients are maintaining the overall care of
g. Cheek biting. their dentition and oral cavity at home.
h. Tongue dimension, position, mobility,
lateral deviation, tremors.
Educating patients about personal
i. Presence of pathologic oral lesions, color,
oral hygiene
lumps or bleeding.
j. Areas of mucosal inflammation, and/or “I’m so excited – I think today I’m going to
possible sore spots. brush all my teeth!”
k. Presence of microbial infection or candida. Woody Allen
l. Presence of inflammation due to foreign
bodies such as seeds, small fish bones or Often, patients who end up in the care of prosthodon-
popcorn skin. tists do not have a very good standard of personal oral
m. The posterior palatal seal (PPS) and the hygiene and are frequently responsible for their de-
retromolar pad area. cayed teeth or the edentulous status of their mouths.
n. The peripheral border seal (PBS). Usually, in a mouth where there is no bacterial plaque,
o. Swallowing problems. caries or periodontal disease hardly ever occur.
p. Presence of plaque and food on both the Therefore, poor expectations exist on the part of
tissues and the prostheses. prosthodontists regarding the personal oral hygiene
q. Flanges extensions and color. of these patients after the prosthodontic treatment,
r. Whether the midline is offset. as their bad habits or the difficulty they experience
cleaning their teeth due to limited dexterity often
recurs during the temporaries stage, and again
when the prosthodontic treatment is over.
The education and guidance of patients regarding
personal oral home hygiene is a professional corner-
stone for prosthodontists. It is wise to take this into
consideration when planning the treatment of pros-
thetic rehabilitations.
Bear in mind that patients’ initial poor oral health
status, particularly when it is due to inadequate oral
hygiene standards or bad habits, may lead to further
Fig 13-2 A complete lack of oral hygiene led to this
situation. Despite the difficulties of the case, it is the dental failures unless you and your team are able to
work of the prosthodontist to successfully rehabilitate modify and guide their behavior during and after the
what has been lost. prosthodontic treatment (Figs 13-2 to 13-6).26-29

Basic prosthodontic maintenance checklists
Fig 13-3 Pretreatment facial photograph. The situation Fig 13-4 After the treatment, the patient changed
shown in Fig 13-2 meant that the patient was not only dramatically. Her new open smile demonstrates all her
malnourished but also experiencing severe psycho positive feelings.
logical frustration.
Fig 13-5 The careful

selection and construc-
tion of any individual-
ized prosthetic solution
should not ignore the
creation of artifacts that
are easy to clean, not
only by patients who
are capable, but also
and above all by those
who are not dexterous
enough to do so. This
image shows the struc-
turally planned spacing
for proxy brushes and
their use.

Fig 13-6 This image shows how the creation of concavities in the tissue part of the fixed prosthesis serves to
facilitate a growing accumulation of food residues – a rich culture medium for the growth of plaque bacteria.
The varying approach of patients to their health In fact, while there are various reasons why
status is due to different reasons. Specific health patients might forget about their personal oral hy-
behavior models have been defined that classify a giene, laziness is one that is frequently admitted to
number of behavioral possibilities, which are ex- by patients. Being lazy about one’s oral hygiene is
plained briefly below.21-25 one of the worst habits that can bring patients to
the dental office.
Laziness
Clinical experience shows that patients often feel Indifference
responsible for the status of their oral hygiene be- Another very challenging habit to break is patient in-
cause they are usually very aware of their inade- difference about oral hygiene or prosthodontic treat-
quate or poor oral hygiene habits. These patients ment. Again, this attitude on the part of the patient
know that the prosthodontist can see that, so they is, in many cases, what caused the decayed or edentu-
may perceive the recall visit as an examination they lous situation in the first place. Unless you are able to
are required to take and to pass. This often makes create a truly empathetic bond with these patients from
them anxious, leading to subjectivity and defensive- the beginning, if you continue with the rehabilitation
ness, which in turn can lead to untruthfulness about the battle is frequently lost during the course of active
their oral hygiene habits. treatment or during the posttreatment recall phase.

Treatment planning fluoride
Often with these patients, once the prosthesis Understanding

has been delivered, they disappear, coming back Some patients, for a variety of physical, mental or
only when something is wrong or when they are in psychologic reasons, may be unable to grasp or un-
discomfort or pain (usually justifying their absence derstand why certain behaviors lead to specific sit-
with many reasons that are usually only excuses). uations and results.
Therefore, it is very worthwhile to spend suf- These patients usually require special follow-up
ficient time during Phase I to motivate and guide maintenance recalls, depending on the challenges
these patients in order to eliminate stress and frus- and obstacles they experience that may limit their
tration in the collaboration with them later on as understanding.
well as for a better prognosis of the restoration. If patients are mentally challenged and cannot
understand the need for personal oral hygiene or
Dexterity why they require follow-up maintenance recall vis-
Some patients are unable to clean their teeth and its, it is best to discuss this part of their treatment
mouths properly. This situation is relatively easy to plan with a next of kin, a guardian, or a carer.
see because there will be certain areas in the mouth
that are clean (and even over-brushed) while other
areas are not.
Therefore, if you see in the initial examination
Treatment planning fluoride
that patients are not cleaning properly, or if they Just like teeth, prosthetic rehabilitations may retain
are not following all the instructions given by the plaque.10,30-36 This is one of the reasons why future
professional oral hygienist during the treatment, it maintenance should be suggested from the begin-
is an excellent idea to write or add to their treat- ning and specifically noted on the treatment plan.
ment plan the urgent necessity of recall visits to the In this way, any further destruction of the abutment
oral hygienist. and natural teeth after the prosthetic work can be
Once this has been stated on the treatment plan avoided. Oral hygiene, effective antibacterial mouth
and witnessed by the dental office staff, it leaves rinses, fluoride treatment, and well-executed dental
little room for patient excuses. Obviously, you can- care are all needed for predictable dental and oral
not force patients to attend appointments or pun- health.37-43
ish them for not attending, but what you can do is In patients where there is evidence of signifi-
constantly and patiently reinforce the message that cant caries in the first visit, the anti-caries Caries
doing so is in their own best interests and for their Management by Risk Assessment (CAMBRA) pro-
own well-being. tocol by Featherstone44-46 may be relevant from the
As a professional caregiver it is your duty to beginning of the treatment as well as during the
explain to patients and help them to understand follow-up phase. CAMBRA is an ad hoc procedure
how best to maintain their oral health throughout created to manage the caries problem in any indi-
the treatment and once it is complete. This duty is vidual. It evaluates the caries risk and the necessity
shared with the dental office team, including the for fluoride treatment. This protocol was created to
oral hygienist, who should carefully follow up pa- assess the risk of caries of patients seeking prostho-
tients’ oral hygiene status and instruct them on all dontic treatment, and to fight the caries problem.
dental care procedures, both on the natural teeth When indicated, it should be an integrated part of
and on the prosthetic replacements. the prosthodontic treatment planning.
The oral hygienist is best placed to predict how If fixed dental prostheses are poorly crafted and
many visits the patient will require and the fre- badly maintained, there is a predisposition to in-
quency of the recall appointments for proper oral flammation and periodontal disease, with bone loss
hygiene maintenance. and the exposure of the remaining enamel and root

dentin of the abutments. In those cases, caries can feed mainly on fermented sugars such as sucrose,
destroy any tooth and overlying prosthetic work. glucose, and fructose as well as on organized poly
Therefore, it must be detected as soon as possible saccharide compounds. They thereby reproduce and
during the periodic recall appointments.10,30-36 destroy the enamel and the dentin minerals with
Always ask patients during the treatment plan- their organic acids. However, while a certain nat-
ning sessions the seemingly obvious question (but ural remineralization of these carious lesions is
one which is often not answered satisfactorily) about possible, an increase of calcium, phosphates, and
predisposing factors or clinical signs that could give fluoride within the saliva has been shown to be ne-
rise to a higher risk of caries. Due to the multifac- cessary to fight caries in people of all ages and to
torial etiology of caries, a first lesion may look like rebuild harder and less soluble enamel minerals in
a little white spot on the enamel, while deepening the lesions.
lesions will manifest as darker spots on the dentin. Nowadays, many prosthodontists use sodium flu-
The first phase of caries is the enamel demin- oride (NaF) and acidulated phosphate fluoride (APF)
eralization that occurs at the pH threshold of 5.5 topical gels. However, be careful when planning
due to the cariogenic action of billions of bacteria APF topical gel applications in patients with porce-
such as Streptococcus mutants, S. sobrinus, lactoba- lain prostheses, bonding to resin cements, titanium
cilli, bifidobacteria, veillonella, Scardovia wiggsiae, implants, and/or composite restorations, as fluoride
and others in lower percentages.47-49 These bacteria compositions might damage them (Table 13-1).49-62
Table 13-1 Main topical fluoride instructions
In-office (professional) high-dose fluoride At-home (patient) mouth rinses and self-applied
application topical gels
1. Chlorhexidine varnish (Cervitec Plus) 1. NaF 0.05% rinses (throughout the day)
2. Fluoride varnish 5% NaF (22,600 ppm) 2. Chlorhexidine mouth rinses (follow the instructions
(Duraphat/Fluor Protector) for use)
3. NaF 2% F (9,040 ppm) 3. Chlorox mouth rinses (follow the instructions for use)
4. APF 1.23% F (12,000 ppm) 4. Gel, PreviDent 1.1% NaF (5,000 ppm)
5. SnF 28% F (19,360 ppm) 5. Gel, 0.4% SnF2 (1,000 ppm)
6. Gel, 1.1 APF (5,000 ppm)
Chewing gums (when toothbrush is temporarily unavailable)

1. Xylitol gum and pills (throughout the day)
2. Sorbitol gum and pills (throughout the day)
Treatment planning When these conditions are diagnosed, appropriate

prophylactic therapy can be suggested. In case of
prophylactic therapies
other systemic conditions, it is best to consult with
Sometimes, while examining prosthodontic pa- the patient’s physician regarding drug-related indi-
tients, bacterial or fungal conditions are diag- cations (Tables 13-2 and 13-3).63,64
nosed that affect both the tissue and the prosthesis.
10

Treatment planning the improvement of the patient’s diet
Table 13-2 Most common antibiotics and their usual of diet education related to oral health, evaluate and
therapies conduct diet and nutritional risk assessment related
Most common antibiotic therapies (follow the
either to general or oral health, and provide proper
instructions for use) dietary education to patients with evident or pos-
1. Penicillin VK 250 to 500 mg (2 to 4 per day for sible lack of management of their oral condition.65
1 week) According to the World Health Organization
2. Amoxicillin 1 g (2 per day for 6 days) (WHO), obesity has nearly tripled worldwide since
3. Cephalexin 1 g (2 per day for 6 days) 1975. Most people in the world live in countries
For patients who are allergic to penicillin where overweight and obesity kills more people
1. Clindamycin 150 to 300 mg (3 per day for 1 week) than underweight. The following figures are for
2. Chlortetracycline 250 mg (2 per day for 6 days) 2016: more than 1.9 billion adults (18 years and
(Aureomycin) older) were overweight. Of these, over 650 million
3. Ciprofloxacin 250 mg (2 per day for 5 days) were obese. 39% of adults aged 18 years and over
(Ciloxan) were overweight and 13% were obese. 41 million
4. Clarithromycin 250 to 500 mg (2 per day for 6 to children under 5 years of age were overweight or
14 days) obese. Over 340 million children and adolescents
aged 5 to 19 were overweight or obese.66 In the
Other antibiotics
1. Metronidazole 250 mg (2 per day for 6 days) USA, this is a serious social problem.67-69
(Flagyl) The above situation results in a corollary of
2. Sulfamethoxazole 200 mg (2 per day for 10 days) physical and oral problems such as an increased in-
(Bactrim) cidence of diabetes that leaves the door wide open
to periodontal disease and can seriously affect the
Table 13-3 Most common antifungal oral medications healing process.70-75
and their usual therapies
Furthermore, clinical experience shows that
Local – Nystatin (Mycostatin) obese patients have certain limitations in terms of
1. Oral suspension: 100,000 U/ml, 5 ml, rinse for a few sitting on a dental chair, which means an increased
minutes then swallow, for 10 days or 2 weeks difficulty to be treated. Surgical access in obese
2. Ointment: 100,000 U/g, apply to affected area patients can also be challenging.
multiple times per day At the other extreme, eating disorders leading
3. Tablets: 500,000 U, dissolve in mouth to forced or excessive weight loss such as anorexia
Systemic (hepatotoxic drugs – best to consult nervosa, bulimia nervosa, and binge eating disor-
with patient’s physician) ders may cause an increase in tooth loss due to al-
1. Ketoconazole (Nizoral), 200 to 400 mg per day for tered bone metabolism.76-80
1 to 4 weeks Also, certain slimming medications that cause loss
2. Fluconazole (Diflucan), 50 to 100 mg per day for of appetite and therefore a reduction in food intake
2 weeks and weight loss can affect bone metabolism, a decrease
of saliva secretion, an increase in caries and periodon-
tal disease, and other problems for mobile and fixed
prostheses wearers, which will affect the predictability
Treatment planning the of the prognosis and of the treatment plan.81-86
Any dietary advice or suggestions you think
improvement of the patient’s
would benefit the patient’s oral health should be
diet sensitively suggested as early as possible, but not
To treatment plan, dental medical professionals and until you have established trust between yourself
prosthodontists need to know the basic principles and the patient. Advise patients in a manner that
11

will not cause offence about a change or modifica- to have a paragraph in the treatment plan to protect
tion in their diets in order to balance the amount yourself and your dental office team. The paragraph
and quality of energy-yielding nutrients they con- should clearly state that if the patient chooses not to
sume: carbohydrates, proteins, fats, and alcohol.87,88 comply with certain requests made by yourself or
members of your team – requests that would clearly
Various nutrients and the body energy benefit the patient and positively affect the overall
(calories) they supply prognosis – that you and your dental office staff can-
not be held responsible for the future damage that this
●● Carbohydrates and proteins: 4 calories per
may cause to the patient’s teeth and/or prosthesis.
gram
Instead of telling patients what to do, try to en-
●● Alcohol: 7 calories per gram
gage in dialogue with them about what are essen-
●● Fat: an average of 9 calories per gram
tially very sensitive topics. It is preferable to em-
power people to come to their own decisions, even
Improving the diet by changing the eating style, if these decisions are in some part based on your
quality, and quantity of food may positively affect advice and suggestions.
the overall physical condition of the patient. It will Make a concerted effort to reinforce patients’
also help to control any change of oral pH and en- awareness, and motivate them to take responsibility
hance the long-term prognosis of the remaining for their dental and oral home care. Encourage them
dentition and periodontium. It will also affect the to avoid bad eating habits and discourage them from
life expectancy of the prosthetic restoration.89-98 using substances that, when ingested or inhaled,
When necessary, these dietary goals and objec- may create caries and other pathologic periodontal
tives should be clearly written into the treatment or oral conditions. Indeed, make sure your patients
plan and explained to the patient as being one of the are fully aware that the use of recreational or psy-
Phase III recall maintenance procedures that needs chotic drugs, smoking, chewing tobacco, drinking
to be carefully followed up. alcohol and/or sugary sodas, vomiting, bruxing,
If you feel it is necessary, refer patients to their clenching, and biting on hard objects such as pens,
physician and/or any registered dietician for more pencils, pipes, and other things negatively affects
thorough medical nutritional therapy. their physical and oral health, starting with their
teeth and prosthetic rehabilitations.9,22,99-110
Again, to avoid problems during the treatment
and after the rehabilitation, it might be helpful
Making patients more aware to customize the treatment plan and scheduled
of dangerous habits Phase III posttreatment care recall appointments.
Some patients behave in ways or practice habits The reason for this customization should always be
that are potentially dangerous for their oral cavity explained to the patient.
and dentition, even though they may not be aware If insurmountable difficulties and disorders are
of it. evident, you may want to have more in-depth (but
It is your medical duty to investigate, try to un- always calm and respectful) conversations with pa-
derstand, and talk to patients about these issues tients to help them to identify the causes of their
from as early as the first visit, and to continue to difficulty or disorder.
communicate with patients about them at recall You may diplomatically want to suggest they
visits. see a psychologist or psychiatrist to help them to
Despite your best efforts, there will always be understand and overcome their issues. This will in-
those patients who will refuse to comply with your crease the chances of success for your prosthetic
suggestions or take your advice. It is therefore best work and rehabiliations.111
12

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16

CHAPTER FOURTEEN
Treatment planning for the elderly
and those with challenging
health conditions
227
Calvani_Ch_14_Sue.indd 227 3/10/20 10:22 AM

14 Treatment planning for the elderly and those with challenging health conditions
It is not the aim of this chapter to outline all possi- smoke cigarettes and an estimated 68% of
ble health conditions that may affect prosthodon- adults are overweight or obese.
tic treatment planning. Rather, the chapter aims to ●● Cardiovascular disease (CVD): When compared
give a general idea of how to plan the treatment of with previous trends, the CVD death rate has
patients with age-related challenges or health con- declined, but there are more people suffering
ditions. It is by no means exhaustive on the topic. from diabetes and obesity. Statistics show
Significant reading suggestions are given at the end that CVD is the leading health problem as
of the chapter, and others can be found in the liter- well as the leading cause of death among both
ature. What the chapter hopes to provide is some males and females. Almost one in three deaths
basic statistics and a brief description of a few health results from CVD. In fact, approximately
conditions, including disorders and disabilities, that 84 million people suffer from some form of
could affect treatment planning. It also touches on CVD, causing about 2,200 deaths per day (one
treatment planning for elderly patients. death every 40 seconds). About one-third of
As a dental medical professional, you should be CVD deaths occur before the age of 75. CVD is
aware of a number of important general statistics the cause of more deaths than cancer, chronic
in relation to medical conditions, including age- lower respiratory diseases, and accidents
related limitations, when examining a patient for combined.
the first time, when devising treatment plans, and ●● Coronary heart disease (CHD): An estimated
during end-of-treatment follow-up care. In addi- 15 million adults have CHD.
tion, extreme sensitivity is required when relating ●● High blood pressure (HBP): Approximately
to such patients during the first visit and exam- 78 million adults have HBP.
ination, and delicacy is required throughout the ●● Heart failure (HF): HF affects more than 5 mil-
treatment planning phase in these more demand- lion adults.
ing cases. ●● Diabetes: An estimated 20 million adults have
Since the world population is growing and aging this disease, an additional 8 million may be
at an unprecedented rate, the particular needs and undiagnosed diabetics, and 87 million have
limitations of elderly patients should be taken into prediabetes. Out of 330 million people,
account when treatment planning. It is also im- 115 million suffer from or are at risk of getting
portant to be aware of the requirements and chal- diabetes.
lenges of treatment planning for patients with drug ●● Stroke: On average, someone suffers a stroke
addictions. The number of patients in this category every 40 seconds. Females have a higher
is also growing worldwide and is increasingly fo- lifetime risk of stroke than males. Stroke is a
cused on by the media. Therefore, the most common leading cause of serious, long-term disability
addictive drugs and the signs and symptoms of their that accounts for more than half of all patients
use are also described, which should be useful for hospitalized for a neurological disease.
diagnostic and treatment purposes.1-8 ●● Lung disease (LD): According to the US Na-
tional Institutes of Health, Department of
Human Services, LDs, excluding lung cancer,
caused an estimated 235,000 deaths in 2010.
Some medical statistics ●● Blood disease (BD): Approximately 10,000
The statistics given in this section apply to the USA deaths per annum are attributed to BDs.
only. ●● Sleep disorders (SD): From 2000 to 2010, pa-
●● Smoking and overweight/obesity: According tients visiting physicians for sleep apnea in-
to the most recent statistics of the American creased from 2.0 to 2.7 million, and for insom-
Heart Association, approximately 20% of adults nia from 2.4 to 5.8 million.
228

Patient awareness and communication
Patient awareness and patients promptly, safely, and successfully. Since

prosthodontic treatment often involves elderly pa-
communication
tients, with needs and conditions that can be limiting
Diseases and disorders, including cardio-circulatory factors, you need to proceed with caution and care
problems, allergies and asthma, arthritis and rheu- in these cases.
matic diseases, bone disorders, digestive disorders, Usually, if they can, patients who are suffering
blood disorders, infectious diseases, mental health from a condition will immediately inform you of
disorders, neurologic disorders, respiratory disor- their main health problem, including the medi-
ders, psychologic and psychiatric disorders, and cations they are taking. In fact, some patients are
cancer may affect patients’ oral health. afraid that the dental treatment they require may
The interaction between yourself and the patient aggravate their condition, which can make these
that is necessary in order for you to treat such a patients anxious when they explain their condition
patient properly may also be affected. to you. They may also over-explain in their attempt
to be helpful and because they are determined to
Unfortunately, clinical experience shows that gen- avoid further complications. On the other hand,
erally patients only visit the dentist or prostho- there are patients who will try to hide their con-
dontist when there is an emergency of which they dition from you because they fear they will not re-
are aware, such as when they are in discomfort or ceive treatment because of it. In other cases, they
pain due to a problem with their prosthesis or the may simply forget to inform you, which is fairly
surrounding periodontium or when esthetic or common among elderly people. Therefore, you need
masticatory conditions become an evident issue. to be extra vigilant and thorough in your examina-
It is important to remind patients that most tion of elderly patients.
diseases and illnesses, including cancer, begin and Sometimes, patients with certain health condi-
progress asymptomatically, becoming perceptible tions may not be able to communicate effectively. In
only when they are confirmed by clinical or radio- these cases, there is usually a person – usually a
graphic examination as part of a routine check-up next of kin, guardian or carer – who will accom-
or when severe clinical localized or generalized pany them in order to assist them during the con-
evidence becomes apparent. sultation. While it is your duty to involve this ac-
Therefore, bear in mind that patients who have companying person in the visit, asking questions or
health conditions may or may not be aware of confirming what has been said or understood, it is
their condition when they visit your dental office important to focus your attention on the patient.
in search of treatment. At the first visit (or dur- Indeed, the way patients communicate – the
ing subsequent consultations), you may observe words they use as well as their posture, facial expres-
signs or symptoms in your examination of these sion, and body language – can impart information
patients that cause you to suspect a health con- that cannot be gleaned from another person, who
dition. In such cases, refer patients immediately may only report with approximation, and who is
to their physician or consult with the physician limited by the subjective nature of the task of inter-
yourself to discuss your suspicion and/or confirm pretation. Bear in mind it is the patient who is suffer-
your diagnosis. ing and who should always be your main concern.
Take your time with elderly patients and those
with challenging health conditions; it is your med-
Some specific patient conditions might become lim- ical duty to properly understand their situation
iting factors in terms of prosthodontic treatment. and how their condition may affect your treatment
Therefore, the more knowledge you have of these planning so that you can treat them in the best pos-
conditions, the better placed you will be to treat sible way.
229

Special attention should be paid to patients with Due to improved living conditions and advances
physical or mental disabilities, as sometimes their in medical science and technology, the latest de-
disability: mographic statistics show that life expectancy is
●● may negatively affect the relationship of lengthening. This means a progressively increasing
understanding and trust that you are trying number of elderly patients who present at our den-
to build with them, and in extreme cases you tal offices. We need to be ready to face this chal-
may not be able to treat them if their disability lenge. Despite the fact that people are living longer,
makes any relationship impossible; individuals of 65 are still considered to be older
●● may slow down your ability to relate to them adults.9
and therefore to treat them immediately, prop-
erly, and in the way the situation demands.
Some basic statistics
Once you have assessed the overall health of pa- In the USA, it is predicted that by 2030 elderly peo-
tients with physical or mental challenges and noted ple will number 72 million, double that of 2000, and
any evident clinical limitations, sensitively explain will make up 20% of the population.
the outcome of your examination and ask them for Many elderly people currently suffer from
their permission to treat them and for their collab- chronic conditions such as hypertension (71%), ar-
oration. thritis (49%), heart disease (31%), cancer (25%), and
Always bear in mind that some patients who are diabetes (21%). Other conditions include:10-12
challenged or disabled are unable to maintain ade- 1. Physiologic changes.
quate dental hygiene, which may result in difficul- 2. Sensory and functional changes.
ties during treatment. 3. Impaired senses.
4. Depression.
In patients with challenging health conditions, 5. Dementia.
try to assess the main issue or chief complaint in 6. Psychosocial factors.
the first interview. After the physical examination 7. Excessive medication and alcohol use.
and the initial collection of data and findings, start 8. Hearing loss.
to screen all possible issues as soon as possible to 9. Eye conditions.
find clinical evidence of the physical health and 10. Chronic obstructive pulmonary disease.
oral problems, connections, directions, indica- 11. Root caries.
tions, and contraindications to any prosthodontic 12. Periodontal disease.
treatment. 13. Oral cancers.
14. Osteoporosis and tooth loss.
15. Xerostomia.
Prosthodontic treatment 16. Nutritional risks.
planning for elderly and
geriatric patients
Table 14-1 shows the diseases that have remained
“Existence for eternity could get a little boring the top causes of death globally in the last dec-
... especially towards the end.” ade. Chronic diseases cause increasing numbers
Woody Allen of deaths worldwide. Diabetes caused 1.6 million
(2.8%) deaths in 2015, up from 1.0 million (1.8%) in
Aging refers to the specific genetic changes that 2000. Deaths due to dementia more than doubled
occur naturally and that lead our body to the last between 2000 and 2015, making it the seventh lead-
moment of our lives. ing cause of death globally in 2015. Injuries are the
230

Prosthodontic treatment planning for elderly and geriatric patients
Table 14-1 Leading causes of death globally in the last essential nutrients in the diets of these patients.
decade (according to the WHO) Related to this are the alimentary disturbances and
physical and oral problems experienced by many
1. Ischemic heart disease elderly people.14-62
2. Stroke All these issues mean that the medical and oral
3. Chronic obstructive pulmonary disease examinations of elderly patients in diagnostic Phase I
4. Lower respiratory infections are particularly sensitive and important procedures.
The first visit should become a thorough and
deeper investigation in these cases, with an aware-
ness that all data gathered may have extra signifi-
cause of death for 5 million people each year. Road cance. Many physical and prosthodontic clinical and
traffic injuries claimed about 3,700 lives each day in technical variables should be taken into considera-
2015, about three-quarters of them were men and tion to plan for a balanced and adequate treatment
boys.13 for elderly people.
It is not the place of this chapter to expand on Therefore, a number of important factors should
the many factors related to the elderly that have be taken into consideration when planning the
been studied and reported on in the medical litera- treatment for elderly patients:
ture, eg, low economic status, loss of independence, 1. The clinical situation or limitations of elderly
excessive introspection, poor eating habits, and de- patients can be a challenge to your dental office
ficient dentition due to an inadequate diet. How- organization. You and your office staff need to
ever, some of these aspects are touched on below as be particularly patient and understanding in
they relate to our professional specialty. order to communicate well with your elderly
patients.
2. It is important for you to recognize the origin of
Treating elderly people
any symptoms elderly patients may complain
Due to the nature of the specialty, prosthodontists about, or any signs you may see when examin-
probably treat more elderly patients than most den- ing them.
tal medical professionals. This means that every 3. Aging means that elderly patients often have
day, increasingly more elderly patients will visit less will, awareness, and ability to maintain
your dental office. adequate oral hygiene, which usually results
Elderly patients may present with the normal in more periodontitis, more caries (both on the
physiologic changes brought about by aging that re- enamel and on the roots of those teeth uncov-
sult in physical, sensory, and cognitive impairments ered by a physiologic or pathologic gingival
and limitations. They may also present with signs inflammation), recession, and bone loss.63-65
and symptoms relating to more serious comorbid 4. Elderly patients usually take more medications
diseases such as cardiovascular or pulmonary con- than younger patients, which can have both
ditions, or metabolic diseases such as diabetes. effects and side effects that have implications
Nutritional imbalances due to an inadequate for the oral cavity such as a lack of saliva or
intake of essential food groups usually affect the xerostomia, with all the related oral clinical
health of the oral cavity first. Elderly people espe- problems.66-73
cially need protein, and mostly, proteins need to be 5. As people age, they are usually more prone to
chewed. Both partial and complete edentulism re- immune changes and adverse reactions such as
sult in chewing and swallowing problems, and first allergies as well as possible cross-reactions to
among all other predisposing factors, they signif- drugs such as anesthesia, analgesics, and other
icantly contribute to a reduction or lack of these laboratory and prosthetic materials.74,75
231

Therefore, during the diagnostic Phase I, carefully Drug addiction is increasingly becoming an en-
investigate what medications, both current and demic problem worldwide that involves people of
chronic, your elderly patients are taking that may all ages. Due to the legalization of some recreational
make them more sensitive to dental and surgical drugs in some countries, their use has increased.
therapy. Be sensitive at all times to the possibly For a more detailed clarification on the situation,
problematic variables related to clinical and surgical we refer the reader to the United Nations Office on
procedures that may affect the prosthodontic treat- Drugs and Crime (UNODC) World Drug Report.80
ment and well-being of these patients. Frequently, patients who are addicted to drugs
Treating aging patients is at times particularly present at our offices for prosthodontic care. These
challenging because often they will be troubled by patients may be physically or psychologically vul-
signs and symptoms that are actually the normal nerable and therefore at a higher risk than other
physiologic changes of aging such as physical, sen- patients. They therefore require our particular dil-
sory, and cognitive impairments and limitations. In igence and careful attention. In certain extreme
some cases, their complaints or worries are due to cases, the usual prosthodontic treatment may not
the symptoms of more complicated comorbid dis- be useful to treat such patients or solve their den-
eases such as cardiovascular/pulmonary conditions tal problems. Whenever you know or suspect that a
or diabetes. patient is addicted to drugs, a thorough evaluation,
Being professionally aware of all the above assessment, and diagnosis should be carried out
points can make a huge difference when treatment before a restorative treatment plan is devised (Figs
planning for these patients. 14-1 to 14-4).81-86
Consider that it is usually a challenge to treat pa-
tients who are addicted to drugs. Make sure your of-
fice staff are aware of the sensitivity of the situation
Prosthodontic treatment in these cases and adhere to the usual strict patient
planning for patients who are confidentiality.
addicted to drugs People of all ages may be addicted to all kinds of
Apart from the challenges of patients on medica- drugs, some of which are much more harmful than
tions and other factors relating to elderly patients others. It is crucial to be aware of this and not lump
of which you need to be aware, the issue of drug all drug use into one general category.
addiction in patients needs to be addressed. Bear Some patients may be addicted to opioid-type pre-
in mind that this is an extremely sensitive topic and scription analgesics. These are often used posttreat-
often a very private matter for individuals, so you ment and can cause euphoria. This posttreatment use
will probably find that very few patients are willing could begin a cycle of addiction to these drugs and
to speak openly about it and reveal what drugs they make these patients more vulnerable to dangerous
have taken or may still be taking or be addicted to. drugs with similar chemical origins to heroin. Some
People have always used psychoactive drugs drugs in this category include codeine, lortab, lorcet,
such as opium and scopolamine. These drugs have fentanyl, sufentanil, and etorphine (very powerful).
been used for several reasons, including for the pur- Patients who are addicted to drugs may present
pose of inebriation and to relieve physical or psy- as being indifferent to your suggestions and care.
chologic pain.76 Regardless of the reasons for tak- They may also be inclined not to meet the sched-
ing them, the effects of drugs occur synergistically, ule of appointments or to suddenly cancel their ap-
creating a powerful cumulative effect that may be pointments. Therefore, the entire office staff needs
addictive to different degrees, depending on the to be prepared for this.
specific drug.77-79 According to the evidence of the diffusion of
these drugs beyond the alarm threshold,80 a recent
232

Prosthodontic treatment planning for patients who are addicted to drugs
Fig 14-1 Case 1. Frontal view of a 27-year-old patient who has been addicted to drugs for several years. This
image shows the dangerous situation that results from the progressive abandonment of oral hygiene, which
has negative implications for the patient’s overall clinical condition (case photographs courtesy of the author’s
former student, Dr Alyssa M ariano).
study published in Lancet87 suggests that there is an

urgent need to expand the use of medications that
treat disorders related to opioid use, including train-
ing of health care professionals in the treatment and
prevention of opioid-use disorders.
During the first visit, be particularly vigilant
during the medical history data gathering process
in the following situations:
1. Accidents: If a patient has been involved in a
serious accident with a post-traumatic recovery
in which analgesics were used for any length
of time, investigate more thoroughly to ascer-
Fig 14-2 Case 1. Maxillary occlusal view. tain whether there may be a possible ongoing
history of addiction to these medications.
2. Communication: If you suspect that patients’
behavior is strange or unusual, especially
younger patients, it is best to try to commu-
nicate with the person responsible for these
patients, such as a parent/guardian or another
family member, or a person who knows them
very well. In any case (and with patients of all
ages), if you are worried about or are unable to
communicate effectively with patients or with
the person accompanying them, consult with
their physician about their medical history. In
this way, you will hopefully be supplied with
Fig 14-3 Case 1. Mandibular occlusal view. useful information about their current medical
233

Fig 14-4 Case 2. Frontal view of a 42-year-old patient who has been addicted to drugs since he was young. This
image shows the progressive deterioration in the oral cavity which is, unfortunately, a local reflection of a more
generally compromised physical condition.
situation that can help you to customize their 5. Different drugs have their own specific signs.
treatment plan accordingly. Look out for the tangible clues that may alert
3. Dissimulation: Often, patients who are addicted you to drug addiction when you meet a patient
to drugs dissimulate very well. It is possible, for the first time (Table 14-2).88-93
therefore, that you will not understand the
overall situation immediately. This problem is
best tackled by allowing your patients to talk Table 14-2 Possible signs of drug addiction
for some time in the first visit. In some cases,
drug addiction may become evident. In these Social and behavioral signs. Patients may:
cases, as time goes by, you will probably notice ●● have a look or sense of self-neglect about them
some signs of addiction and be in a better posi- ●● mention that they are lonely
tion to understand the drug dependency and how ●● demonstrate antisocial behavior
●● not be in touch with their families
to treat the patient accordingly.
4. Signs of addiction: People who are addicted to Physical signs. Patients may show:
drugs are all around us in our social and pro- ●● changes in their circadian rhythms
fessional milieu. It is not always obvious that ●● bloodshot eyes
people are addicted to drugs; nevertheless, they ●● mydriasis (dilated pupils) (cocaine, amphetamines,
may (even unconsciously) send out a number THC, MDMA)
of behavioral signs that will allow you to arrive ●● irritated nose
●● intraoral dryness
at a suspicion or diagnosis of drug addiction.
●● altered speech
Therefore, as a dental medical professional, you
●● a large number of oral and dental problems
need to be constantly vigilant and aware of cer- (excessive caries, periodontal disease, edentulism)
tain behavioral and physical signs and signals.
234

Signs and symptoms of the most common drugs
You may suspect that patients are addicted to Prescription analgesics

drugs if they behave in an unusual, uncontrolled
or other unselfconscious way. They may be aggres- Often patients become addicted to analgesics after
sive or overly passive or emotional, with reduced they have been treated with prescription medica-
self-awareness. You may be able to understand the tions for extreme pain. Usually, these patients have
situation by the worried, astonished or lost look access to multiple prescriptions, which may result
in their eye, or the fact that they avoid your direct in accidental misuse or deliberate abuse of these
gaze. Watch out for this type of behavior when talk- medications.
ing to your patients. Pay particular attention to their Strong analgesics relieve pain but can also cause
speech capability and to the sense of what they say euphoria, drowsiness, and a sense of dazedness or
as well as how they say it. confusion. Clinically, patients addicted to analgesics
In patients who are addicted to drugs, the prost- may be slightly or even very excited or confused. They
hodontic restorative treatment plan that under may speak or move very quickly, talk to themselves
other circumstances would take a longer period of or be prone to smiling without a reason, have dry lips
time and use more resources may need to be simpli- and a dry mouth or be slightly nauseous. They may
fied in order to do as much as possible in the least then try to dissimulate their unusual behavior.
amount of time. This is particularly true for those If you see any of these signs in new patients,
cases where the patient is particularly uncoopera- immediately contact their next of kin or person re-
tive, and you do not feel in control of the progres- sponsible for them. Alternatively, consult with their
sion of the treatment process. physician to try to gain some insight into what is
going on.
The misuse of prescription analgesics is an increas-
Remember that you are not obliged to treat all pa- ingly growing problem in the western world today
tients who visit your office. If you cannot commu- and can be seen as an international emergency.80,87,88
nicate at all with patients or if you foresee insur-
mountable difficulties in taking on or managing
Sedatives, anxiolytics, and
a patient case, refer the patient to another dental
antidepressants
office where they may have the resources, struc-
tures or ability to treat them. Always behave in Sedatives are often used (and sometimes abused) by
a professional and humble manner and with the patients to sleep. Depending on the amount taken,
utmost sensitivity in such cases. these medications affect patients’ motor functions,
lower their level of awareness, and alter their atten-
tion span. They can also reduce salivation, which
has negative intraoral clinical consequences.
Signs and symptoms of the When used in a controlled manner, sedatives are
most common drugs not problematic, but they can become so if they are
used for a very long period of time. Sometimes, the
The following section briefly describes a few signs initial prescribed dose no longer works and needs to
and symptoms of the most common drugs. It is not be continually increased to achieve the same effect.
exhaustive but aims to help you to make a faster High doses of sedatives over long periods can become
and more certain diagnosis, be in a better position addictive.
to respond professionally to the clinical situation, Anxiolytics and antidepressants are very widely
possibly collaborate with other specialists, and for- prescribed today. Patients will usually disclose to
mulate appropriate treatment plans in cases of pa- you on the questionnaire in Phase I whether they
tients who are addicted to these drugs. are taking them. As with sedatives, the effects or
235

side effects of anxiolytics and antidepressants may Patients who are addicted to cocaine may be
affect prosthodontic treatment; these include seda- absentminded or may appear anxious. They are
tion, ataxia, confusion, amnesia, seizures, hypoten- often garrulous, speaking quickly and/or repeat-
sion, arrhythmia, nausea, xerostomia, and mouth ing the same words, syllables or phrases (palilalia).
dryness with its possible inflammatory and infec- Intraorally, the mouth and lips may be dry, and
tious consequences.80-83,85 often there is an increase of caries and periodon-
titis.80,100
Marijuana
MDMA and ecstasy
Marijuana is probably the most common recrea-
tional drug used by people today. While it is still Patients who are addicted to these drugs may show
illegal in most countries, in the USA the use of rec- a loss of appetite and sometimes an increased body
reational marijuana is now legal in 10 states, and temperature and a heightened degree of sensorial
medical marijuana in 33. It has also been decrim- perception. They may experience cramps in the
inalized and/or made legal in some other coun- masticatory and other muscles due to constant
tries.80 bruxing. Some may show slight nausea when you
Some possible signs of marijuana use are com- approach their mouths.80,100
pulsive behavior and unusual or slurred speech or
other speech impairment, bloodshot eyes, strabis-
Methamphetamines
mus, and difficulty in keeping the mouth open.99
The presence of these signs may vary in inten- These are sympathomimetic drugs. Their use has in-
sity according to the amount of the drug used by creased dramatically in recent years. They are used
the patient. The intraoral examination may show by people of all ages and across all social classes,
signs of a very dry mouth and a sweet-smelling including professionals, who may require a higher
breath. and constant attention span or the need to work for
longer hours at an increased level of focus.
The effect of these drugs is often extreme phys-
Cocaine
ical exhaustion due to physical and mental overload.
After marijuana, cocaine is probably the most Signs of methamphetamine use are dilated pupils,
widely used recreational drug in the world today. It mydriasis, decreased appetite, dry mouth, excessive
is difficult to detect its use in patients, and users are weight loss, and mood changes. Sometimes, these
often very good at dissimulating their habit. patients are overexcited and garrulous; they may
The drug is mainly inhaled through the nose, even try to speak when you are working in their
which can result in reflex inflammation of the mu- mouths.
cous membrane of the turbinates and nasal sep- Patients addicted to methamphetamines may
tum due to the vasoconstrictor effect of the drug. feel uncomfortable in some seated positions or
Therefore, one obvious sign of cocaine addiction when they are reclined, and may constantly try to
is constant sniffing or touching of the nose on the find a more comfortable position, even suddenly
part of the patient, and sometimes the appearance standing up and moving away from the chair. They
that the patient has a cold. Another sign of the may also sweat excessively and/or tremble, and can
continual inhalation of cocaine through the nose show an increased degree of muscular force.
is ulcerations of the nasal septum (Hajek’s ulcer). It can be a huge challenge to treat patients who
Look out for dilation of the pupils (mydriasis), a are addicted to methamphetamines (the author has
further sign of the ongoing use of cocaine (see had two unforgettable cases where the patients
Chapter 7, Fig 7-5). were extremely difficult to control and treat).80,99,100
236

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240

CHAPTER FIFTEEN
How to write
a prosthodontic treatment plan
241

15 How to write a prosthodontic treatment plan
I. How to write a 2. The possible solutions for solving the

problems; there is usually more than one,
prosthodontic treatment
unless the patient’s wishes are particularly
plan for your patient clear. This should be carried out according
to the limitations of the system; it should be
Treatment plans are projects, and projects are the best compromise that takes into account
not static entities. Instead, they are a dynamic se the patient’s chief complaint/s, health status,
quence of organized phases in which the writer of wishes, and financial constraints.
the treatment plan has to engineer and develop,
step by step, the rationale of what should be done, Immediately after considering these two main
from beginning to end; in this case, the clinical parameters, we have to explain:
rehabilitation of the mouth and the delivery of the 3. The cost of the entire treatment therapy.
final prostheses. 4. The approximate duration of the therapy.
5. How the patient should best maintain the new
prosthetic rehabilitation (this is done with the
Therefore, recalling the many concepts covered in help of the dental office staff).
the previous chapters, any written treatment plan 6. Information regarding the informed consent
should be composed of six main points, corres the patient will need to sign.
ponding to six working considerations that need to
be addressed (Table 1). Practically and materially – the given treatment
plan must be composed of a variable number of
Translated into practice, a treatment plan written pages, not necessarily only one, in which the above
for a patient should show and explain clearly and information is shown and carefully explained to the
briefly: patient. Then, when everything is well understood and
1. What will happen, our assessment or diagnosis, accepted by the patient, all pages must be signed and
and the practical problems afflicting the photocopied, and a copy given to the patient.
patient’s oral cavity.
Table 15-1 Treatment plan: summary of description
A. Part 1 – Description of the treatment

1. Pretreatment diagnosis of the problem/s
2. Description of the proposed solution/s
3. Cost/s and payment modalities
4. Timeline and approximate length of treatment/s
5. Posttreatment care
B. Part 2 – Informed consent

6. Informed consent to be signed
242

III. Main text and writing guidelines
II. How to write a follow in the next section indicate how this check
list can be expanded to encompass the full clinical
prosthodontic treatment
details of each specific case.
plan for a professional case
presentation
Students and colleagues are often uncertain and

III. Main text and writing
anxious about describing the narrative of a case guidelines
presentation, perhaps due to insufficient under
standing of the process as well as too much im Describe the:
provisation regarding what can/should/ought to be A. PATIENT DESCRIPTION AND PERSONAL
written, or not written. HISTORY
In this chapter, a number of guidelines and suc 1. Who is the patient? (age, gender, race,
cessful case narratives are presented to help focus nationality)
the reader’s attention on the most important con 2. Occupation? (job, profession)
cepts and how they should be expressed when writ 3. Marital status? (single, married, divorced)
ing a treatment plan. B. CHIEF COMPLAINT
1. Describe the current problem in the patient’s
Differences exist in the way treatment plans are own words.
written and presented, depending on the teach 2. Is the patient in pain or discomfort? Are
ing requirements of the Advanced Education Pro there any other symptoms?
gram Director at individual postgraduate schools 3. What are the possible secondary complaints?
as well as on each student’s knowledge, clinical 4. What are the patient’s wishes and expecta
experience, and judgment. These differences may tions?
focus the interest on some clinical and/or techni C. MEDICAL HISTORY
cal aspects rather than on others when describing 1. PRESENT
the case, even though the main substance of treat a. Current health status.
ment planning always remains the same. There b. Current vital statistics:
fore, this chapter presents several formats show i. Height: 153 cm (5ˈ 4ˈˈ);
ing various typical samples of how to present a ii. Weight: 58 kg (150 lbs);
treatment plan. Furthermore, the American Board iii. Blood pressure: 120/74 mm/Hg;
of Prosthodontists (ABP) has defined certain cri iv. Pulse rate: 64 bpm;
terion statements for a patient presentation nar v. Respiration: 16 br/pm.
rative, in which specific guidelines are clearly c. Current cardiac or blood conditions.
suggested for each aspect, in a format necessary d. Current medications the patient is taking,
to prepare for the ABP examinations. Updates are and why.
always announced and well explained ahead of e. Drug allergies or intolerances.
the time online on their website, and also during f. Allergies to substances and/or environmental
all ABP proficuous courses. allergies.
g. Smoking and drinking habits.
h. Eating disorders (anorexia, bulimia,
The following section shows the rationale and or dysphagia).
ganization of preparing a treatment plan. It provides i. Diet (acidic, sodas) and sugar consumption.
a checklist outlining the most important aspects of j. Possible medical contraindications for dental
most clinical cases. The specific clinical cases that treatment.
243

2. PAST F. PROSTHODONTIC HISTORY

a. Date of the patient’s last physical. 1. What types of prostheses have been
b. Illness (family history). customized and delivered to the patient?
c. Serious illness or infectious diseases (past, 2. When did the patient receive them?
recent). 3. Is the patient happy with past prostheses?
d. Other diseases or changes in health. 4. Was the patient able to clean them properly?
e. Medical treatments, hospitalizations, 5. What are the problems the patient has with
surgeries (past, recent). them?
f. Possible breathing problems and/or diffi
culties. G. EXTRAORAL EXAMINATION
g. Possible physical disorders. 1. INSPECTION
a. Head:
D. PSYCHOLOGIC EVALUATION i. Skull type;
1. Personality according to House classification ii. Dimensions;
(H) (I) (P) (E) (useful to report). iii. Position;
2. Collaborative attitude (or not) (anxiety, fears, iv. Lip support (vertical and horizontal).
depression, behavioral patterns). b. Neck:
3. Does the patient understand his or her tooth i. Dimensions;
conditions? ii. Position;
4. Does the patient understand where and why iii. Muscle contractions;
he or she is there (cognitive, dissociative iv. Deformities and swellings.
disorder)? c. Face:
5. Is the patient willing to be treated? Front view
i. Face midline (glabella-nose-mental pro
E. DENTAL HISTORY tuberances);
1. Last and previous dental visits and their ii. Frontal right and left symmetry and
regularity. volumes;
2. Has the patient ever received oral hygiene iii. Nose asymmetries;
instructions (OHI)? iv. Mandibular right or left asymmetries;
3. What type of previous dental treatments v. Facial midline vs dental midline while
have been performed on the patient? smiling;
4. Possible biting, grinding, clenching habits vi. Smile line (high, medium, low);
the patient may or may not be aware of. vii. Lip line at rest;
5. Possible difficulties in opening and closing viii. Frontal occlusal plane and bipupillary
the mouth. line parallelism;
6. Possible previous treatments for gum ix. Anterior teeth vertical angulation;
problems (periodontal disease). x. Lip support at rest;
7. Possible previous extractions and reasons for xi. Lip support while smiling (SPL and SPG
them (root canals, caries, prostheses). presence);
8. Good or reduced salivation, possible xii. Vermillion border support;
presence of xerostomia and awareness of xiii. Cheek support (concavities);
why it is present. xiv. Amount of tooth display during phone
9. Possible loss of taste, and if so, since when tics.
and why?
244

III. Main text and writing guidelines
Lateral view I. AUSCULTATION

i. Facial profile at rest (Rickett’s line evalu 1. Listen to the patient’s phonetics.
ation); 2. Listen to whether the maxillary and
ii. Facial profile while smiling; mandibular teeth touch when the patient is
iii. Anteroposterior occlusal plane and speaking.
ala-tragus Camper’s plane parallelism; 3. Listen to whether one or both TMJs emit
iv. Lateral lip support at rest; noises while opening and/or closing such as
v. Lateral lip support while smiling (SPL clicking, popping or crepitus.
and SPG presence).
d. Lips: J. OLFACTION
i. Tissue evaluation; Try to perceive whether the patient smokes,
ii. Volume and color; drinks, and/or smells of something particular,
iii. Possible use of fillers (liquid, others); and other signs that may help you to draw a
iv. Symmetry; more precise medical and psychologic profile.
v. Possible angular problems;
vi. Presence of pathologies. K. INTRAORAL EXAMINATION
e. Mandible at rest and in motion: In any case presentation narrative, all major
i. Mandibular teeth midline compared findings related to any intraoral soft and hard
with maxillary teeth midline; tissue problems and issues should be reported.
ii. Range of motion; This should be followed by detailed infor
iii. Laterodeviation on opening and closing; mation gained from a comprehensive dental
iv. Possible deflection; examination, describing problems related to
v. Maximum opening. the remaining teeth as listed in the examin
ation questionnaires reported in Chapter 9. In
H. PALPATION addition, report whether tapping on some teeth
1. Head and neck lymph nodes (see Chapter 7, produces symptoms such as sensitivity and/or
Figs 7-15 and 7-16). pain due to inflammation, and/or whether there
2. Neck (localized or diffused muscle are any visible signs of parafunctional habits.
contraction, tension, pain).
3. Head: masseter and/or temporalis masti L. COMPREHENSIVE PERIODONTAL
catory muscles (contraction, tension, pain). EXAMINATION
4. Nerves: Show the periodontal chart or form you filled
i. Pain or numbness at the emergence of the in that reports detailed information gained
trigeminal nerve, ophthalmic, maxillary from a comprehensive periodontal examin
and/or mandibular divisions; tion, with a description of all active periodontal
ii. Facial nerve: pain or numbness. treatment parameters you have evaluated.
5. Maxilla: areas of localized or diffused elicited
pain. M. OCCLUSAL EXAMINATION
6. Mandible: areas of localized or diffused 1. STATIC ANALYSIS OF OCCLUSION
elicited pain. a. Angle’s Class I, Class II division I, Class II
7. Temporomandibular joint (TMJ) (sensitivity, division II, Class III.
pain, crepitus). b. Vertical dimension of occlusion (VDO)
(excessive, normal, reduced).
c. Overjet or overbite.
d. Evident anomalies in tooth position.
245

e. Examination of the maxillary arch, shape 6. The presence of caries and where they occur
and arch form, missing teeth, anomalies in (tooth numbers).
tooth position. 7. The presence of remaining roots and where
f. Examination of the mandibular arch, shape they occur (tooth numbers).
and arch form, missing teeth, anomalies in 8. The presence of included teeth and where
tooth position. they occur (tooth numbers).
2. FUNCTIONAL (DYNAMIC) ANALYSIS OF 9. The presence of overcontoured fillings and
OCCLUSION where they occur (tooth numbers).
a. Possible laterodeviations in opening and 10. The presence of overhanging fixed pros
closing. theses and where they occur (tooth
b. Possible discrepancy between centric numbers).
relation (CR) position and centric occlusal
(CO) position or maximum intercuspation P. INDIVIDUAL TOOTH CLINICAL AND RADIO
position (MIP). GRAPHIC ASSESSMENT
c. Possible presence of prematurities in CR. From tooth 1 to tooth 32, show the photo
d. Describe the lateral guidance: canine (R) to graphic image and the periapical radiograph
(L); group function (R) to (L). of the tooth, tooth by tooth, and for each tooth
e. Describe protrusive tooth contacts. describe the following possibility:
f. Describe possible interfering contacting on 1. Absence of the tooth (missing).
the nonworking, balancing side. 2. Inclined (mesially, lingually, buccally).
3. Rotated (mesially, lingually, buccally).
N. EXAMINATION OF THE TEMPORO 4. Amount of bone loss (10%, 20%, 30%, and
MANDIBULAR JOINTS more).
1. The patient may or may not refer symptoms. 5. Pocket depth in millimeters (DB, DL, MB,
2. You may report signs like pops or clicks ML).
noted during the examination. 6. Furcation involvement (Grade I, II, II; mesial,
distal, buccal).
O. COMPREHENSIVE RADIOGRAPHIC EXAM 7. Mobility pattern (+1 or +2 or +3).
INATION 8. Endodontically filled (description).
Show the panorex and the comprehensive 9. Periapical radiolucency.
periapical radiographic examinations and point 10. Defective amalgam restorations.
out on these examinations: 11. Composite restoration.
1. The possible presence of calculus and where 12. Inlay or onlay.
it occurs (tooth numbers). 13. Porcelain-fused-to-metal (PFM) crown.
2. The overall percentage of bone loss, 14. Ceramic crown.
horizontal and vertical, on both arches of all 15. Pontic.
teeth, tooth by tooth, starting from tooth 1. 16. Individual tooth prognosis (good, guarded,
3. The possible widening of the periodontal hopeless).
ligament (PDL) and where it occurs (tooth
numbers). Q. CASE DIAGNOSIS
4. The presence of periapical pathosis and 1. Possible caries?
where it occurs (tooth numbers). 2. Possible poor oral hygiene?
5. The possible presence of furcation 3. Possible periodontal conditions (generalized
involvement and where it occurs (tooth moderate to severe periodontitis, mucogin
numbers). gival conditions, white lesions)?
246

IV. Prosthodontic case presentation narratives
4. P ossible missing teeth? IV. Prosthodontic case

5. Possible generalized recession?
presentation narratives
6. Possible primary or secondary trauma from
occlusion? Examples and scenarios
7. Possible moderate or severe attrition?
8. Possible asymptomatic TMJ dysfunction? It is not the aim of this chapter to set standards of nar-
9. Possible defective restorations? rative formats but to describe and rationalize a few
10. Possible defective prosthetic restorations of them, offering outlines and useful working hints to
(either fixed or removable)? students and professionals for possible critical read-
11. Possible defective endodontic restorations? ing, rehearsing, and learning.
The following cases have been selected to show sev-
R. ETIOLOGY eral different prosthodontic ‘narrative frameworks,’
1. Primary etiologic factors (possible presence written according to the rationale of each prosthodon-
of supragingival or subgingival plaque and tic and perioprosthodontic clinical case presentation,
calculus, food impaction associated with and developed to be discussed during specialty pro-
open contacts, smoking habit)? grams, treatment planning, and examinations.
2. Secondary etiologic factors (possible No names, photographs, radiographs, and treat
trauma from occlusion, possible defective ment schemes are included. All cases have been
restorations, possible tooth loss without formatted only to show the step-by-step frameworks
replacement, possible loss of posterior of the rationale, including the terminology, that has
support)? been followed to describe the treatment plans.
In these narratives you may find a number of
S. CASE PROGNOSIS useful Phase I diagnostics descriptions of what
1. SHORT-TERM PROGNOSIS (good, fair, guarded)? should be investigated during this important assess
2. LONG-TERM PROGNOSIS ment process as well as how they can be described,
a. Good, fair to guarded, guarded, poor? submitted, and reported.
b. Patient compliance with maintenance recalls Some of these case presentation narratives sim
(ability, motivation)? ply end with the formulation of a treatment plan
to highlight the description of this initial important
T. TREATMENT PLAN 1 ‘Phase I’ topic. Other cases describe a completed
Treatment plan must be well organized and prosthodontic case narrative to give a thorough
chronologically sequenced in its rationale to vision of the overall descriptive format of a final
prevent and correct oral disease. ized case.
1. Step-by-step description of your rationale of Bear in mind that due to the ongoing evolution of
the three treatment phases: science and the resultant improvements in the field of
a. Phase I; prosthodontics, this process is always changing.
b. Phase II;
c. Phase III.
2. Create an illustration or drawing of the
maxillary and mandibular Treatment Plan 1.
U. TREATMENT PLAN 2.
V. TREATMENT PLAN 3.
247

Case 1
Perioprosthetic treatment
Phase I diagnostics – case narrative
Date: XX/XX/XXXX
Doctor: XXX, DDS
Department of Prosthodontics, University of XXX
Miss XXX
Personal history Weight: 58 kg (150 lbs)

Miss XXX, a 27-year-old Afro-American female, Blood pressure: 120/74 mm/Hg
presented to the University of XXX for a periopros Pulse rate: 64 bpm
thodontic evaluation. Respiration: 16 br/pm
Chief complaint Dental history

Upon initial examination, the patient stated: “My The patient stated that she had visited the dentist
anterior teeth are too loose and I definitely need gum regularly every 6 months over the past 2 years. Her
treatment and a rehabilitation of my teeth.” The pa last visit was last month (June 1990) for an eval
tient was an assistant manager in a store and liked uation of her anterior teeth. Her major treatment
her job. She was single and living with her parents. consisted of a few fillings and a tooth cleaning. Her
last extraction was 3 months ago (April 1990) due to
Medical history caries on tooth 19.
The patient’s condition was reasonably good. Her The patient’s last prophylaxis was last month.
last physical was on XXX and nothing remarkable Her oral hygiene consisted of brushing twice per
was evident. She had experienced no medical com day with a medium brush and flossing occasionally.
plications during the past 10 years. She did not take She used Scope mouthwash. She was not aware of
any medication, nor did she smoke or have any his any dental paranormal habits, although she seemed
tory of smoking. She was not allergic to any drug. to bite her lower lip.
She had no history of diabetes and nor did anyone Flaring of her anterior teeth started 3 to 4 years
in her family. ago. Her anterior teeth used to make contact when
A dietary survey revealed a balanced intake she closed her mouth and lips. The patient had a rea
from the four basic food groups. Her consumption sonably positive attitude toward dental treatment
of sweets was minimal. She was on a weight reduc and stated that she knew the condition of her teeth
tion diet at the time and had lost 10 lbs since XXX. well and understood the necessity of extractions.
She drank no alcohol and only two cups of tea with
milk per day. Clinical findings
1. Extraoral examination:
Vital statistics Head and neck survey revealed no sign of patho
Height: 153 cm (5ˈ 4ˈˈ) logy. She had an open bite due to the flaring of
248

Case 1 Perioprosthetic treatment
her maxillary anterior teeth. There were no Static analysis of occlusion

signs of TMJ dysfunction and no history of TMJ Analysis of occlusion revealed Angle’s Class I clas
problems. sification on the right side and Class III on the left
2. Intraoral examination: side.
The tongue, oropharynx, mucosa, and salivary Curve of Spee was exaggerated on both sides
flow were within normal limits. The floor of the due to the extrusion of the maxillary teeth.
mouth was a little shallow. Interproximal open contact between teeth 3 and
3. Gingival examination: 4, 7 and 8, 20 and 21, 21 and 22, 29 and 30, 30 and 31.
• In general, the gingiva showed dark pink Caries were found on teeth 3, 4, 5, 14, and 18.
due to melanin pigmentation. Marginal
redness was found around teeth 7, 8, 9, 10, Functional analysis of occlusion
11, 24, and 25. A bluish color was noted on Functional analysis of occlusion revealed fremi
the palatal side of both maxillary posterior tus on tooth 10. Centric pathway prematurity was
teeth. Papillae enlargement was found in found between teeth 3 and 31, 14 and 18, and 19.
the mandibular anterior teeth and a soft Right lateral movement was guided by teeth 7 and
tissue crater was noted between teeth 8 and 27, and balancing contacts were noted between
9. The maxillary anterior area was fibrotic- teeth 14 and 18. Left lateral movement was guided
edematous while the rest of the area appeared by teeth 12 and 21, and 13 and 20, and no balanc
to be edematous. The mandibular posterior ing contact was found. Protrusive movement was
segments and the lingual side of the anterior guided by teeth 7 and 28, and interference was seen
teeth appeared to be less edematous with a between teeth 14 and 18.
normal contour, except for teeth 18 and 30
due to juxtagingival caries. Radiographic findings
• In general, a slight to moderate amount Radiographic analysis revealed severe bone loss in
of plaque and calculus were found the maxillary arch with respect to teeth 6, 11, and
supragingivally. 12. A slight-to-moderate bone loss was noted, with
• The disclosing agent indicated an O’Leary localized severe bone loss in the mandibular arch.
index of 60%. The pattern of bone loss was horizontal and angu
• Bleeding index (BI) was 89%. lar. Widened PDL was noted for most of the maxil
• PD 4 to 6 mm on teeth 6, 17, 20, 23, 25, 26, lary teeth and for tooth 30. Periapical pathosis was
and 27 was 7 mm in general. found for teeth 13, 18, and 30. Caries were found on
• PAL 4 to 6 mm on teeth 6, 17, 23, 24, and 25 teeth 3, 4, 5, 14, and 18. Possible furcation involve
was 7 mm in general. ment was found for teeth 1, 3, 14, 15, 18, 30, and 31.
• No MG problems.
• Furcation involvement: Individual tooth clinical and radiographic
Grade I: None. analysis
Grade II: IMP & DP, 12 M, 15 D, 18 B, and 31 B. Tooth 1: 50 to 60% bone loss; 10 mm PD; widened
Grade III: Teeth 3, 5, 14, and 15 MB. PDL; Grade II furcation involvement; no mobility.
• Mobility: Prognosis: poor to guarded.
Grade I: Teeth 20, 21, 23, 24, and 25. Tooth 2: Missing due to caries.
Grade II: Teeth 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, Tooth 3: 60 to 90% bone loss; 11 mm PD; 13 mm
14, 15, 18, 28, 29, and 30. PAL; Grade III furcation involvement; caries; 3 mo
• Recession: Teeth 3, 7, 8, 9, and 14. bility; widened PDL; extrusion. Prognosis: hopeless.
Tooth 4: 60% bone loss; 12 mm PD; widened PDL;
caries; 3 mobility. Prognosis: poor.
249

Tooth 5: 70% bone loss; 12 mm PD; Grade III furca Tooth 26: 10 to 30% bone loss; 4 mm PD; + mobility.
tion involvement; widened PDL; 2+ mobility. Prog Prognosis: good.
nosis: hopeless. Tooth 27: No bone loss; 6 mm PD; Prognosis: good.
Tooth 6: 10% bone loss. Prognosis: good. Tooth 28: 20 to 70% bone loss; 11 mm PD; 3 mobil
Tooth 7: 70 to 80% bone loss; 9 mm PD; 15 mm PAL; ity. Prognosis: poor.
widened PDL; 3 mobility. Prognosis: hopeless. Tooth 29: 60 to 70% bone loss; 12 mm PD; 2+ mo
Tooth 8: 70 to 80% bone loss; 7 mm PD; 15 mm bility. Prognosis: poor to guarded.
PAD; widened PDL; 3 mobility; pathological migra Tooth 30: 10 to 70% bone loss; 7 mm PD; Grade II
tion. Prognosis: hopeless. furcation involvement; widened PDL; 2+ mobility;
Tooth 9: 80 to 90% bone loss; 9 mm PD; 15 mm periapical pathosis. Prognosis: hopeless.
PAD; widened PDL; 3 mobility. Prognosis: hopeless. Tooth 31: 20 to 50% bone loss; 8 mm PD; Grade II
Tooth 10: 70 to 100% bone loss; 9 mm PD; 10 mm involvement; 2 mobility. Prognosis: poor to guarded.
PAD; 2+ mobility. Prognosis: hopeless. Tooth 32: Impacted.
Tooth 11: 10 to 30% bone loss; 9 mm PD; no mobil
ity. Prognosis: good. Diagnosis
Tooth 12: 10 to 0% bone loss; 9 mm PD; Grade II 1. Generalized moderate to severe periodontitis.
furcation involvement; 2 mobility. Prognosis: poor. 2. Rapidly progressive periodontitis or generalized
Tooth 13: 0 to 90% bone loss; 10 mm PD; widened PDL; juvenile periodontitis.
periapical pathosis; 3 mobility. Prognosis: hopeless. 3. Trauma from occlusion.
Tooth 14: 70 to 90% bone loss; 10 mm PD; 12 mm 4. Caries with possible pulpal involvement were
PAD; Grade III furcation involvement; caries; 3 mo found on teeth 3, 14, 18, and 30.
bility. Prognosis: hopeless. 5. Periapical pathosis for teeth 13, 18, and 30.
Tooth 15: 30 to 70% bone loss; 11 mm PD; Grade III
and II furcation involvement; 2 mobility. Prognosis: Etiology
poor. 1. Supra- and subgingival calculus.
Tooth 16: Impacted. 2. Immune deficiency.
Tooth 17: 10 to 50% bone loss; 6 mm PD; caries; 3. Severe bone loss contributing to secondary
periapical pathosis; 2+ mobility; Grade II furcation trauma from occlusion.
involvement. Prognosis: poor. 4. Missing teeth.
Tooth 18: 40 to 50% bone loss; 8 mm PD; caries;
periapical pathosis; 2+ mobility; Grade II furcation Treatment plan
involvement. Prognosis: poor to guarded. PHASE I
Tooth 19: Missing. 1. Consultation with immunologist Dr XXX about
Tooth 20: 10 to 40% bone loss; 6 mm PD; 1+ mobil the T4 to T8 cell ratio.
ity. Prognosis: good. 2. Blood test.
Tooth 21: 10 to 30% bone loss; 1 mobility. Progno 3. Antibiotic therapy (doxycycline for 2 weeks).
sis: good. 4. Mouthwash (Peridex and Listerine).
Tooth 22: 20 to 30% bone loss; 7 mm PD; + mobility. 5. Consultation with:
Prognosis: good. a. Periodontist Dr XXX for clinical evaluation
Tooth 23: 10 to 20% bone loss; 6 mm PD; 1 mobility. and treatment planning.
Prognosis: good. b. Oral surgeon Dr XXX for extraction of hope
Tooth 24: 10 to 30% bone loss; 1 mobility. Progno less teeth.
sis: good. c. Endodontist Dr XXX for teeth 18, 6, and 11
Tooth 25: 20 to 30% bone loss; 5 mm PD; 1+ mobil for possible endodontic care if patient needs
ity. Prognosis: good. an overlay denture.
250

d. Prosthodontist Dr XXX for clinical evalua PROSTHETIC TREATMENT PLANS

tion and treatment planning. A. Treatment 1
6. Plaque control. 1. Maxilla: complete overdenture (teeth 6 and
7. Scaling and root planing under local anesthesia. 11 as abutments).
8. Reevaluation, endodontic therapy, and possible 2. Mandible: PFM fixed prosthesis on tooth
temporalization should take place during this 18 and tooth- to mucosa-borne removable
phase after acceptance of treatment and once partial denture (RPD).
informed consent has been signed by the
patient. B. Treatment 2
1. Maxilla:
PHASE II a. Two metal fused post and cores on teeth
1. Teeth 17 and 18: pocket elimination and possible 6 and 11.
osseous surgery (regenerative therapy). b. Six PFM unit bridges with two distal
2. Teeth 20 to 27: pocket elimination and open extracoronal ERA attachments and two
clean-up on teeth 23 to 26. cingulum rests as lingual stabilizing
3. Teeth 28 to 31: pocket elimination with regener arms distally on teeth 6 and 11.
ative procedure. c. One maxillary RPD with complete
4. Prosthodontic treatment. palatal major connector, two ERA at
5. Finalization of prosthodontic treatment with tachments, two cingulum rests, indirect
delivery of the prostheses. retainers, mesial arms.
2. Mandible: PFM fixed prosthesis on tooth 18,
PHASE III and tooth- to mucosa-borne RPDs.
1. Periodontic follow-up schedule.
2. Prosthodontic follow-up schedule. C. Treatment 3
1. Reevaluate an implant therapy with the patient
and, in case of acceptance, formulate a maxillary
and mandibular placement for implant-sup
ported prostheses.
251

Case 2
Date: XX/XX/XXXX
Doctor: XXX, DDS
Mr XXX
Personal history Dental and prosthodontic history

Mr XXX was a 67-year-old white male, retired, mar The patient explained that he first went to the den
ried with two children. tist when he was 17 years old. Since then he has had
a good relationship with dentists. He has had many
Chief complaint different restorations but only when he thought
The patient reported to the University of XXX for a they were necessary. His brother had referred him
prosthetic evaluation to possibly replace a missing to the undergraduate clinic for evaluations. His
maxillary anterior tooth. After the evaluation, he chief complaint was his missing anterior teeth. He
was assigned to the postgraduate clinic. also complained of a visible swelling on his right
cheek that manifested 15 years ago. Two years ago,
Medical history he went to the ear, nose, and throat clinic for a clin
Medical history appeared unremarkable considering ical evaluation and tests as he was worried about
that at the last examination a year ago everything the evident increased dimensions of the little nod
was within normal limits. The only exception was ule. After the first biopsy, the physician told him he
the Warthin’s tumor on the right parotid gland and needed a selective surgery to remove this benign
a history of smoking and drinking, which convinced tumor. He was then referred to an oral patholo
the patient’s clinician to prescribe antidepressants gist, who also suggested surgical removal to avoid
(Norpramin, 50 mg, three times per day). However, further complications or major problems and who
since starting the medication last year, he no longer warned him of the risk of facial paralysis that could
smokes or drinks alcohol. No dietary problems were occur upon removal of the tumor. The patient then
reported. decided not to undergo the surgery. Furthermore,
Vital statistics he stated that his last dental examinations had been
Height: 165 cm (5ˈ 5ˈˈ) irregular. He brushed his teeth once a day, and his
Weight: 75 kg (165 lbs) last prophylaxis was performed 3 years ago. The
Blood pressure: 140/90 mm/Hg patient has never used a proximal brush or dental
Pulse rate: 60 bpm floss. He said he did not grind his teeth, and also
Respiration: 23 br/pm stated that he felt comfortable with the dentist but
not with his mouth. Nevertheless, he was confident
with our last professional treatment recommenda
tions.
252

Extraoral examination Individual tooth clinical and radiographic

The extraoral examination revealed a significant assessment
swelling in the area of the right cheek and a smaller Tooth 1: Missing.
one on the left. The lips were dry. The head and neck Tooth 2: 30% bone loss; 4 mm pocket depth; furca
were within normal limits. Palpation of the mus tion Grade I buccally; mesial decay; amalgam MOD
cles revealed no tenderness or pain. The two TMJs filling; sinus proximity. Prognosis – periodontic:
revealed no fremitus, popping or any other sign of fair to good; prosthodontic: good.
pathology. Tooth 3: 30 to 50% bone loss; 5 to 7 mm pocket
depth; furcation Grade I buccally; amalgam MOD
Intraoral examination filling; sinus proximity. Prognosis – periodontic:
The intraoral examination revealed that the mu fair to guarded; prosthodontic: fair.
cosa, lips, and tongue appeared to be within normal Tooth 4: 20 to 30% bone loss; Grade I mobility; pins;
limits except for the evidence of a dry mouth that huge complete restoration; sinus proximity; peri
was due to the medications the patient was taking. apical radiolucency. Prognosis – periodontic: good;
prosthodontic: good.
Periodontal examination Tooth 5: 30 to 40% bone loss; 5 mm probing depth;
The gingival tissue appeared reddish-pink, with se PFM crown. Prognosis – periodontic: good; pros
vere redness present around tooth 6. The gingival thodontic: good.
margin was enlarged, rolled, and generally firm. Tooth 6: 20 to 30% bone loss; 6 mm probing depth;
The papillary tissue appeared soft and spongy. Loss short endodontic treatment. Prognosis – periodon
of stippling was observed in both arches. The BI was tic: poor; prosthodontic: poor.
100% and the plaque index (PI) was 100%. Tooth 7: 40% bone loss; 5 mm probing depth; root
proximity; overcontoured PFM crown. Prognosis –
Occlusion periodontic: fair; prosthodontic: fair.
The static analysis of occlusion revealed a right and Tooth 8: 50 to 60% bone loss; 8 mm pocket depth;
left Angle’s Class II relationship. The curve of Spee root proximity with 7; Grade 2 mobility; short endo
was moderately flattened on both sides. The over dontic treatment; post; overcontoured PFM crown.
bite was 50% and the overjet was 4 to 5 mm. Prognosis – periodontic: fair to poor; prosthodon
The functional analysis of occlusion revealed tic: poor.
that the left lateral excursion was canine guided, Tooth 9: Tip of the apex was present.
while the right lateral excursion was guided by Tooth 10: 30% bone loss; 4 mm probing depth;
teeth 15 and 18. There was a slight slide in the CR, short endodontic treatment; post; pins; complete
and fremitus was seen on tooth 8. composite restoration. Prognosis – periodontic: fair
to good; prosthodontic: good.
Radiographic examination Tooth 11: 20% bone loss; Grade I mobility; peri
The pattern of bone was irregular. Proximity of the apical radiolucencies; pins; complete restoration.
apices to the maxillary sinus was visible on teeth 2, Prognosis – periodontic: fair to good; prosthodon
3, 4, 14, and 15. The crown-to-root ratio was gener tic: good.
ally favorable except for teeth 6, 7, 8, and 25. Peri Tooth 12: 20 to 30% bone loss; 5 mm probing depth;
apical radiolucencies were seen on teeth 10, 11, 14, Grade I mobility; pins; complete restoration. Prog
and 28. nosis – periodontic: fair to good; prosthodontic:
good.
Tooth 13: 20 to 40% bone loss; 5 mm probing depth;
short endodontic treatment; post; gold crown. Prog
nosis – periodontic: fair to good; prosthodontic: good.
253

Tooth 14: 20 to 40% bone loss; 6 mm pocket depth; Tooth 30: 10% bone loss; Grade I furcation involve
slight periapical radiolucency on the palatal root; ment; pin; overcontoured MOD amalgam. Progno
overcontoured MOD amalgam. Prognosis – perio sis – periodontic: good; prosthodontic: good.
dontic: fair to good; prosthodontic: good. Tooth 31: 20% bone loss; huge MOD amalgam fill
Tooth 15: 20% bone loss; 6 mm probing depth; ing. Prognosis – periodontic: good; prosthodontic:
Grade 2 furcal involvement buccally; pin; overcon good.
toured MOD amalgam. Prognosis – periodontic: fair Tooth 32: Missing.
to guarded; prosthodontic: guarded.
Tooth 16: Missing. Diagnosis
Tooth 17: Missing. 1. Slight to moderate adult periodontitis.
Tooth 18: 10 to 20% bone loss; 5 mm probing depth; 2. Trauma from occlusion.
pin; huge MO amalgam. Prognosis – periodontic:
good; prosthodontic: good. Etiology
Tooth 19: 20 to 30% bone loss; 5 to 7 mm probing 1. Primary factors: subgingival plaque and
depth; pin; huge MO amalgam. Prognosis – perio calculus.
dontic: good; prosthodontic: good. 2. Contributory factors: iatrogenic dentistry that
Tooth 20: Root with pin remaining. favored plaque and calculus accumulation.
Tooth 21: 20% bone loss; MOD amalgam. Prognosis 3. Parafunctional activity triggered by emotional
– periodontic: good; prosthodontic: good. problems and occlusal prematurities.
Tooth 22: 10% bone loss; possible distal decay;
complete composite restoration. Prognosis – perio Prognosis
dontic: good; prosthodontic: good. The overall short-term prognosis was good. The
Tooth 23: 20% bone loss; Grade II mobility; spindle long-term prognosis was fair to good.
root. Prognosis – periodontic: good; prosthodontic:
good. Sequence of treatment
Tooth 24: 20 to 30% bone loss; 5 mm probing depth; PHASE I
Grade I mobility. Prognosis – periodontic: good; 1. Consultations with physician, endodontist,
prosthodontic: good. periodontist, oral surgeon, and prosthodontist.
Tooth 25: 40% bone loss; 5 mm probing depth; 2. Plaque control and fluoride treatment.
Grade II mobility. Prognosis – periodontic: good; 3. Extractions.
prosthodontic: good. 4. Removal of cavities on decayed teeth.
Tooth 26: 20 to 30% bone loss; 6 mm pocket depth; 5. Scaling and root planing.
Grade I mobility; endodontic treatment; distal de 6. Possible temporization.
cay; composite restoration. Prognosis – periodon 7. Occlusal adjustment.
tic: good; prosthodontic: good. 8. Reevaluation.
Tooth 27: No bone loss; no mobility; distal decay;
amalgam filling. Prognosis – periodontic: good; PHASE II
prosthodontic: good. At the time of presentation, it seemed that surgery
Tooth 28: Grade I mobility; periapical and distal was required for both maxillary quadrants as well
radiolucencies; endodontic treatment; post; pin; as for the mandibular left area and the mandibular
overcontoured PFM crown. Prognosis – periodon incisors area.
tic: good; prosthodontic: good. Final restorative and prosthetic treatment.
Tooth 29: 10% bone loss; Grade I mobility; periapi
cal radiolucency; decay; amalgam filling. Prognosis PHASE III
– periodontic: good; prosthodontic: good. Recall schedule to be determined.
254

Case 3
Date: XX/XX/XXXX
Doctor: XXX, DDS
Mr XXX
Personal history been wearing his partial denture at night. His last
Mr XXX was a 66-year-old Caucasian male. He re dental prophylaxis was performed 4 years ago. He
ported to the Department of Prosthodontics for a had never used a proximal brush or dental floss and
prosthetic consultation after being referred by an did not grind his teeth. He felt comfortable with his
other patient who is his friend. His major concern present prosthesis and did not think he needed a
was mouth odor and a broken tooth on his partial new one. Nevertheless, he was confident with the
denture. The patient was retired and was married last professional treatment decision.
with two children. There were no family problems.
He was employed at a megastore and had no par Extraoral examination
ticular interests. The head and neck did not reveal any unusual find
ings. There was no evidence of TMJ dysfunction,
Medical history nor was there any contraction, soreness or asym
The patient’s medical history was unremarkable, metrical function of the neck and masticatory mus
with no problems except for the usual colds and cles.
sore throats. He had never had surgery and had no
sensitivity or allergy problems. The patient had an Intraoral examination
adequate dietary intake from the four basic food The lower lip showed the result of an accidental
groups. He did not smoke, nor did he drink coffee wound that occurred 20 years ago. The tongue was
or any alcoholic beverages. within the normal limits and the salivary flow was
Vital statistics adequate. There was evidence of an ulcerative le
Height: 183 cm (6ˈ 0ˈˈ) sion on the oral mucosa close to tooth 14. The pala
Weight: 80 kg (176 lbs) tal vault presented an area of compression due to
Blood pressure: 115/70 mm/Hg the major connector of the existing RPD. The same
Pulse rate: 65 bpm effect of compression was evident on the man
dibular arch in the area corresponding to the major
Dental and prosthodontic history connector of the RPD.
The patient stated that his last visits to the dentist
had been irregular. His major dental treatment had Periodontal evaluation
been a prosthetic rehabilitation 16 years ago. He The gingival tissue showed a generalized reddish
said that he brushed his teeth once a day and had color change, with the papillae and the adherent gin
255

giva swollen and of a soft consistency. Generalized Radiographic assessment and findings
areas of severe inflammation were noted around all The radiographs showed generalized moderate to
the teeth as well as areas of mucosa compressed by severe bone loss. Severe defects and irregular bone
the RPD adaptation. Areas with moderate to severe areas were noted between teeth 22 and 23, and 26 and
pocket depth were revealed on probing, and par 27. Root proximity was present between teeth 23 and
ticularly severe defects existed between teeth 17 24, 25 and 26, and 17 and 18. The apices of teeth 14
and 18, with 8 mm probing depth. A large amount and 4 were close to the maxillary sinus. Periapical ra
of supra- and subgingival plaque and calculus were diolucency was shown on tooth 18. A slight amount
present, with excessive accumulation in the area of of subgingival calculus was noted on the maxillary
the mandibular incisors. Bleeding on probing was teeth, with a moderate to severe amount of calculus
revealed around all teeth, with some sensitivity dis on the mandibular teeth. Defective endodontic treat
tal to tooth 22. Areas of localized recession could ment was present on tooth 17, with a short or nonex
be seen on teeth 4, 8, 11, 17, 18, 21, 26, 27, and 32. istent root canal filling, and on tooth 18 with a short
Mucogingival defects were apparent on teeth 18, 21, root canal filling. Unfavorable crown-to-root ratio
and 27. Furcal involvement was found buccally on for the mandibular incisors was evident. Caries were
tooth 14 (Grade I). Mobility patterns were + on teeth found on teeth 11, 14, 17, and 18 as well as defective
17 and 18, and 1 on teeth 24, 25, 26, and 27. overcontoured prosthetic restorations.
Occlusal analysis Individual tooth clinical and radiographic

STATIC ANALYSIS OF OCCLUSION assessment
The static analysis of occlusion revealed an Angle’s Tooth 1: Missing.
Class II division I classification, based on the canine Tooth 2: Missing.
to canine relationship. The overjet was 9 mm and Tooth 3: Missing.
the overbite was 50%. The curve of Spee was accen Tooth 4: 40 to 50% bone loss; 4 to 5 mm pocket
tuated on the right side. Teeth 1, 2, 3, 4, 9, 10, 13, 15, depth; normal mobility; defective overcontoured
16, 19, 20, 28, 29, 30, and 31 were missing. Tooth 4 crown; proximity of the apex to the maxillary sinus.
was supraerupted, tooth 17 was supraerupted and Prognosis – periodontic: good; prosthodontic: fair.
mesially tilted, and teeth 18 and 32 were mesially Tooth 5: Missing.
tilted. Generalized wear facets were present on both Tooth 6: 20 to 30% bone loss; 3 to 5 mm pocket
arches and prostheses. depth; normal mobility; defective overcontoured
crown; Prognosis – periodontic: good; prosthodon
FUNCTIONAL ANALYSIS OF OCCLUSION tic: good.
The functional analysis of occlusion revealed a first Tooth 7: 20 to 30% bone loss; 4 to 6 mm pocket
contact in CR between teeth 12, 13, and 21. The right depth; normal mobility; defective overcontoured
lateral excursion was guided by teeth 6, 7, 8, and 25, crown. Prognosis – periodontic: good; prosthodon
while tooth 26 had nonworking interferences. The tic: good.
left lateral excursion was guided by teeth 11 and Tooth 8: 20 to 30% bone loss; 4 to 5 mm pocket
12, and 21, 22, and 23 without balancing interfer depth; N mobility; defective overcontoured crown.
ences. With the RPD, the right lateral excursion was Prognosis – periodontic: good; prosthodontic: fair.
guided by teeth 3 and 4, and 29, 30, and 31, with a Tooth 9: Missing.
slight balancing interference on tooth 15. The left Tooth 10: Missing.
lateral excursion with the prostheses was guided by Tooth 11: 20% bone loss; 3 to 5 mm pocket depth;
teeth 11, 12, and 21, and teeth 22 and 23 without possible mesial decay; defective overcontoured
posterior interferences. crown. Prognosis – periodontic: good; prosthodon
tic: good.
256

Tooth 12: 20 to 30% bone loss; 3 to 5 mm pocket with tooth 25; crowding. Prognosis – periodontic:
depth; defective overcontoured crown. Prognosis – fair; prosthodontic: fair.
periodontic: good; prosthodontic: good. Tooth 27: 20% bone loss; 3 to 5 mm pocket depth;
Tooth 13: Missing. possible distal decay; defective overcontoured
Tooth 14: 30 to 40% bone loss; 3 to 6 mm pocket crown; calculus. Prognosis – periodontic: good;
depth; defective overcontoured restoration; mesial prosthodontic: good.
decay; sinus proximity; furcal involvement; buccal; Tooth 28: Missing.
Grade I mobility. Prognosis – periodontic: guarded; Tooth 29: Missing.
prosthodontic: guarded. Tooth 30: Missing.
Tooth 15: Missing. Tooth 31: Missing.
Tooth 16: Missing. Tooth 32: 20% bone loss; 3 to 6 mm pocket depth;
Tooth 17: 10 to 30% bone loss; 3 to 7 mm pocket mesially tilted; fused roots; calculus; Grade I mo
depth; mesially tilted; mesial decay; root proxim bility; root proximity with mandibular canal. Prog
ity with tooth 18; calculus; defective endodontic nosis – periodontic: fair to guarded; prosthodontic:
treatment; periapical radiolucency; fused roots; two fair to guarded.
ParaPosts; defective crown. Prognosis – periodon
tic: guarded; prosthodontic: guarded. Diagnosis
Tooth 18: 10 to 30% bone loss; 4 to 6 mm pocket 1. Generalized moderate to severe localized adult
depth; mesially tilted; distal decay; root proximity periodontitis.
with tooth 17; calculus; defective endodontic treat 2. Defective prosthetic restorations, either fixed or
ment; periapical radiolucency; fused roots; defec removable.
tive crown. Prognosis – periodontic: guarded to 3. Defective endodontic restorations.
poor; prosthodontic: guarded to poor. 4. Poor oral hygiene, also induced by the iatro
Tooth 19: Missing. genic restorations.
Tooth 20: Missing. 5. Occlusal trauma.
Tooth 21: 20 to 30% bone loss; 3 to 5 mm pocket
depth; overcontoured crown. Prognosis – periodon Etiology
tic: good; prosthodontic: good. 1. Primary factors: supra- and subgingival
Tooth 22: 20 to 30% bone loss; 3 to 6 mm pocket calculus, bacterial plaque deposits.
depth; overcontoured crown. Prognosis – periodon 2. Secondary factors: defective overcontoured
tic: good; prosthodontic: good. prosthetic restorations and occlusal trauma.
Tooth 23: 50 to 60% bone loss; 3 to 5 mm pocket
depth; Grade I mobility; calculus; root proximity Prognosis
with tooth 24; crowding. Prognosis – periodontic: The short-term prognosis was good. The overall
fair; prosthodontic: fair. long-term prognosis was fair to guarded, according
Tooth 24: 40 to 50% bone loss; 3 to 4 mm pocket to the different areas of bone loss as well as to the
depth; Grade I mobility; calculus; root proximity ability or motivation of the patient to observe oral
with tooth 23; crowding. Prognosis – periodontic: hygiene and maintenance recall visits.
fair; prosthodontic: fair.
Tooth 25: 40 to 50% bone loss; 3 to 5 mm pocket Treatment plan
depth; Grade I mobility; calculus; root proximity PHASE I
with tooth 26; crowding. Prognosis – periodontic: A. Consultation with:
fair; prosthodontic: fair. 1. Endodontist for teeth 14, 17, and 18.
Tooth 26: 50 to 60% bone loss; 3 to 6 mm pocket 2. Periodontist.
depth; Grade I mobility; calculus; root proximity
257

3. Implantologist for teeth 21 and 29, depend After the periodontal surgery healing, a possible
ing on the ability of the patient to perform prosthetic repreparation can be considered as well
good oral hygiene. as retemporization of the new exposed root struc
4. Reevaluation after a period of 6 to 8 weeks, tures. Assessment for the final prosthetic treatment
during which time the patient needs to will depend on the level of cooperation of the pa
show cooperation in maintaining adequate tient in maintaining adequate oral hygiene.
oral hygiene.
PHASE III
PHASE II Recall schedule and maintenance according to pa
After periodontal reevaluation, surgery may be ne tient’s needs.
cessary for the acidulated phosphate fluoride (APF)
on the maxillary right and left quadrants.
258

Case 4
Date: XX/XX/XXXX
Doctor: XXX, DDS
Mr XXX
Personal history Weight: 80 kg (165 lbs)

The patient was a 56-year-old white male. He was Blood pressure: 120/80 mm/Hg
an attorney employed by a law firm in the govern Pulse rate: 66 bpm
ment sector, married, and the father of a daughter Respiration: 26 br/pm
and son.
Dental and prosthodontic history
Chief complaint The patient stated that his recent visits to the dentist
The patient reported to the University of XXX for had been irregular. All his restorative procedures
a periodontal evaluation. He was then referred to were performed about 10 years ago. Teeth 13 and 19
the Prosthodontics Department for his prosthetic were replaced by a removable appliance. Due to the
needs. His chief complaint was the loosening of flaring of the maxillary centrals, orthodontic treat
his teeth, bleeding of the gums, and bad taste in his ment was performed 3 years ago and the teeth were
mouth. He also complained of the extrusion and splinted with composite; however, soon afterwards
flaring of his anterior teeth. the bonding failed and the teeth relapsed. Teeth 2,
17, and 32 had been extracted during the past year.
Medical history The patient stated that he was biting his fingernails
The patient had his last physical a year ago and was and grinding his teeth. He was concerned about
within normal limits. He reported a history of low his esthetics and was not afraid of the dentist. He
blood pressure. He had undergone psychiatric treat reported to brush his teeth twice per day but did
ment a few years ago, reporting that he had expe not floss. His financial situation was a limitation to
rienced many deaths in his family. Currently, the receiving dental treatment.
patient was in treatment with Nardil, 15 mg three
times per day. Nardil is an antidepressant of the Extraoral examination
monoamine oxidase inhibitors (MAOI) group. No The extraoral examination revealed no unusual
allergies were reported. The patient used to smoke findings. Palpation of the head and neck nodes and
one pack of cigarettes a day but gave up 3 months the muscles of mastication revealed no signs of
ago. He rarely drinks alcohol. His nutritional survey pathology. Analysis of the TMJ was asymptomatic,
was good. with no evident clicking, popping or crepitus. The
Vital statistics patient reported no history of TMJ dysfunction.
Height: 180 cm (5ˈ 9ˈˈ)
259

Intraoral examination 6. Th
ere were open contacts between teeth 7 and
The lips and tongue were within normal limits and 8, 8 and 9, 9 and 10, and 11 and 12.
the salivary flow was adequate. The oral mucosa 7. Toot 31 was supraerupted and buccally dis
was also within normal limits. played.
8. Generalized wear facets were present.
Periodontontal evaluation of the gingival 9. Abrasions were present on teeth 11, 12, 13, and
tissues 30.
The gingival tissues were pinkish-blue in color,
slightly enlarged, with a scalloped contour. The gin FUNCTIONAL ANALYSIS OF OCCLUSION
gival margin was slightly bulbous and spongy. 1. Fremitus was detected on teeth 8 and 11.
An area of severe inflammation was noted 2. First contact in CR was between teeth 4 and 30.
around teeth 18 and 20 due to plaque accumula 3. Right lateral excursion was guided by teeth 6
tion caused by the removable appliance that had and 27, without balancing interferences.
replaced tooth 19. 4. Left lateral excursion was guided by teeth 11
• Suppuration was present on teeth 8 and 9. and 22, without balancing interferences.
• BI (Tufts): 100%. 5. Protrusive contact was noted between teeth 8
• PI (O’Leary): 100%. and 26.
• Probing depth of 4 to 6 mm on teeth 4, 6, 10,
11, 13, 14, 18, 22, 27, 28, and 29. Radiographic examination and findings
• Probing depth of more than 6 mm on teeth 5, 1. The radiographs revealed generalized moderate
8, 9, 30, and 31. to localized severe bone loss.
• Mucogingival condition was present for tooth 2. Severe involvement was present for the maxil
11. lary anteriors and for teeth 22 and 31.
• Furcation involvement on teeth 14 (Grade 3. The pattern of bone loss was generally horizon
II, mesial and distal); 30 (Grade I, buccal); 31 tal, except for teeth 5, 11, and 22, where vertical
(Grade II, buccal and lingual). bone loss was also present.
• Attachment loss on teeth 4, 5, 6, 7, 8, 9, 10, 11, 4. The crestal lamina dura was not well defined.
13, 14, 18, 22, 26, 27, 30, and 31. 5. Sinus proximity was present for teeth 4 and 14.
• Mobility pattern: Grade I for teeth 6, 7, 10, 11, 6. Poor crown-to-root ratio was present on teeth
12, 13, 14, 18, 22, 23, 24, and 25; Grade II for 5, 8, 9, and 10.
teeth 4 and 26; Grade III for teeth 5, 8, and 9. 7. PDL was noted on the mandibular incisors.
• Generalized mobility pattern due to both loss 8. Tooth 4 showed mesial decay.
of attachment and trauma from occlusion. 9. Tooth 5 showed a presumable root fracture.
Occlusion Individual tooth clinical and radiographic

STATIC ANALYSIS OF OCCLUSION assessment
1. The patient presented with an Angle’s Class II Tooth 1: Missing.
on the left side and a Class I on the right, based Tooth 2: Missing.
on the canine to canine relationship. Tooth 3: Missing.
2. The overjet was 7 mm and the overbite was Tooth 4: 20% bone loss; 4 to 5 mm pocket depth;
10 mm. 5 mm attachment loss; Grade 2 mobility; widened
3. The curve of Spee was accentuated on the right PDL; mesial decay; sinus proximity. Prognosis:
side and normal on the left side. good.
4. Teeth 1, 2, 3, 15, 16, 17, 19, and 32 were missing. Tooth 5: 40 to 70% bone loss; 4 to 8 mm pocket
5. Teeth 8 and 9 were supraerupted and flared. depth; 5 to 8 mm attachment loss; Grade 3 mobility;
260

endo treated; post and core; possible root fracture? Tooth 20: 30 to 40% bone loss; 4 to 6 mm pocket
Prognosis: guarded. depth; 6 mm attachment loss; Grade 1 mobility;
Tooth 6: 20% bone loss; 4 to 5 mm pocket depth; wear facet. Prognosis: good.
5 mm attachment loss; Grade 2 mobility; widened Tooth 21: 10 to 20% bone loss; wear facet; widened
PDL; mesial decay; sinus proximity. Prognosis: PDL. Prognosis: good.
good. Tooth 22: 30 to 40% bone loss; 4 to 6 mm pocket
Tooth 7: 20 to 40% bone loss; 5 mm pocket depth; depth; 6 mm attachment loss; Grade 1 mobility;
5 mm attachment loss; Grade 1 mobility; widened wear facet. Prognosis: good.
PDL; wear facets; open contact. Prognosis – perio Tooth 23: 30 to 50% bone loss; Grade 1 mobility;
dontic: fair; prosthodontic: guarded. lingual recession; wear facet; rotated. Prognosis:
Tooth 8: 70% bone loss; 6 to 8 mm pocket depth; 7 good.
to 9 mm attachment loss; Grade 3 mobility; buccally Tooth 24: 20% bone loss; lingual recession; lin
displaced; wear facets; open contact; suppuration. gually displaced; Grade 1 mobility. Prognosis: good.
Prognosis: hopeless. Tooth 25: 20% bone loss; lingual recession; Grade 1
Tooth 9: 70% bone loss; 6 to 7 mm pocket depth; mobility. Prognosis: good.
7 to 8 mm attachment loss; Grade 3 mobility; buc Tooth 26: 30 to 40% bone loss; 4 mm pocket depth;
cally displaced; wear facets; suppuration. Prognosis: wear facet; recession; short endodontic treatment;
hopeless. defective crown; Grade 2 mobility; root proximity.
Tooth 10: 30 to 50% bone loss; 6 mm pocket depth; Prognosis: fair to guarded.
6 mm attachment loss; Grade 1 mobility; open con Tooth 27: 20% bone loss; 5 mm pocket depth; 5 mm
tact. Prognosis – periodontic: fair; prosthodontic: attachment loss; wear facet. Prognosis: good.
guarded. Tooth 28: 20% bone loss; 4 mm pocket depth. Prog
Tooth 11: 20 to 40% bone loss; 4 to 6 mm pocket nosis: good.
depth; Grade 1 mobility; angular bony defect; Tooth 29: 10% bone loss; 4 mm pocket depth. Prog
Grade I mucogingival condition; wear facets; open nosis: good.
contact. Prognosis: fair. Tooth 30: 20 to 40% bone loss; 6 to 7 mm pocket
Tooth 12: 10% bone loss; 4 mm pocket depth; Grade depth; 6 to 7 mm attachment loss; Grade I buccal
1 mobility; wear facet; open contact. Prognosis: furcation; occlusal amalgam; recession. Prognosis:
good. good.
Tooth 13: 20 to 40% bone loss; 4 to 6 mm pocket Tooth 31: 40 to 60% bone loss; 6 to 7 mm pocket
depth; 6 mm attachment loss; rotated; Grade 1 mo depth; 6 to 7 mm attachment loss; Grade II lingual
bility; widened PDL. Prognosis: good. furcation; occlusal amalgam; supraerupted and buc
Tooth 14: 20 to 40% bone loss; 4 to 6 mm pocket cally displayed. Prognosis – periodontic: guarded;
depth; 5 to 6 mm attachment loss; Grade 2 mobility; prosthodontic: poor.
furcation distal; amalgam restoration; sinus proxi Tooth 32: Missing.
mity. Prognosis – periodontic: fair to guarded; pros
thodontic: guarded. Diagnosis
Tooth 15: Missing. 1. Generalized moderate to localized severe adult
Tooth 16: Missing. periodontitis.
Tooth 17: Missing. 2. Trauma from occlusion.
Tooth 18: 20% bone loss; 5 to 6 mm pocket depth; 3. Decay on tooth 40.
6 mm attachment loss; amalgam restoration; mesi 4. Mucogingival defect on tooth 11.
ally tipped. Prognosis: good.
Tooth 19: Missing.
261

Etiology 3. xtraction of teeth 5, 7, 8, 9, 10, 14, and 31.

E
1. Supra- and subgingival plaque and calculus. 4. Temporization.
2. Excessive forces due to parafunctional activity. 5. Scaling and root planing.
3. Iatrogenic dentistry. 6. Reevaluation.
Prognosis PHASE II
With periodontal and prosthetic treatment, along 1. Apically positioned flap and osseous surgery
with the patient’s positive attitude, the overall for the maxillary left quadrant.
short-term prognosis was good and the long-term 2. Apically positioned flap and osseous surgery
prognosis was fair. for the mandibular right quadrant.
3. Mucogingival surgery for tooth 11.
Treatment 4. Restorative procedures and night guard.
SEQUENCE OF TREATMENT
PHASE I PHASE III
1. Consultations with physician, periodontist, and Recall schedule.
endodontist for tooth 26.
2. Control program.
262

Case 5
Date: XX/XX/XXXX
Doctor: XXX, DDS
Miss XXX
Personal history Dental history

The patient was a 35-year-old white female, married The patient stated that she visited her general den
with two children. She was successfully self-em tist about once a year for a cleaning and any ne
ployed with her own business providing home care cessary fillings. In July XXXX, she was referred to
for the elderly. a periodontist who performed pocket elimination
surgery on all four posterior quadrants. No surgery
Chief complaint was performed in the anterior region. A telephone
The patient was recommended to the PG Prostho consultation with the periodontist revealed that he
dontic Program by her general dentist. She stated thought that this surgery had reduced the pocket
that she was unhappy with the esthetics of her ing, but that the patient’s poor oral hygiene and her
anterior teeth. She also understood that she had a smoking habit could result in a recurrence of her
problem with her gums and complained of extreme past condition. He did not perform any surgery in
sensitivity to cold around all her maxillary teeth the anterior region because he was waiting to see
since recent gum surgery had been performed. what was going to be done restoratively. The pa
tient expressed the preference to be treated in our
Medical history clinic for both her periodontic and prosthodontic
The patient’s medical history was relatively unre needs as she was uncomfortable with that par
markable. As a child, she recalled having measles ticular periodontist. Her oral hygiene consisted of
and chicken pox. A medical examination 3 months brushing twice per day but she did not floss. She
prior to her first visit revealed high cholesterol, was not aware of any paranormal habits such as
which was presently being controlled with a low bruxing or clenching.
cholesterol diet. She used to smoke about one pack
of cigarettes per day, but since her medical examin Extraoral examination
ation and due to our recommendation, she had quit The head and neck regions were within normal lim
smoking completely for almost a year. The patient its.
reported no allergies or sensitivities and was not
taking any medication. A review of her vital signs Intraoral examination
revealed a blood pressure of 110/70 and a pulse of Examination of the lips, tongue, mucosa, and sali
68 bpm. A nutritional analysis showed that she had vary flow revealed that they were all within normal
an adequate intake from the four basic food groups. limits.
263

Periodontal examination Radiographic examination

The gingiva showed generalized slight to moderate 1. Generalized moderate to severe horizontal
inflammation with redness of the interdental papil bone loss in the maxillary arch, with moderate
lae: deposits of supra- and subgingival plaque and horizontal bone loss in the mandibular arch.
calculus were present throughout both arches. An 2. Crestal funneling was seen around teeth 22, 27,
initial PI of 60% was found. Initial probing of both 28, 29, and 30.
arches resulted in a 50% BI and some degree of dis 3. Teeth 4, 7, 8, and 10 were all endodontically
comfort to the patient. Probing depth ranged from treated and all had periapical radiolucencies.
4 to 6 mm. Furcation involvement was noted in the
maxillary first bicuspid areas (mobility patterns are Individual tooth clinical and radiographic
discussed in the individual tooth analysis). assessment
Tooth 1: Missing.
Occlusion Tooth 2: Missing.
STATIC ANALYSIS OF OCCLUSION Tooth 3: 20% bone loss; 6 mm pocket depth DB and
1. Examination revealed an Angle’s Class I classifi DL, 5 mm ML; + mobility; defective amalgam res
cation based on the molar relationship. toration. Prognosis: good.
2. A horizontal overlap of 3 mm and a vertical Tooth 4: 40 to 60% bone loss; 7 mm pocket depth
overlap of 3 mm were present. DB, DL, and MB, 6 mm ML; 2+ mobility pattern;
3. The mandibular molars were rotated and periapical radiolucency; endodontically filled; PFM
lingually inclined. crown. Prognosis: hopeless.
4. Examination of the maxillary arch revealed that Tooth 5: 20 to 50% bone loss; 6 mm pocket depth
it had a normal U-shaped arch form. Teeth 1, 2, MB, 5 mm ML; + mobility; Grade I mesial furca
15, and 16 were missing. tion involvement; amalgam restoration. Prognosis:
5. Examination of the mandibular arch revealed guarded.
that it also had a normal U-shaped arch form, Tooth 6: 10 to 20% bone loss; 5 mm pocket depth MB;
with the exception of rotated and lingually 1+ mobility; composite restoration. Prognosis: good.
inclined molars. Teeth 19 and 32 were missing. Tooth 7: 40 to 60% bone loss; 5 mm pocket depth
Tooth 17 was impacted. MB, 6 mm ML; 1+ mobility; periapical radiolucency;
silver point endodontic filling; PFM crown. Progno
FUNCTIONAL ANALYSIS OF OCCLUSION sis: guarded.
1. There was a slight CO-CR discrepancy, but no Tooth 8: 40 to 50% bone loss; 1 mobility; periapi
gross prematurities were obvious. cal radiolucency; endodontic filling with retrograde
2. The right lateral excursion revealed contact of amalgam; PFM crown. Prognosis: guarded.
teeth 6 and 7 with teeth 26 and 27. No contacts Tooth 9: 30 to 40% bone loss; 1 mobility; PFM
were noted on the balancing side. crown. Prognosis: good.
3. The left lateral excursion revealed contact of Tooth 10: 40% bone loss; 5 mm pocket depth DB,
tooth 11 with tooth 22. No contacts were noted 5 mm MB; 1 mobility; silver point endodontic filling;
on the balancing side. periapical radiolucency; PFM crown. Prognosis: good.
4. Protrusion revealed contact of teeth 8 and 9 Tooth 11: 30% bone loss; 6 mm pocket depth MB
with teeth 23 to 26. and DL, 5 mm DB; + mobility; composite restor
ation. Prognosis: good.
Temporomandibular joints Tooth 12: 40 to 50% bone loss; 6 mm pocket depth
The patient revealed no signs or symptoms of TMJ MB and ML; + mobility; Grade I mesial furcation
dysfunction: no pops or clicks were noted during involvement; defective amalgam restoration. Prog
examination. nosis: guarded.
264

Tooth 13: 40 to 60% bone loss; + mobility; Grade I Prognosis

distal furcation involvement; amalgam restoration. 1. The short-term prognosis was good.
Prognosis: guarded. 2. The overall long-term prognosis was guarded.
Tooth 14: 20 to 50% bone loss; 6 mm pocket depth The patient’s compliance with home and profes
DB; normal mobility; defective amalgam restor sional care were essential.
ation. Prognosis: good.
Tooth 15: Missing. Etiology
Tooth 16: Missing. 1. Supra- and subgingival deposits of plaque and
Tooth 17: Missing. calculus.
Tooth 18: 20% bone loss; normal mobility; mesially 2. Trauma from occlusion.
and lingually inclined. Prognosis: good. 3. Tooth loss without replacement.
Tooth 19: Missing.
Tooth 20: 30% bone loss; normal mobility; distally Treatment
rotated; amalgam restoration. Prognosis: good. SEQUENCE OF TREATMENT
Tooth 21: 20 to 30% bone loss; normal mobility; de PHASE I
fective amalgam restoration. Prognosis: good. 1. Consultations with oral surgeon for extraction
Tooth 22: 20 to 30% bone loss; 6 mm pocket depth of teeth 4 and 17; periodontist, endodontist,
ML; normal mobility. Prognosis: good. prosthodontist, and orthodontist for alignment
Tooth 23: 20 to 40% bone loss; 6 mm pocket depth of mandibular arch.
DL; normal mobility. Prognosis: good. 2. Scaling and root planing under local anesthesia.
Tooth 24: 20 to 40% bone loss; 4 mm pocket depth 3. Caries control.
MB and DB; normal mobility. Prognosis: good. 4. Extraction of teeth 4 and 17.
Tooth 25: 20 to 40% bone loss; 4 mm pocket depth 5. Removal of existing crowns on teeth 7, 8, 9, and
MB and DB; normal mobility. Prognosis: good. 10, and temporization.
Tooth 26: 20 to 40% bone loss; 6 mm pocket depth 6. Endodontic treatment of tooth 13 and
DL; 4 mm DB; normal mobility. Prognosis: good. retreatment of teeth 7 and 10, if possible.
Tooth 27: 20% bone loss, 6 mm pocket depth DL; 7. Reevaluation.
5 mm DB; normal mobility. Prognosis: good.
Tooth 28: 20 to 30% bone loss; 5 mm pocket depth PHASE II
MB, DB, and DL; normal mobility; amalgam restor 1. Pocket reduction surgery was performed in the
ation. Prognosis: good. area of teeth 3 to 5.
Tooth 29: 20 to 30% bone loss; 5 mm pocket depth 2. Some osseous recontouring was performed in
DL and MB; normal mobility. Prognosis: good. the area of teeth 12 to 16.
Tooth 30: 20% bone loss; 5 mm pocket depth MB 3. Minimal osteoplasty was performed.
and DVB, 6 mm ML and DL; normal mobility; amal 4. Pocket reduction surgery was performed in the
gam restoration. Prognosis: good. area of teeth 27 to 31.
Tooth 31: 10 to 20% bone loss; normal mobility; 5. Minimal osteoplasty was performed buccally
composite restoration. Prognosis: good. and lingually to improve the architecture.
Tooth 32: Missing. 6. Core buildup of all endodontically treated teeth.
7. Reevaluation, especially of teeth 5, 12, and 13.
Diagnosis
1. Generalized recurrent moderate to severe perio PHASE III
dontitis. 1. Maintenance.
2. Trauma from occlusion. 2. Recall according to patient’s needs.
3. Missing teeth and defective restorations.
265

Case 6
Maxillary complete dentures and mandibular fixed/
removable partial denture
Completed case narrative 1
Date: XX/XX/XXXX
Doctor: XXX, DDS
Mr XXX
Personal history Blood pressure: 120/68 mm/Hg

The patient, a 75-year-old Caucasian male, pre Pulse rate: 68 bpm
sented for the first time for prosthodontic treat Respiration: 14 br/pm
ment. He was single and a pensioner.
Medical evaluation form
Chief complaint 1. Anemia: No
The patient stated that he rarely used his prostheses 2. Bleeding disorders: No
because he could not chew or speak and did not like 3. Cancer: No
the way he looked. At that time, initial study casts, 4. Cardiopulmonary problems:
Panorex, and periapical radiographs were taken a. Circulation/cardiac: No
but the patient re-presented for treatment after b. Pulmonary: No
4 months. He explained that for personal reasons 5. Allergies to medication/materials: No
he could not at first commit to the prosthodontic 6. Alcohol: Occasionally
care, and that a dentist had extracted two sore teeth, 7. Tobacco: No
replacing them on the dentures with two plastic 8. Endocrine disease: No
teeth. He said he was now determined to get new 9. Eye problems: No
prostheses and asked for the simplest and least-ex 10. Gastrointestinal disease: No
pensive treatment. 11. Hepatitis/jaundice: No
12. Infectious disease: No
Medical history 13. Kidney problems: No
The patient’s medical and dental histories were re 14. Medical emergencies during past dental visits:
viewed in detail. He reported to be in good general No
health with no significant illnesses in the past. He 15. Musculoskeletal/connective tissue conditions:
was not taking any medication and reported to have No
no allergies. He had no history of hospitalization 16. Neurological disorders: No
and said he was a non-smoker and a very moderate 17. Psychologic conditions: No
social drinker. 18. Radiation therapy: No
Vital statistics 19. Seizures/syncope: No
Height: 162 cm (5ˈ 4ˈˈ) 20. Skin conditions: No
Weight: 68 kg (150 lbs) 21. Transplants: No
266

Case 6 Maxillary complete dentures and mandibular fixed/removable partial denture
Nutrition risk history nor palpable nodes were evident. The patient exhib
1. Are there times when you cannot afford to buy ited an ovoid facial form and a slightly concave tis
the food you need? No sue profile. It seemed that the corners of the mouth
2. Do you eat fewer than two meals per day? No were not well supported. Wearing the prostheses at
3. Do you have tooth or mouth problems that the MIP, the patient showed almost no lip vermil
make it difficult to eat? Yes lion border. When asked to smile, he smiled without
4. Are there times when you are not physically opening his mouth.
able to shop, cook, and/or feed yourself? No
5. Do you eat very few or no fruits, vegetables or INTRAORAL EXAMINATION
dairy products in your normal diet? No The initial intraoral examination revealed a horse
6. Do you have more than three drinks of beer, shoe-shaped maxillary complete denture and a Ken
wine or other alcoholic beverages almost every nedy Class I mandibular RPD slightly impinging
day? No on the gingival tissue. The patient’s current pros
7. Do you usually eat alone? Yes theses revealed poor esthetics due to inadequate
8. Do you take three or more different prescribed tooth positioning, inadequate plane of occlusion,
or over-the-counter drugs per day? No and severe occlusal wear on both dentures. The
denture teeth consisted of acrylic resin. After their
Dental and prosthodontic history removal, examination of the soft tissues of the lips,
The patient stated that he had not had much dental cheek, tongue, oral mucosa, floor of the mouth, and
treatment and never on a regular basis, only if and pharyngeal tissues revealed them to be within nor
when a problem arose. He reported that through mal limits for the patient’s age.
out the years he had lost teeth (presently missing) There was a normal flow of serous-type saliva.
and that he received his first maxillary RPD at the Both the maxillary and mandibular arches were
age of 38. He also reported that he had many RPDs U-shaped.
replaced, both on the maxilla and the mandible, The maxillary alveolar ridge showed severe
but none of them was really useful to him. His last resorption and irregular contour. An accentuated
maxillary tooth, in the area of tooth 15, was ex ridge resorption was noted in the areas of the left
tracted a year ago, and a complete maxillary den premolars, particularly in the area related to the
ture was made for him by another general practi left tuberosity, which was at the same level as the
tioner, adding the missing tooth to his present RPD. maxillary portion of the pterygomandibular ra
Three months ago, tooth 28 was extracted. Also, phe. Both the retrozygomatic fossae were evident
this tooth was replaced, adding one plastic tooth to and wide. A thin firm mucosa was covering the
his mandibular RPD, after which his dental prob edentulous ridge. Both buccal freni were evident,
lems worsened. with a very high insertion onto the resorbed crest.
The labial frenum was evident and short. Palatal
Clinical findings form was Class I, according to the House classi
EXTRAORAL EXAMINATION fication.
Examination of the head and neck revealed no fa The intraoral examination of the mandibular
cial asymmetry or any visible swelling or pathology. arch showed only 6 teeth (22, 23, 24, 25, 26, and 27).
The skin was normal in appearance and texture. An The remaining edentulous areas were found to be
examination revealed that the TMJs were asymp severely resorbed, and a thin firm mucosa was cov
tomatic, with no evidence of clicking, crepitus or ering the ridge crest. The lingual frenum showed a
tenderness on palpation. The mandibular range of rather wide bony insertion. Two retromolar pads,
motion was within normal limits, with no pain or two buccal freni, and a short labial frenum were
deviation on opening. Neither muscle tenderness evident. All six remaining teeth were found to be
267

vital, and some calculus accumulation was evident 3. Th

e presence of inadequate prostheses led to
on all of them. Caries were found at the CEJ of the a lack of facial posterior lip support and some
distal aspect of tooth 22. The lateral throat form was facial esthetic problems.
Class I, according to Neil’s classification. 4. According to the ACP classification, the patient
was Class IV:
Periodontal examination a. Location and extent of edentulous area –
The gingiva was pink in color, with an area of light substantially compromised; Class III.
marginal redness observed on all remaining teeth. b. Abutment condition – substantially com
Probing depth was 2 to 3 mm on all teeth, with an promised, three sextants; Class III.
area of 4 mm distal to tooth 24, and mesially on c. Occlusion – severely compromised, change
tooth 23. No mobility was found on any teeth. The in VDO; Class IV.
patient’s oral hygiene was not acceptable and a PI d. Residual ridge – minimum influence to
(O’Leary) of 70% was found. For this reason, the pa resist horizontal and vertical movements of
tient was referred to a periodontist for evaluation, the denture base; Class III.
care, and instructions. 5. Lack of adequate posterior supporting dentition
resulted in possible wear of the remaining man
Occlusal examination dibular teeth, chipping of some incisal edges,
The patient did not present with a well-defined oc and loss of VDO.
clusal scheme due to the two inadequate removable 6. Caries were found on tooth 22.
prostheses. Instability of the prostheses, together 7. The periodontal consultation confirmed mild
with teeth malposition and severe tooth wear, did gingivitis around all the remaining teeth and mild
not allow for any proper occlusal evaluation. The periodontitis on the mesial aspect of tooth 23.
remaining teeth showed incisal wear. 8. Initially, the patient exhibited a hysterical
personality, but this changed during the course
Radiographic analysis of treatment to become more philosophical,
The panoramic radiograph revealed severe resorp according to the House classification.
tion of the maxillary edentulous ridge, with sinus
proximity in both the right premolar and molar Treatment plan
areas. Some resorption was displayed in the eden The following treatment plan was based on the pre
tulous areas of the mandibular ridge. vious diagnosis and the patient’s wishes, mainly
The periapical radiographs showed generalized driven by financial considerations and prosthetic
mild horizontal bone loss around the remaining comfort:
mandibular teeth, ranging from 10% to 20%. The 1. Evaluation and discussion with the patient of
PDL space was found to be of a uniform dimension. his chief complaint, wishes, and expectations.
Only tooth 23 presented with a large amount of 2. Initial OHI for both the old prostheses and for
bone loss on its mesial aspect; however, there was the oral tissue care.
still sufficient bone to meet the minimum standards 3. Evaluation of the health condition of the
for crown placement. patient’s soft tissue. He declined the proposed
possibility of an interim set of dentures to
Diagnosis reestablish and test the maxillomandibular re
1. The patient presented with good medical health lationship, the esthetics, and the phonetics. The
and had no medical contraindications to pros patient asked to proceed to the final treatment.
thodontic treatment. 4. Periodontal treatment on the remaining teeth.
2. The patient exhibited complete maxillary eden 5. Construction of an appropriate maxillary com
tulism and partial mandibular edentulism. plete denture.
268

6. C onstruction of two PFM crowns on teeth 22 cast. A single sheet of wax spacer was
and 27 to better support, stabilize, and retain an placed on the casts in the edentulous
appropriate Kennedy Class I mandibular tooth- area, while the remaining teeth were
to mucosa-borne RPD. covered and blocked out with properly
7. Provide postinsertion instruction and care. molded baseplate wax. Custom trays
8. Setting of a schedule of maintenance. were then created and highly polished
with the same resin that was used for the
Sequence of treatment denture base for impression taking.
A. The patient was informed of the treatment plan. c. On the third set of mandibular casts, two
His expectations as well as the case limitations, heat-cured polymethyl methacrylate
techniques, and materials were discussed. He temporary resin crowns were fabricated
understood and accepted the proposed treat that had the same shape and dimensions
ment plan and was instructed not to wear as the original mandibular canines.
his dentures for at least 48 hours before any C. The patient was then recalled, and the old max
appointment. illary and mandibular complete dentures were
B. The patient was periodontally treated and placed in the mouth. He was asked to close
instructed as to proper oral hygiene and care of gently for the MIP of the maxillary and man
his old dentures and remaining teeth. dibular dentures.
1. Preliminary impressions were made with 1. Two dots were marked on the nose tip and
stock trays and irreversible hydrocolloid on the chin skin to record the present VDO
impression material. with the old dentures.
2. Impressions were poured in a vacuumed 2. The new bases and wax rims were positioned
type IV dental stone. in the patient’s mouth and their fitting and
3. Initial study casts were duplicated in a extensions were verified and adjusted using
vacuumed type IV gypsum product by Pressure Spot Indicator Paste and Sorenson’s
means of an addition-vulcanizing duplication Paste.
silicone. 3. The maxillary occlusal plane was established
a. On one set of maxillary and mandibular making the rim parallel to the ala-tragus line
study casts, two trial denture bases, and and to the interpupillary line. A first attempt
wax rims were fabricated with autopo at establishing proper length and the antero
lymerizing polymethyl methacrylate posterior position of the maxillary wax
resin material, then left on the cast for rim occlusion was established according to
24 hours for final setting before being esthetics and phonetics.
mounted on the articulator. The bases 4. Then, the mandibular wax rim record base
were then removed, cleaned, trimmed, was introduced and related to the maxillary
and polished. Wax rims were then con wax rim. On the first attempt, an increase of
structed with baseplate wax. vertical dimension was tried in to establish
b. On the second set of duplicated study better lip support, esthetics, and phonetics
casts, maxillary and mandibular custom using the vertical dimension of rest position
trays were also fabricated. Custom tray and phonetics.
outlines were drawn and a score line 5. A facebow record was accomplished using a
was placed. Tissue stops were drawn on Hanau Earpiece Facebow, and the maxillary
the ridge crest of the maxillary study study cast was mounted on a Hanau semi
cast and on both the ridge crest and the adjustable articulator using a fast-setting
remaining teeth of the mandibular study mounting stone.
269

6. The wax rims record bases were then methacrylate resin to fit the old RPD, and
repositioned in the patient’s mouth. The cemented with free eugenol temporary
midline was drawn, and V-shaped occlusal cement.
indices were cut into the posterior region of F. In the laboratory, the maxillary custom tray
the maxillary rims, and lightly coated with final impression was poured in type IV dental
petroleum jelly. stone. The definitive cast was separated and
7. A CR record was made using a very thin trimmed.
layer of Aluwax on the mandibular wax 1. A trial denture base was constructed on
rim to index the position with the maxillary the definitive cast and left on for 24 hours
occlusal rim. for final setting, then removed, cleaned,
8. Next, the mandibular study cast was trimmed, and carefully polished. A maxillary
mounted. The preliminary models were wax rim was constructed on the trial denture
saved and studied to better understand the bases with baseplate wax.
maxillomandibular relationship. G. The mandibular polyether definitive impression
D. On the same day, the maxillary custom tray of the canines was poured in type IV dental
was checked and adjusted in the patient’s stone. The definitive cast was separated and
mouth before border molding. The extent of trimmed.
the posterior border and posterior palatal seal 1. A trial denture base with wax rims was fabri
was palpated, and the upper tray was trimmed cated to mount this cast on the articulator.
according to the palatal posterior border. H. The patient was then recalled. The old maxil
1. Border molding of the custom tray periphery lary and mandibular complete dentures were
was performed according to muscle and soft placed in the patient’s mouth and he was asked
tissue attachments using gray stick modeling to close gently again to establish MIP.
compound. 1. The present VDO with the old dentures was
2. After border molding, the compound was measured and recorded.
reduced by approximately 1 mm to provide 2. The new bases and wax rims were evaluated
space for the final impression material. Holes in the patient’s mouth and adjusted.
were made in the tray for better retention, 3. The maxillary occlusal plane of the rims
and a polysulfide adhesive was applied on was established according to esthetics and
the periphery of the border molded tray and phonetics.
allowed to dry. 4. The mandibular record base and wax rim
3. Selective pressure impression of the arch were then related to the maxillary wax rim.
was made using regular body polysulfide Appropriate vertical dimension was recorded
impression material. The posterior palatal using the vertical dimension of rest position,
seal was ink drawn and then transferred esthetics, and phonetics.
onto the definitive maxillary impression. 5. A Hanau Earpiece Facebow record and
E. The two mandibular canines were then pre transfer was accomplished, and the
pared with a shoulder finishing line. maxillary definitive cast was mounted on a
1. The gingival tissue was retracted using Hanau semi-adjustable articulator using a
knitted cord saturated with ferric sulfate fast-setting mounting stone.
and a full-arch impression was made 6. After mounting, the record bases and wax
using a regular stock tray and a polyether rims were repositioned in the patient’s
impression material. mouth and the midline was verified again
2. The two temporary crowns were then and drawn. V-shaped occlusal indices were
relined with autopolymerizing polymethyl also cut into the posterior region of the
270

maxillary rims and lightly coated with K. Then, the two PFM restorations where tried in,
petroleum jelly. seated, and retained by means of eugenol-free
7. A CR record was made using a very thin cement.
layer of Aluwax on the mandibular wax 1. The mandibular custom tray was then
rims to index the position with the maxillary checked in the mouth, and its stability and
occlusal rim. The mandibular definitive cast the extent of the posterior border over the
was also mounted. buccal shelf, retromolar pad, and lingual
8. Maxillary anterior teeth were chosen extensions of the two posterior edentulous
according to the patient’s facial esthetics and areas were verified and adjusted.
wishes. The setup of the teeth was guided 2. Border molding of the custom tray periphery
by the patient’s esthetics, phonetics, and was performed using gray stick modeling
suggestions. A full-contour wax-up was compound, which was then reduced by
made for the two canines with base plate approximately 1 mm to provide space for the
wax. final impression material.
9. Protrusive and lateral interocclusal records 3. An impression of the arch was made using
were made with PVS registration material, regular body polysulfide impression material,
and the articulator was programmed. then poured in type IV dental stone.
10. On the mandibular master cast, dies were 4. The definitive cast was surveyed and
sectioned and trimmed, margins were tripoded.
marked and hardened with cyanoacrylate 5. The definitive cast, design cast, and
cement, and two coats of die spacer were laboratory prescription were then sent to the
applied. dental laboratory for RPD framework fabri
I. The full-contour wax-up of the dies was har cation in a chrome-cobalt-molybdenum alloy.
monized with all posterior teeth on both 6. The RPD framework was tried in together
arches, and the mandibular definitive cast was with the two PFM restorations and its fit
surveyed as well as 22 and 27 wax patterns for was verified using an Occlude Green Aerosol
placement and carving of guiding planes, cin Indicator Marking Spray disclosing medium.
gulum rests, and the evaluation of the desired 7. Two recording bases made with autopoly
buccal shape to create proper undercuts for the merizing methyl methacrylate resin with
retentive arms. occlusion wax rims were fabricated on the
1. Then a wax cutback was performed to leave RPD framework extension bases.
the appropriate space for the porcelain appli 8. A CR record was made utilizing Aluwax on
cation. the occlusion rim of the mandibular RPD
2. Wax patterns were invested in a phosphate wax rims to relate to the maxillary occlusion.
bonded investment and cast in a gold-pal 9. The mandibular definitive cast was mounted
ladium alloy. The castings were evaluated on the articulator.
under microscope, and the fitting was 10. Ivoclar Orthotyp DCL acrylic resin denture
verified on the master dies. posterior teeth were set onto the mandibular
J. The patient was recalled, and the metal frame wax rims and arranged in a lingualized
works were evaluated in the mouth. bilateral balanced occlusal scheme, and
1. Porcelain application followed, and no the wax-up of both the maxillary and
undercuts were established at the mesio mandibular denture bases was finalized.
buccal aspects of teeth 22 and 27. 11. Both dentures were tried in for esthetics,
2. The two metal-ceramic restorations were phonetics, VDO, and CO try-ins and
then glazed and polished. approved by the patient.
271

12. The trial dentures were then invested in a Instructions to the patient
type III and IV gypsum in denture flasks. The patient was instructed not to wear the dentures at
Then, wax was eliminated, separating the bedtime for soft tissue recovery. He was also told that
applied media, and the flasks were allowed the dentures should be placed in water to avoid des
to cool down. Heat activated polymethyl iccation and possible distortion of the resin. Proper
methacrylate resin (Lucitone 199) was denture brushing and cleansing was strongly recom
mixed, and pressure was molded in the mended. Soaking the dentures in denture cleanser
flasks. was also suggested and explained, along with the use
13. Both dentures were processed for 9 hours at of a soft brush for cleaning and a wash cloth to mas
165° F, then deflasked, remounted to verify the sage the denture-bearing soft tissue areas daily. The
occlusion, and adjusted. The dentures were patient was instructed about chewing techniques to
then finished and polished for use. minimize instability and avoid tissue trauma.
14. The patient was recalled and the dentures The patient was happy with the results, he fol
inserted. Pressure Spot Indicator Paste and lowed the instructions, did well, and was placed on
Sorenson’s Paste were used to verify possible a 3-month maintenance recall for 1 year.
excessive pressure areas and extensions of the
bases as well as occlusion. Prognosis
15. An Aluwax record was made for the clinical The patient was already familiar with complete den
remount procedure. tures and RPDs and was very motivated to have a
16. The dentures were then delivered to the new set. His philosophical and positive attitude along
patient and checked after 24 hours, at 3 days, with his constant commitment to recall and mainten
at 1 week, and then when needed. ance should guarantee a good long-term prognosis.
272

Complete dentures diagnosis record form Clinical examination and patient

Patient name: XXX classification
Date: XX/XX/XXXX A. Development of the muscles of mastication and
General health: Excellent: ___X_____ expression:
Average:__________ Poor:__________ 1. Heavy: ________
2. Medium: __X___
Denture history: 3. Light: __________
At the initial presentation at the dental office, the B. Present condition of mucosa:
patient reported that he had not had much dental 1. Healthy: Maxilla ___X____
treatment and never on a regular basis as a child. He Mandible ____X____
said he was only taken to the dentist when a prob 2. Irritated (IPH, denture irritation, etc):
lem arose. He reported that throughout the years Maxilla _________ Mandible _________
he lost all his missing teeth due to dental caries, 3. Pathologic (epulis, hyperkeratosis, etc):
and that he received his first maxillary RPD at the Maxilla ________ Mandible _________
age of 38. He also reported that he had many RPDs C. Supporting potential of soft tissues:
replaced, on both the maxillary and mandibular 1. Normal, uniform density. Ideal cushion for
arches, but not one of them was really useful to a basal seat for denture: Maxilla __X____
him. His last maxillary tooth (15) was extracted a Mandible ____X____
year ago due to periodontal problems, and a com a. Very thin investing membrane that is
plete maxillary denture was made for him by an highly susceptible to irritation under
other general practitioner, adding the last missing pressure: Maxilla ______ Mandible _____
tooth to the RPD he was wearing. On the mandible, b. Hypertrophied tissue condition resulting
tooth 28 was extracted 9 months ago, and again it in the soft tissues having a mucous mem
was replaced, adding one plastic tooth on his man brane approximately twice the normal
dibular RPD. XXX months later, he re-presented for thickness: Maxilla ______
dental care, reporting that tooth 28 was extracted Mandible ______
3 months earlier and a plastic tooth was added to 2. Greatly hypertrophied tissue resulting
the old prosthesis, after which his dental problems in an excessively thick membrane filled
worsened. with redundant tissue: Maxilla______
Mandible______
A. Length of time edentulous: maxillary – about D. Muscle and frenum attachments (all lingual
6 months; mandibular – about 1 year. tissues are classified as muscular attach
B. Previous partial dentures: ments):
1. Number of sets of partial dentures: Patient 1. The attachment height is at least ½ inch
did not remember how many sets he had away from the crest of the ridge:
received in the past. Maxilla______ Mandible______
2. Length of service of last set of partial 2. The attachment height is between
dentures: 7 years. ¼ and ½ inch from the crest of the ridge:
3. Patient’s chief complaint: The maxillary Maxilla______ Mandible______
denture did not look good and the patient 3. The attachment height is less than ¼ inch
complained that he could not speak properly. from the crest of the ridge: Maxilla ___X___
4. Patient’s expectation of the new denture: Mandible ___X___
The patient thought he would have a new, E. Lateral throat form (Neil’s classification): A
better-looking denture that would improve mouth mirror is placed in the retromylohyoid
his ability to speak and eat. areas and the patient is instructed to protrude
273

the tongue ¼ inch past the lower lip. How 1. Plenty of clearance (usually seen with
much is the mirror displaced? significant ridge resorption): ________
1. No appreciable movement: ____X_____ 2. Adequate but not excessive: ____X____
2. About ½ of the mirror is displaced occlusally: 3. Minimal or possibly insufficient: ________
__________ K. Torus:
3. Mirror entirely displaced: __________ 1. No torus present or torus not large enough
F. Tongue form: to interfere with satisfactory construction
1. Normal or ideal development, size, and and use of dentures: Maxilla ___X___
function. A sufficient number of natural or Mandible ___X___
artificial teeth are properly distributed to 2. Torus offers mild difficulties for the
maintain the normal form and function of adaptation of dentures but does not require
the tongue: _______ surgical intervention: Maxilla ______
2. Slight increase in size or reduced function. Mandible______
Natural teeth have been absent for a suffi 3. Torus present that demands surgical
cient period of time to permit a change in intervention to permit the satisfactory
the functional action and form of the tongue: construction and use of dentures:
___X____ Maxilla______ Mandible______
3. Tongue is excessively large. Most teeth have L. Ridge parallelism:
been absent for an extended period of time 1. Both parallel to occlusal plane (the occlusal
and there may be an abnormal development plane is a plane that is parallel to an
of the size of the tongue. Inefficient dentures imaginary line from the ala of the nose to
sometimes create a Class III condition in the tragus of the ear in one direction and
the functional action form of the tongue: through the pupils of the eyes in the other
_______ direction): ____X____
G. Quality of osseous structure (determined in 2. Mandibular arch diverges: _________
radiographs): 3. Maxillary arch diverges: _________
1. Average bone density: ____X______ 4. Both arches diverge: __________
2. Below-average bone density: __________ M. Ridge relations:
3. Above-average bone density: __________ 1. Anterior ridge:
H. Resorption of the alveolar structures: a. Normal horizontal overlap (approxi
Normal: Maxilla______ Mandible______ mately 2 mm) of ridges: _________
Excessive: Maxilla ___X___ Mandible ___X___ b. Vertical ridge-to-ridge relationship with
Incomplete (suggest recent extractions): no horizontal overlap: ___X____
Maxilla ______ Mandible______ c. A protrusive relationship of the mandible
I. Stability and support potential of residual to the maxilla with varying degrees of
ridges: horizontal overlap (> 2 mm): _______
1. Highly calcified bony foundations afford the 2. Posterior ridges:
greatest possible advantage for stabilizing a. Normal vertical overlap of the maxilla to
and supporting the dentures: __________ the mandible: ____
2. Medium-sized bony foundations afford fewer b. Vertical ridge-to-ridge relation:
advantages: ____X____ _________
3. Small bony foundations with low-grade c. Unilateral crossbite: ___________
bone structure may stabilize and d. Bilateral crossbite: ____X____
support the dentures: _________ N. Arch form:
J. Vertical space or interocclusal clearance: 1. Square: Maxilla ______ Mandible ______
274

2. Tapering: Maxilla______ Mandible______ 3. Excessive amount of thick, ropy saliva:

3. Ovoid: Maxilla ___X___ Mandible __X____ _______
4. Reverse tapering: Maxilla ______ S. Mental attitude:
Mandible______ 1. Philosophical – Patient accepts the dentist’s
O. Vault form: judgment and his or her own oral condition
1. Square: _________ and knows the dentist will do the best job
2. Arched or gently curved: _________ possible. May be an experienced denture
3. Tapering or V-type: _________ wearer with minimal past problems or a new
4. Flat: ___X_____ denture wearer who expects no significant
P. Palatal throat form: problems: ____X____
1. Large and normal in form. Has a relatively 2. Exacting (critical) – Patient is often in ill
immovable soft palate: _____X____ health and finds fault with everything the
2. Medium and normal in form. Moderate dentist does. Not happy with previous
mobility of the soft palate. The soft palate dentist because he or she would not do as
‘curtain’ drops down more or less at a line the patient wished. Often has a collection of
drawn between the two hamular notches: several sets of dentures. Expects the dentist
___________ to guarantee his or her work: ________
3. Excessive function of the soft palate. Usually 3. Hysterical (sceptical) – Patient has had
accompanies a small maxilla. The ‘curtain’ negative experiences with previous dental
to the soft palate turns down abruptly 3 to care and now does not trust any dentist.
5 mm. Anterior to the line drawn between Often in poor health with long-neglected
the hamular notches: ________ oral conditions. May have a series of
Q. Sensitivity of the palate: personal problems such as job loss, divorce,
1. Normal: ___X___ death in the family, etc: _________
2. Sensitive: ________ 4. Indifferent – Patient has little concern for
3. Hypersensitive: ________ his or her teeth and appearance. May feel
R. Saliva: no need for dentures for mastication. Often
1. Normal in quality and quantity. Cohesive seeks care only because of pressure from
and adhesive qualities are ideal: ___X___ family and therefore will often not make
2. Reduced amount (patient on medication?): much effort to become accustomed to the
_______ dentures.
275

INFORMED CONSENT FORM FOR IMAGES AND CASTS
Following an explanation and discussion during which answers were provided to all my questions,
I hereby give authorization to Dr XX to publish images of my mouth and face taken during the pros
thodontic treatment that will be performed on me with my full consent.
Date: XX/XX/XXXX
Patient’s signature: ___________________________________
Doctor (print name and signature): ________ ____________
REMOVABLE PARTIAL DENTURE LABORATORY PRESCRIPTION FORM
Mandibular
Kennedy Class: I
Material: Vitallium chrome-cobalt alloy.

Major connector: Lingual bar.
Tooth 22: Distal guide plate, cingulum rest and wrought wire retentive clasp arm of 0.9 mm engaging
a 0.025 mm mesiobuccal undercut.
Tooth 27: Distal guide plate, cingulum rest and wrought wire retentive clasp arm of 0.9 mm engaging
a 0.025 mm mesiobuccal undercut.
Considerations for framework:

1. Provide 0.4 mm relief under the major connectors.
2. Provide 0.25 mm relief under the minor connectors.
3. Provide 0.9 mm relief under the mesh.
4. Place two tissue stops that were marked on the design cast.
5. Follow the major connector design, outline of minor connectors, rests, and mesh retention areas
for denture base areas.
276

Case 7 Rehabilitation of complete dentures
Case 7
Rehabilitation of complete dentures
Completed case narrative
Date: XX/XX/XXXX
Doctor: XXX, DDS
Miss XXX
Medical evaluation form Dental and prosthodontic history

The patient described her past dental problems that,
Personal history by her own admission, possibly related to her poor
The patient was a 78-year-old Caucasian female, oral hygiene. Her last teeth were extracted a year
with two sons and three grandchildren, retired. ago and they were part of two combined fixed and
removable maxillary and mandibular prostheses.
Chief complaint Two immediate dentures were delivered, which
The patient was referred to prosthodontics for the were then relined 4 months and again 10 months
fabrication of a new set of complete dentures. Her later using a hard laboratory relining material. She
chief complaint was that she had never found her came to the USA 2 months ago, and a general den
dentures adequate. She said they were esthetically tist relined her dentures twice with a soft relining
unacceptable and that she could never speak or material. The last time was about 10 days before she
chew properly. presented to be treated by a prosthodontist for a
new set of dentures. Some basic OHI were given to
Medical history the patient, who now feels better and is willing to
A review of the patient’s medical history revealed receive a new set of dentures.
that she was in excellent health with no signs or
symptoms of any systemic diseases. She did not take Clinical findings
any medication and had no allergies. The patient EXTRAORAL EXAMINATION
occasionally drank alcohol and did not smoke. Her The head and neck appeared to be within normal
last medical examination, 4 months ago, showed no limits. Palpation of the lymph nodes and muscles
problems. The patient had no medical contraindica of mastication revealed no signs of pathology. The
tion to any prosthodontic treatment. patient’s mandibular range of motion was within
Vital statistics normal limits and there was no deviation upon
Height: 160 cm (5ˈ 24ˈˈ) opening. The TMJs were within normal limits and
Weight: 65 kg (143 lbs) asymptomatic, with no evidence of clicking, crepi
Blood pressure: 125/75 mm Hg tus or tenderness on palpation. The patient, who
Pulse rate: 75 bpm exhibited a square facial form, showed signs of loss
of VDO. Her profile was slightly concave and her
lip line at smile was low to moderate. The corners of
her mouth and her lips did not seem to be well sup
277

ported. The midline of the maxillary incisors was The palatal form was Class I, according to the
not coincident during smiling and was positioned House classification.
slightly to the right of her facial midline. The mandibular alveolar ridge was also resorbed,
mainly in the premolar and molar areas. A thin firm
INTRAORAL EXAMINATION mucosa was overlying the edentulous ridge crest,
The patient’s current prostheses were recently re and a fold of mucosa that resembled a postextrac
lined and showed poor esthetics due to inadequate tion site remnant was evident in the area of the
tooth positioning and a slightly tilted plane of oc mandibular right bicuspids (teeth 28 to 29). Very
clusion. Some occlusal wear was noted on both the small or no frenula were evident, and on the lingual
maxillary and mandibular posterior denture teeth. side the right retromolar pad was slightly flattened
The denture teeth consisted of acrylic resin. The compared to the left one. There was a normal flow
tooth form and shade were not acceptable to the of thin serous saliva. Very small lingual, buccal, and
patient. Some plaque and calculus accumulation labial frenula were evident and revealed the height
were also noted on the polished surface and around of attachment.
the teeth. Some calculus was observed on the lin The lateral throat form was Class I, according to
gual surface of the anterior teeth of the mandibular Neil’s classification.
denture.
Examination of the mouth revealed a normal Radiographic analysis
flow of serous-type saliva. Inspection and palpation The panoramic radiograph revealed a rather severe
of the soft tissues of the lips, cheeks, tongue, floor of resorption of the maxillary posterior edentulous
the mouth, overall oral mucosa, and pharyngeal tis ridge with sinus proximity in both the right and left
sues showed them to be within normal limits for the premolar and molar areas. A similar resorption was
patient’s age. The maxillary and mandibular arches also noted at the mandibular ridge on both the pre
were U-shaped. molar and molar areas. Signs of condensing osteitis
The ridges were generally parallel and showed a were observed in the area of the lower left man
slightly Class II ridge relationship. The patient pre dibular region. A retained root tip was observed
sented with an apparently large tongue that filled mesial to the previously mentioned radiographic
the floor of the mouth. The tongue position was finding. No evidence of pathology was observed on
normal, according to Wright evaluations. the radiographs.
The maxillary alveolar ridge had an irregular
contour, and there was a transversal fold in the al Diagnosis
veolar mucosa in the area between where the two A. The patient exhibited complete maxillary and
maxillary canines were meant to be. An accentu mandibular edentulism.
ated ridge resorption in the premolar and molar B. According to the ACP classification, the patient
areas was present on both sides, and the tuberos was Class III due to:
ities were strongly reduced and levelled almost at 1. Mandibular bone height: 18 mm.
the same height as the maxillary portion of the 2. Residual ridge morphology – maxilla
pterygomandibular raphe. Despite this amount of (poorly defined tuberosities and hamular
resorption, the retrozygomatic fossae were evident, notches).
with the left one slightly wider than the right, prob 3. Muscle attachments – mandible (limited
ably due to more resorption of the left tuberosity. A influence on denture base and stability).
thin, firm mucosa covered the maxillary edentulous 4. Maxillomandibular relationship (skeletal
ridge. Very small or no buccal frenula were evident. Class II).
The labial frenulum had modest dimensions. C. The patient exhibited a philosophical personal
ity, according to the House classification.
278

Treatment plan 4. The custom trays were checked and ad

The following treatment plan was based on the pre justed in the mouth before border molding.
vious diagnosis and the patient’s wishes. The extent of the posterior border and
1. Evaluation and discussion with the patient of posterior palatal seal was palpated, and the
her chief complaints, wishes, and expectations. upper tray was trimmed according to the
2. OHI to care for either the dentures or the oral palatal posterior border.
soft tissue. 5. Border molding of the custom tray periph
3. Evaluation of the patient’s soft tissue health ery was performed according to muscle and
condition, and evaluation of the relining ma soft tissue attachments of the mouth using
terial already positioned on her denture bases. gray stick modeling compound.
The patient declined the proposed possibility of 6. After border molding was completed,
a new relining of the bases because the last one the modeling compound was reduced by
had been done a few days ago. approximately 1 mm to provide space for
4. Construction of appropriate maxillary and the final impression material. Holes were
mandibular complete dentures. made in the trays for better retention, and
5. Provide postinsertion instructions and care. a polysulfide adhesive was applied on the
6. Setting of a schedule of maintenance periphery of the border molded trays and
allowed to dry.
Treatment description 7. Selective pressure impressions of both
A. The patient was informed of the treatment plan. arches were made using regular body poly
Her expectations as well as the case limitations, sulfide impression material. The posterior
techniques, and materials were discussed. She palatal seal was ink drawn and then trans
understood and accepted the proposed treat ferred to the maxillary impression.
ment plan. She was instructed not to wear 8. The impressions were boxed in wax and
her dentures for at least 24 hours before any poured with vacuumed type IV dental
appointment. stone. The master casts were separated and
B. The patient was instructed regarding proper trimmed.
oral hygiene and denture care. 9. The undercuts were blocked out, and a sep
C. The fabrication of a new set of dentures: arating medium was applied to the casts.
1. Preliminary impressions were made with 10. Trial denture bases were constructed using
stock trays and irreversible hydrocolloid an Ivolen acrylic resin on the master casts
impression material. and left on for 24 hours for final setting. It
2. Impressions were poured in a vacuumed was then removed, cleaned, trimmed, and
type III gypsum product. carefully polished.
3. Custom tray outlines were drawn on the 11. Wax rims were constructed on the trial
preliminary casts and a score line was denture bases with baseplate wax.
placed on the lines. Tissue stops were 12. The old maxillary and mandibular com
drawn on the ridge crest. Undercuts were plete dentures were placed in the patient’s
blocked out with wax. A single sheet of wax mouth, and she was asked to close gently
spacer was placed on the casts on the area for MIP of those dentures.
limited by the score and tissue stop lines. 13. Two dots were marked on the nose tip and
Custom trays were fabricated using auto the chin skin to record the present VDO
polymerizing polymethyl methacrylate tray with the old dentures, and the measurement
resin material and were highly polished for was recorded.
impression taking.
279

14. The new bases were then evaluated in the 23. The anterior teeth setup was tried in and
patient’s mouth and their fitting and exten better arranged, guided by the patient’s es
sions verified using Pressure Spot Indicator thetics and phonetics. The CR and the VDO
Paste and Sorenson’s Paste. were verified. Also, protrusive and lateral
15. Then, the maxillary occlusal plane was interocclusal records were made with PVS
established by making the rim parallel to registration material, and the articulator
the ala-tragus line and the interpupillary was programmed.
line. A first attempt was made to establish 24. Posterior teeth were chosen and arranged
the proper length, and the anteroposterior in a bilateral balanced occlusal scheme,
position of the maxillary wax occlusion rim then tried in. The esthetics, phonetics,
was established according to esthetics and VDO, and CO were verified and approved
phonetics. by the patient. Tooth position modification
16. The mandibular record base and wax rim was carried out according to the patient’s
were then introduced and related to the request.
maxillary wax rim. On a first attempt, a 25. The trial dentures were then invested in a
slight increase of vertical dimension, com type III gypsum and type IV stone in den
pared with the old prosthesis, was tried in ture flasks. The wax was then eliminated,
to establish better lip support, esthetics, and separating medium was applied, and the
phonetics by using the vertical dimension flasks were allowed to cool down. Heat ac
of rest position and phonetics. tivated polymethyl methacrylate (Lucitone
17. Also, a first attempt to position the maxil 199) was mixed and pressure molded in the
lary incisal edge was established based on flasks.
lip support, esthetics, and phonetics. 26. Both dentures were processed for 9 hours
18. A facebow record was accomplished using a at 165°F, then deflasked and remounted on
Denar Slidematic Facebow, and the maxil their casts to be verified on the articulator.
lary cast was mounted on a Denar Mark II 27. Occlusal adjustment was performed on the
Semi-Adjustable Articulator by means of a remounted cast. The dentures were then
fast-setting mounting stone. finished and polished for use.
19. After the mounting, the record bases and 28. The dentures were inserted in the patient’s
wax rims were repositioned in the pa mouth and Pressure Spot Indicator Paste
tient’s mouth. The midline was drawn, and and Sorenson’s Paste were used to verify
V-shaped occlusal indices were cut into the possible excessive pressure areas and exten
posterior region of the maxillary rims and sions of the bases.
lightly coated with petroleum jelly. 29. An intraoral check was performed to verify
20. A CR record was made using a very thin the bilateral balanced occlusion.
layer of Aluwax on the mandibular wax 30. An Aluwax record was made for the clinical
rim to index the position with the maxillary remount procedure.
occlusal rim. 31. The dentures were then delivered to the pa
21. The mandibular cast was then mounted on tient and checked after 24 hours, at 3 days,
the articulator in relation to the maxilla. at 1 week, and then as needed. Postinser
22. The maxillary and mandibular anterior tion instructions were given to the patient.
teeth were chosen in conjunction with the
patient, then set according to the midline
and incisal wax rim.
280

Instructions to patient adjusted due to a slight irritation detected in the

The patient was instructed not to wear the dentures mandibular posterior area. The patient was also
at bedtime to ensure soft tissue recovery. She was recalled after 3 days and at 1-week postinsertion.
also told that the dentures should be placed in water She was happy with the results, was following the
to avoid desiccation and possible distortion of the hygiene instructions, and was doing well. She was
resin. Proper denture brushing and cleansing was placed on a 6-month maintenance recall.
also strongly recommended. The use of a detergent
and soaking the dentures in denture cleanser was Prognosis
also suggested and explained, along with the use of The patient was already familiar with complete den
a soft brush for cleaning and a wash cloth to mas tures and was well motivated to receive a new set,
sage the denture-bearing soft tissue areas daily. The which motivated her even more. Her philosophical
patient was instructed about chewing techniques to nature along with her positive attitude and regular
minimize instability and avoid tissue trauma. She recall maintenance should guarantee a good long-
was seen after 24 hours, when the dentures were term prognosis.
281

Case 8
Fixed and removable combined rehabilitation
Completed case narrative
Date: XX/XX/XXXX
Doctor: XXX, DDS
Mrs XXX
Personal history dentist in the patient’s local community. After that,

The patient, a 68-year-old Caucasian female from she only went to the dentist for emergency care.
a small mountain village, presented for evaluation The patient reported that she brushed her teeth
and treatment. once per day but did not use dental floss or proxi
mal brushes.
Chief complaint
The patient stated that her crowns were 15 years old Clinical findings
and that there is now some black color evident near EXTRAORAL EXAMINATION
the gums as well as a bad odor. She said that she The head and neck were within normal limits. Pal
has never been happy with the way her restorations pation of the lymph nodes and muscles of masti
looked as she did not like the display of the metal. In cation revealed no signs of pathology. There was
addition, her grandson broke her mandibular partial no facial asymmetry. Examination of the TMJs re
denture while playing with it. She said she wanted vealed no pain, crepitus or clicking.
to restore her teeth before it was too late.
INTRAORAL EXAMINATION
Medical history Examination of the lips, palate, cheeks, floor of the
The patient’s medical history was unremarkable. mouth, and oropharynx revealed no abnormalities.
Her last medical examination was 6 months ago The mucosa appeared to be generally smooth and
with no abnormal findings and no contraindications shiny with a loss of stippling. Salivary flow was
for dental treatment. The patient does not smoke or within normal limits. The periodontal examination
drink alcohol. revealed probing depths of 3 to 5 mm, with the
Vital statistics exception of tooth 14, which had a 9-mm probing
Height: 162 cm (5ˈ 4ˈˈ) depth at the distal root and a Class II furcation in
Weight: 67 kg (148 lbs) volvement. Plaque was evident on all the restora
Blood pressure: 130/75 mm Hg tions and on the natural teeth.
Pulse rate: 74 bpm The existing restorations had poor marginal in
tegrity and recurrent decay. Caries were found on
Dental and prosthodontic history tooth 7, extended subgingivally. Caries were also
The acrylic fixed partial denture (FPD), the crowns, found in the furcation area of tooth 14. A defective
and the RPD were constructed 15 years ago by a composite resorption with recurrent decay existed
282

Case 8 Fixed and removable combined rehabilitation
on tooth 22. There was also decay on the lingual B. Presentation and discussion of the proposed
surface of tooth 25. treatment plan with the patient. The patient
Teeth 1, 2, 3, 5, 10, 12, 13, 15, 16, 17, 18, 19, 20, 27, opposed the idea of clasps showing on the
29, 30, 31, and 32 were missing. The residual ridges maxillary prosthesis but did not mind them
were firm with a consistent thickness. showing on the mandibular one since this had
also been the case with her previous RPD.
Occlusal examination and findings C. Oral health counseling.
CR was not coincidental with MIP. CR contact was
between teeth 5 and 29. Right working was guided PHASE II
by teeth 5 and 29 with no balancing interferences. Clinical treatment
Left working was guided by teeth 11, 12, and 21 1. Extraction of teeth 14 and 28.
with no balancing interferences. Protrusion was 2. Crown lengthening on teeth 6, 7, 8, 9, and 11.
guided by teeth 6 and 29. 3. Endodontic therapy (re-treatment) of teeth 6, 7,
and 9; also of teeth 8 and 25.
Radiographic findings 4. Cast post and cores on teeth 4, 6, 7, 8, 9, 11, and
The alveolar bone appeared to have general normal 25.
density and trabeculation, with slight to moderate 5. Tooth 4 to 5 (pontic); teeth 6, 7, and 8 full
horizontal bone loss in the mandibular anterior re veneer metal ceramic FPD. Distal to tooth 4,
gion. Tooth 14 displayed a furcation involvement the matrix portion of a precision dowel (PD)
and bone loss at the distobuccal root. Teeth 4, 6, 7, semi-precision attachment, and a mesiolingual
9, 11, and 14 were endodontically treated. Teeth 4, 6, 0.02-inch undercut. Mesial to tooth 6, a lingual
7, 8, 9, and 11 had pins. Teeth 9, 25, and 28 exhibited ball rest for indirect retention. Mesial to tooth
periapical lesions. The mandibular anterior teeth 8, the patrix portion of a minimal space (MS)
displayed root proximity. semi-precision attachment.
6. Teeth 9 and 10 (pontic). Tooth 11 full-veneer
Diagnosis metal ceramic FPD. Distal to tooth 11, the ma
1. Generalized gingivitis with localized advanced trix portion of a PD semi-precision attachment,
periodontitis associated with tooth 14. and a mesiolingual 0.02-inch undercut. Mesial
2. Incomplete endodontic therapies on teeth 6, 7, to tooth 9, the matrix portion of a NEY MS
9, and 14. semi-precision attachment.
3. Periapical lesions associated with teeth 9, 25, 7. Teeth 21, 22, 23, 24, 25, and 26 splinted full
and 28. veneer metal ceramic crowns. Distal to teeth 21
4. Defective restorations and carries on teeth 4, 6, and 26, distal guide planes. Lingual to teeth 21
7, 8, 9, 11, 14, 21, 22, 26, and 28. and 26, lingual rests. Mesiobuccal to teeth 21
5. Partial edentulism. and 26, 0.01-inch undercuts.
8. Maxillary Kennedy Class I RPD replacing teeth
Treatment plan 2, 3, 12, 13, 14, and 15, with a chrome-cobalt
PHASE I alloy framework, modified palatal plate major
Preliminary treatment connector, and acrylic resin bases.
A. Consultations: 9. Mandibular Kennedy Class I RPD replacing
1. Periodontist: For maxillary and mandibular teeth 18, 19, 20, 27, 28, 29, 30, and 31, with a
pocket elimination and crown lengthening chrome-cobalt alloy framework, lingual bar
procedures at the maxillary anterior region. major connector, and acrylic resin bases.
2. Endodontist: For evaluation of teeth 4, 6, 7,
9, 11, 14, 25, and 28.
283

PHASE III PHASE II

Postinsertion treatment Clinical treatment
Postinsertion instructions were given to the patient, 1. The existing metal acrylic restorations were
the prostheses were adjusted, and a periodic recall removed and caries control was carried out.
program was established. 2. The provisional restorations were cemented
with free eugenol temporary cement.
Treatment description 3. The patient was referred to a periodontist for
PHASE I the extraction of teeth 14 and 28.
Preliminary procedures 4. Polyether impressions of the maxillary and
1. The patient understood and accepted the pro mandibular arches were taken for the construc
posed treatment plan and received OHI. tion of the interim RPDs.
2. Two preliminary impressions were made by 5. Crown lengthening procedures were performed
using stock trays and irreversible hydrocolloid by the periodontist for teeth 6 to 11 to expose
impression material. The impressions were sound tooth structure for all the abutments.
poured with type III dental stone. 6. The endodontist provided therapy (re-treat
3. Four recording bases with wax occlusion rims ment) for teeth 6, 7, and 9, and therapy for
were fabricated from autopolymerizing methyl teeth 8 and 25.
methacrylate resin. 7. Teeth 4, 6, 7, 8, 9, 11, and 25 were prepared to
4. A facebow record was made using a Denar receive cast dowel and cores. The patterns were
Slidematic Facebow. generated using prefabricated burnout posts
5. A CR record was made using Aluwax on the and autopolymerizing polymethyl methacrylate
mandibular rim to register the occlusal surfaces resin. The patterns were then invested in a
of the maxillary FPDs. gypsum bonded investment and cast in type III
6. A protrusive and two (right and left) lateral gold. The cast post and cores were luted with
eccentric recordings were made to adjust glass-ionomer cement.
the condylar settings of the Denar Mark II 8. Interim RPDs with a cast chrome-cobalt frame
Semi-Adjustable Articulator. work and acrylic resin bases were delivered
7. Diagnostic waxing was completed at the exist to the patient. Both maxillary and mandibular
ing VDO. A custom anterior guide table was provisional RPDs utilized I-bars as retentive
fabricated utilizing the diagnostic waxing as a components. The patient objected to the ex
guide. tended palatal coverage and the minor con
8. Distal guide planes and lingual rests were nector at the mesial rest of tooth 6. She also
fabricated with autopolymerizing polymethyl confirmed her opposition to metal displacing in
methacrylate resin and incorporated in the the maxillary arch. The disadvantages of a nar
waxing of teeth 4, 6, 11, 21, and 26. rower major connector and the elimination of
9. The acrylic resin patterns were cast in type III the indirect retainer on tooth 6 were explained
gold and incorporated in the diagnostic waxing to the patient.
of the above-mentioned teeth. 9. The application of oral hygiene measures was
10. The diagnostic waxing was flasked in a come- evaluated during the provisionalization period.
apart flask, boiled out, and processed with heat- 10. Six weeks after the crown lengthening pro
cured acrylic resin. cedure, the maxillary and mandibular teeth
were re-prepared with a chamfer finishing line.
11. The patient was placed on chlorhexidine rinses
for 2 weeks (twice per day).
284

12. The gingival tissue was retracted using knitted veyed for the placement of the PD attachments,
cord saturated with ferric sulfate. Maxillary the establishment of the guiding planes, and
and mandibular full-arch impressions were the evaluation of the desired undercuts for the
made using methyl methacrylate acrylic resin retentive arms for teeth 4 and 11.
custom trays and polyether impression ma 23. Wax patterns were invested in a phosphate
terial. bonded investment and cast in a gold-palladium
13. Impressions of the maxillary and mandibular alloy.
provisional restorations were taken with stock 24. The castings were evaluated under a micro
trays and irreversible hydrocolloid. scope and the fitting was verified on the master
14. Final impressions were poured in type IV dies.
dental stone, and master casts were fabricated 25. The metal frameworks were evaluated in the
using the AccuTrac system. mouth and were cut and indexed with auto
15. Impressions of the interim restorations were polymerizing polymethyl methacrylate resin.
poured with type III dental stone. Soldering followed, and the metal frame
16. Four recording bases (two for the maxillary and works were reevaluated to ensure proper
two for the mandibular arch) with wax occlusal marginal fit and the absence of any rocking
rims were fabricated from autopolymerizing movement.
methyl methacrylate resin, utilizing the work 26. Pick-up impressions were taken, and casts were
ing casts. constructed by using type IV dental stone.
17. A facebow record was made using a Denar 27. Four recording bases (two for the maxillary and
Slidematic Facebow. two for the mandibular arch) with wax occlusal
18. Three CR records were made, as follows: rims were fabricated from autopolymerizing
a. Maxillary prepared teeth opposing methyl methacrylate resin, utilizing the new
mandibular prepared teeth. pick-up working casts.
b. Maxillary prepared teeth opposing 28. A new facebow record (with the metal frame
mandibular interim restorations. work) was made using the Denar Slidematic
c. Mandibular prepared teeth opposing Facebow.
maxillary interim restorations. 29. Three new CR records were made, as follows:
19. Master casts were mounted on a Denar Mark II a. Maxillary framework opposing mandibular
Semi-Adjustable Articulator. Dies were sec framework.
tioned and trimmed, and margins were marked b. Maxillary framework opposing mandibular
and hardened with cyanoacrylate cement. Two interim restorations.
coats of die spacer were then applied. c. Mandibular framework opposing maxillary
20. The casts of the interim restorations were also interim restorations.
mounted on the articulator. The working casts 30. Porcelain application followed, and 0.01-inch
and the casts of the provisional restorations undercuts were established at the mesiobuccal
were interchangeable. aspects of teeth 21 and 26.
21. Polyvinylsiloxane keys were constructed from 31. The restorations were inserted into the mouth
the casts of the provisional restorations, to for a bisque bake try-in.
be used for the fabrication of the full-contour 32. The metal-ceramic restorations were glazed and
waxing. polished.
22. Full-contour waxing of the dies followed, which 33. The restorations were placed on the abutment
were then cut back to leave the appropriate teeth and a maxillary and mandibular irrevers
space for porcelain application. The master ible hydrocolloid impression was taken using
casts were tripoded, and wax patterns were sur stock trays.
285

34. Impressions were poured with type III dental onlays were waxed, invested, and cast, then ce
stone, and custom trays were fabricated using mented to the acrylic denture teeth with resin
autopolymerizing methyl methacrylate acrylic cement.
resin. 44. At the try-in appointment, the accuracy of the
35. The custom tray of the maxillary arch was CO-CR record was evaluated.
border molded using a green modeling com 45. The RPDs were flasked and processed using
pound. The custom tray of the mandibular arch heat-activated polymethyl methacrylate resin.
was not border molded. Two pick-up polyether 46. The restorations were remounted and the oc
impressions were then taken and poured in clusion adjusted. A group function was estab
type IV dental stone. Master casts were sur lished for the right side and a canine guidance
veyed and tripoded. Master casts, design casts, for the left side.
and laboratory prescriptions were then sent to 47. The acrylic resin was polished.
the dental laboratory for RPD framework fabri 48. The metal ceramic restorations were cemented
cation in a chrome-cobalt alloy. with glass-ionomer cement and the RPDs were
36. Acrylic resin indices were fabricated, connect evaluated by using a pressure indicator and
ing the major connectors with the incisal edges Sorenson’s Paste.
of the anterior teeth in order to act as a third 49. The adjusted areas of the borders were re-pol
point of reference. These indices were main ished, and the RPDs were delivered to the
tained as part of the patient’s record for future patient. Postoperative instructions were given
reference. to the patient.
37. The RPD frameworks were tried in, and the
fit was verified by using a disclosing medium PHASE III
(rouge and chloroform). After border molding, Instructions to the patient
a corrected cast impression was made of the 1. The importance of thorough brushing was
mandibular distal extension ridges and poured explained to the patient. The use of Super Floss
in type IV dental stone. and proximal brushes was demonstrated and
38. Recording bases made with autopolymerizing their significance explained.
methyl methacrylate resin with wax occlusal 2. The patient was instructed to receive an exam
rims were fabricated on the RPD frameworks. ination at least twice per year.
39. A new facebow record with the metal ceramic 3. The patient was shown proper insertion and
restorations and the RPD framework with removal techniques for both the maxillary and
the occlusal rims was made using the Denar mandibular RPDs. She then demonstrated the
Slidematic Facebow. ability to place and remove the RPDs without
40. A CR record was made utilizing Aluwax on the assistance.
occlusal rim of the mandibular RPD framework 4. Daily cleaning of the RPDs with a soft brush
to register the occlusal surfaces of the maxillary and mild soap was emphasized. It was ex
metal ceramic restorations and the indices of plained that these procedures should take place
the maxillary occlusal rim. over a towel or water-filled basin to prevent
41. The casts were mounted on the Denar Mark II breakage or distortion if the RPDs were acci
Articulator. dentally dropped.
42. Acrylic resin denture teeth were set to the 5. The patient was instructed to remove the RPDs
framework, and the denture bases were waxed nightly for a period of 6 to 8 hours and to store
to completion. the prostheses in water to prevent desiccation
43. Acrylic resin denture teeth 27, 28, and 29 were and distortion of the acrylic resin.
prepared to receive all-ceramic onlays. The
286

Posttreatment therapy problems. She was checked again after 1 week,

The patient was seen 24 hours after delivery of the and again after 2 weeks, and stated that she was
RPDs. She stated that she had an irritation under very pleased.
the mandibular right denture base. Pressure Spot
Indicator Paste was used to identify the pressure Prognosis
spot. The acrylic resin was adjusted and the occlu The short-term prognosis for the maxillary and
sion reevaluated. A new appointment was made mandibular prostheses was good. The long-term
for the patient within 48 hours, and at that ap prognosis was guarded due to her opposition for
pointment the patient stated that there were no more extended palatal major connector coverage.
287


Fundamentals of Treatment Planning

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Fundamentals of Treatment Planning

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FUNDAMENTALS OF TREATMENT PLANNING

Calvani_Frontmatter.indd 1 3/10/20 9:28 AM

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Names: Calvani, Lino, author.

©2020 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

Editing: Quintessence Publishing Co Ltd, London, UK

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“Great spirits have always encountered violent

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As science teaches, the concepts

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Foreword XIII Prosthodontists: Who we are and what we

The distant past 2 ‘Hyper-science’ and the future 4

Some definitions and basic premises 10 || Costs in the face of disease 14

How prosthodontists can help their patients 22 Removable overdentures 24

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|| Digital software treatment revolution 25 || 3D virtual articulators 26

Data 34 || Simultaneous symptoms and signs 36

Approaching and meeting the patient 50 || Emergency examination 53

Diagnosis 70 || New predictive technologies 71

Clinician qualities 86 || Prepare the environment 87

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|| Check the evaluation questionnaire with the Nerves 97

Intraoral examination procedure 122 || Anatomy 132

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Clinical extraoral examination 154 || Case assessment occlusal evaluation 158

Prosthodontic treatment algorithms 164 Classification of prosthodontic treatments 168

Some preliminary remarks 174 || Diagnostic digital dental technology 180

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|| Professional oral hygiene emergencies 184 References 185

Some preliminary remarks 190 || Long-term fixed provisionals 195

Planning for Phase III 212 || Educating patients about personal oral

Some medical statistics 228 Prosthodontic treatment planning for elderly and

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|| Some basic statistics 230 || Sedatives, anxiolytics, and antidepressants 235

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PowerPoint or Keynote presentations. A number

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Past, present, and future of

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23. Tallett F. War and Society in Early Modern Europe

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at all times in order to inspire trust in our patients 4. Positive professional

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atient properly, we have the right and the duty