Chapter 1 Diagnosis and Treatment Planning

Chapter 1

1. Diagnosis and Treatment Planning of

Partially Edentulous Patients

he clinician is responsible for the diagnosis and treatment

of a variety of basic parameters in respect of the provision of a complete
denture service. These include the recognition of a broad spectrum of the
relevant and applied anatomical, physiological and psychological
conditions of each patient, with an understanding of the significance of
each patient’s medical status. The development of a treatment plan that
leads to the prescription of appropriate prostheses follows and, finally, the
clinician must ensure that the technical requirements for each prosthesis
are clearly communicated to the technician.

Importance of Proper Diagnosis of Partially Edentulous

Patients:
1. Proper diagnosis, careful evaluation of all diagnostic data and
formation of the proper treatment plan are keys for a successful
prosthetic treatment.

2. Proper treatment planning is based on proper diagnosis helps

according the patients' demands.

3. Construction of a successful partial denture requires thorough

extra and intra-oral examination of the patient.
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Chapter 1 Diagnosis and Treatment Planning

4. The condition of the existing denture, denture-supporting teeth, the

condition of the temporomandibular joint and the appearance
should be carefully examined as well.
The examination can be completed most effectively if two appointments
are used (Figure ‎1-1).
I- First Diagnostic Appointment
A. Health questionnaire
B. Patient interview
C. Preliminary examination of oral cavity
D. Oral & dental prophylaxis
E. Collecting diagnostic data: • Photography • Radiography •
Diagnostic Casts

II-Second Diagnostic Appointment

A-Definitive oral examination
B-Radiographic survey
C-Analysis of mounted diagnostic casts:
D. Consultation requests
E. Development of treatment plan

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Chapter 1 Diagnosis and Treatment Planning

Health Questionnaire
Patient's interview.
Patient's history which including:
1- Personal history.
2- Medical history.
3- Dental history.
Clinical examination of the patient including:
1- Intra-oral examination.
2- Extra- oral examination.
Radiographic examination.
Evaluation of mounted diagnostic casts
Development of treatment plan.
Figure ‎1-1: Overview of the steps of diagnosis

I- FIRST DIAGNOSTIC APPOINTMENT

1. Patient's Interview:
Personal history, chief complaint, medical history, psychological
health, frequency of dent examinations, previous dental treatment,
habits and type of diet and patient expectations are part of a successful
diagnosis and treatment planning.
The patient interview is important to:
1. Establish good relation with the patient.
2. Evaluate the systemic disturbances that may affect the patient’s
treatment.
3. Know the patient chief complaints.
4. Ascertain the patient's expectations of the treatment.
5. Obtain important diagnostic data from the patients.
6. Assessment of patient motivation and attitudes towards dentures
7. Gaining insight into the psychological make-up of the patient
(Patient's attitude).

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A. The Psychological attitude of patients:

The patient’s attitudes and opinions relative to the dentist and
dentistry can greatly influence the success or failure of treatment. Many
clinically acceptable prostheses have been discarded because patients were
not mentally prepared to receive them. Therefore knowing the patient’s
psychology and attitude might avoid lots of failures, misunderstanding and
increase patients’ acceptance for his prosthesis.
In 1950, Dr M. M. House classified patients into four major
categories based upon psychological characteristics:
A1-Philosophical patients:
Philosophic patients have an ideal attitude for successful treatment
& good prognosis.
 They have the best mental attitude, definite way of thinking and
ability to adjust rapidly.
 They are caring, kind, usually optimistic, cheerful and co-
operative.
 They have self confidence, accept their oral situation and accept
the dentist's advice
A2- Exacting patients:
 Exacting Patients are not easy to please as philosophical ones.
 Exacting patients are precise in everything they do. They have
high expectations & require explanations for each step in the
treatment.
 They are difficult to treat, require patience, extreme care and effort.
 A firm control of these patients is essential to obtain successful
treatment & good prognosis.

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A3- Hysterical patients:

 Hysterical patients are unstable, excitable, apprehensive and
nervous.
 They are pessimistic, worried and usually in poor health.
 They need kind, sympathetic help & sometimes psychiatric
consultation may be required.
 Require more time to explain treatment details & to relief the
patient's fear & improve the patient's confidence in
prosthodontist.
 They show poor prognosis

A4- Indifferent patients:

 Indifferent patients are passive, not interested, in-cooperative,
depressed, and lack motivation.
 They have little concern about their teeth, or health and even for
the general appearance.
 They are usually pushed for treatment by their families; therefore
they give- up quickly on facing problems with new dentures.
 They usually have unfavorable prognosis.
B. Cosmetic Index:
 It basically speaks about the aesthetic expectations of the patient.
 Based on the cosmetic index, patients can be classified as:
i. Class- I: High cosmetic index.
 They are more concerned about the treatment and wonder if their
expectations can be fulfilled.
ii. Class II: Moderate cosmetic index.
 They are patients with nominal expectations.
iii. Class III: Low cosmetic index.
 These patients are not bothered about treatment and the esthetics.
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 It is very difficult for the dentist to know if the patient is satisfied

with the treatment or not.
C. Patient's history
 History taking is a systematic procedure used to collect details
about the patient that help in developing a proper treatment plan.
Personal & medical data are gathered to rule-out general diseases
& to determine the best line of treatment for that patient. All
information about the patient can be obtained directly by asking the
patient or by letting him fill a health questionnaire.
Patient history includes:
C1. Personal history
C2. Medical history
C3. Dental history
C1. Personal History:
Name of the patient, address, telephone number, age, sex and
occupation to determine the socio-economic standard of the patient and
facilitate contacting him.
 Name: When the patient is addressed by his name, it gives him
some confidence, creates a social relation between the dentist and
his patient and enhances the psychological security.
 Age : Patients belonging to the fourth decade of life will have
good healing abilities and patients above the sixth decade will
have compromised healing.

 Sex :
- Male patients are generally busy people who appear indifferent
treatment.
- They are only bothered about comfort and nothing else.
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- On the other hand, female patients are more critical about

aesthetics.
- It is important in selection of artificial teeth form & shade
 Race & sex: are important factors in selection of artificial teeth
form & shade.
 Occupation:
- Executives and sales representatives require more idealistic teeth.
- People with higher income have greater expectations.
- Busy people are more critical about comfort.
 Location: Some endemic disorders like fluorosis are confined to
certain localities. People from that locality may want
characterization (pattern staining) in their teeth for a natural
appearance.
 Socio-economic standard: gives an idea about the fees that the
patient can afford and hence might affect the final treatment plan.
 The patient's Community: gives an idea about the dietary habits
and helps to design the denture accordingly and to determine the
best form of treatment for that patient.
C2. Medical History:
 Importance of medical history:
General health & systemic condition of the patient may help the dentist
to:-
- Take the necessary precautions to prevent contamination &
transmission of infectious diseases.
- Consider the effect of certain systemic disease on the supporting
structures, teeth, bone or soft tissues.
- Consider the side effects of medication on the oral tissues and saliva.
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Chapter 1 Diagnosis and Treatment Planning

- Make the dental visit more comfortable to the patient with less risk
of affecting his systemic condition.
 Systemic diseases that may affect prosthodontic treatment:
- Diabetes mellitus:
Uncontrolled diabetes is frequently accompanied by:
i. Poor tissue tolerance.
ii. Varying degrees of gingival and periodontal diseases
iii. Increased rate of bone resorption.
iv. Loose teeth due to periodontal diseases and loss of alveolar bone.
v. Reduced salivary flow which may affect denture retention, and
increased caries susceptibility.
vi. Red and sore tongue.
vii. Decreased resistance to infection. Hence, special care should be
given to the patient regarding his oral and denture hygiene.
- Cardiovascular Diseases:
 It is advisable to consult the patient’s cardiologist before
beginning treatment.
 Cardiac patients may require shorter & morning appointments.
- Blood diseases:
 Blood diseases like anemia may show oral manifestations in the
form of pale, weak mucosa, bleeding gum, red, sore tongue &
reduced salivary flow. Thus, overextended prostheses should be
avoided from the first day of denture delivery. If possible less
palatal coverage could be also useful.
- Bone diseases:
 Paget's disease causes maxillary tuberosity enlargement.
 Acromegaly causes enlargement of the mandible.
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Chapter 1 Diagnosis and Treatment Planning

Both diseases might, therefore, later the fir of the delivered

prosthesis.
- Transmissible diseases:
 Diseases can be transmitted through inhalation tuberculosis
or by contact with the patient's blood, saliva or through
contaminated instruments as hepatitis, influenza, or AIDS.
Infection control procedures should be meticulously
followed to minimize transmission of infectious diseases
- Diseases of the Joints
 The most common disease of the joint in old age is
osteoarthritis. Partial denture patients with osteoarthritis
affecting the finger joints may find it difficult to insert
and clean dentures.
- Osteoarthritis in the TMJ:
 It induces limited mouth opening & painful movements of
the jaw.
 Patients require special impression trays.
 Difficult jaw relation registration and achievement of
satisfactory occlusion
- Diseases of the Skin
 Some skin diseases like Pemphigus have oral
manifestations as ulcers. Such painful conditions make the
denture use impossible. Constant use of the prosthesis
could be discouraged for these patients.
- Neurological Disorders
 Diseases such as Bell’s palsy & Parkinson’s disease may
complicate jaw relation record & affects denture retention
and stability.
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- Endocrinal diseases
 Some of them like hyperparathyroidism may affect the
metabolism and the quality of the supporting bone.
- Oral Malignancies:
 Patients under radiotherapy of head & neck should delay
their prosthetic treatment.
 Only the radiotherapist determines the time of prosthetic
treatment.
 Tissues are not suitable for denture support.
 After denture insertion, the tissues should be examined
frequently because of the increased risk of developing
osteoradionecrosis.
- Salivary gland disorders: Xerostomia results in painful and
burning mucosa while affecting the prosthesis retention and
increasing the risk of mucosal injury.
- Epilepsy: The construction of removable partial denture is
contraindicated if the epileptic patient has severe sudden attack
with little or no warning.
 Drugs that might affect prosthodontic treatment:
These drugs include the following:
- Anticoagulants: They increase the risk of bleeding.
- Antihypertensive agents: They cause decrease in salivary flow
- Endocrine therapy: They cause sore mouth and discomfort.
- Saliva-inhibiting drugs They cause decrease in salivary flow
- Dilantine used for treating epilepsy: They cause gingival
enlargement.

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C3. Dental History

Dental history includes:

i. Chief Complaint: Should be recorded in the patient’s own
words. It gives ideas about the patient’s psychology.

ii. Expectations:

 The patient should be asked about his/her expectations.

 The dentist should evaluate the patient’s expectations & classify

them as realistic or unrealistic.

 If the patient has unrealistic expectation e.g. a removable partial

denture (RPD) without major connector crossing the palate. This
patient expectation should be changed through education.

iii. Cause of teeth extraction:

 If the teeth were lost due to caries, the patients should be motivated
to improve their oral hygiene procedures.

 If the teeth were lost because of periodontal disease, every effort

must be made to discover and eliminate its cause

 The cause & sequence of the tooth loss provides information

about the underlying supporting tissues & alveolar bone.

iv- Chewing habits:

 The patient is asked about the preferred and non preferred side for
chewing.

 This will determine the amount of support, retention and bracing of

the denture on each side.
v- Para functional habits: Clenching and bruxism may have
adverse effects on the denture supporting structures.

iv- Previous denture:

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 If the patient had a previously constructed RPD, it is important to

know much about the patient' experience during and following
treatment.
 The cause of failure of previous dentures should be evaluated.
Patient should be asked about the cause for constructing a new
denture & what he expects from the new one?
2. Clinical Examination of The Patient (Error! Reference source
not found.)
It consists of
A. Extra-oral Examination
B. Intra-oral Examination
 Extra-oral Examination  Intra-oral examination
Visual, digital and radiographic examination
of:
 Patient Evaluation. Visual examination, Pain relief and temporary
 Facial appearance restorations, Oral prophylaxis, Radiographs,
 TMJ examination Evaluation of existing teeth and periodontium, Vitality
tests of individual teeth, Determination of the floor of
the mouth position,
Impression of each arch
Some other factors:
1-Tongue size & type
2-Floor of the mouth.
3-Saliva
4-Oral lesions
Figure ‎1-2: Components of extra- and intra-oral examination of the patient

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Chapter 1 Diagnosis and Treatment Planning

A. Extra-oral examination:
i. Gait:
 People with neuromuscular disorders show a different gait.
 Such patients will have difficulty in adapting to the denture.

ii. Complexion and Personality:

 The color of the eye, hair and the skin helps to determine the shade
of the teeth.
 Executives require smaller teeth.
iii. Facial Examination:
 Evaluation of the facial form, facial profile, facial features &
lower facial height. This helps in selecting the tooth form.
 Facial Features: Collapsed face indicates loss of vertical
dimension (VDO).
 Decreased VDO produces wrinkles around the mouth.
 Excessive VDO will cause the facial tissues to appear stretched.
iv. Lip Examination:
 Lip support: lips may be adequately supported or
unsupported.
 The fullness & normal contour of the upper lip may be lost
due to lack of tooth support.
 Length of the lips:
- Based on the length: lips are classified as long,
normal or & short
- In short lips…… more teeth display and the opposite
in long lips
v. Facial profile:
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The facial profile is important to determine the maxilla-mandibular

relation , teeth arrangement &occlusion.
Angle classified facial profile as:
 Angle Class- I: Normal or straight profile .The curvature of the
labio mental sulcus is gentle. (i.e) forms an obtuse angle.
 Angle Class- II: Retrognathic profile. The curvature of the labio
mental sulcus forms an acute angle.
 Angle Class- III: Prognathic profile. The curvature of the labio
mental sulcus forms a nearly straight angle.
vi. Speech Examination:
 It includes the examination of speech and neuromuscular co-
ordination.
Speech is classified according to the ability of the patient to articulate &
coordinate it.
Type 1: Normal
 Patients are able to produce articulated speech with their existing
dentures.
 Easily accommodate to the new dentures.
Type 2: Affected
 They have impaired articulation of speech with their existing
dentures.
 Their speech may be altered due to a poorly-designed denture
 Require special attention during anterior teeth arrangement
(setting).
 Require more time to adapt to a proper articulated speech in the
new denture.

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vii. Facial movements:

 Abnormal facial movements like lip sucking, tongue tremors,
uncontrollable chewing movements may lead to prosthetic failure
viii. Temporomandibular joint (TMJ) Examination: (Error! Reference
source not found.)
Examination of TMJ is done through palpation, stethoscope,
radiographs and through examining the jaw movements.

TMJ disorders can be detected by one or more of the following signs:

 Reduced inter-incisal opening (Normal maximum opening is
55mm ± 15mm).
 Pain and tenderness over the TMJ at rest and during movement.
 Clicking during opening and closing.
 Midline deviation during wide opening.
 Muscle pain and tenderness.
 Headache and ear pain.

Figure ‎1-3: a. Palpation of TMJ b. using a stethoscope to identify TMJ Sounds

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B. Intra-oral Examination:
Thorough oral examination should precede any treatment decision.
Sequence for intra-oral examination of partially edentulous patients:
Intra- oral examination should be accomplished in the following
sequence:
i. Initial visual oral examination
ii. Pain relief and temporary restorations
iii. Oral prophylaxis
iv. Radiographs
v. Evaluation of existing teeth and periodontium
vi. Vitality tests of individual teeth
vii. Determination of the floor of the mouth position
This should be followed by mounted diagnostic casts obtained by making
impression of each arch
Thorough and Complete Oral Prophylaxis
 An adequate examination can be better accomplished with the teeth
free of accumulated calculus and debris.
 Accurate diagnostic casts of the dental arches can be obtained only
when the teeth are clean.
B1. Initial visual intra-oral examination
i- Initial oral examination is carried-out to detect any problem
require immediate attention.
ii- Evaluation of oral hygiene
iii- Evaluation of caries susceptibility
iv- Detection of oro-nasal communications
v- Assessment of applied forces: (Opposing occlusion, Muscular
force and elevator muscle development, Para-functional habits,
Length of edentulous span, History of prosthesis failure)
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vi- Condition of the supporting tissues verified by history of poor

tissue tolerance.
B2. Definitive visual intra-oral examination:
Complete intra-oral examination should be done to evaluate the
following:
i. Existing Teeth
 The condition of the existing teeth is important for RPD
construction.
 All carious teeth must be restored prior to starting definitive
prosthodontic treatment (Figure ‎1-4).
 Pulpitis, pulp necrosis & sensitivity to percussion should be
monitored.
 Mobility and C/R ratio: The degree of mobility of all teeth should
be recorded using a scale commonly used for classifying mobility:
a. Class 1: A tooth demonstrates greater than normal movement, but
less than 1 mm of movement in any direction.
b. Class 2: A tooth moves 1 mm from normal position in any
direction.
c. Class 3: A tooth moves more than 2 mm in any direction, including
rotation or depression. They have a poor prognosis and usually
require extraction.
- Teeth mobility may induce traumatic occlusion and periodontal
disease.
- Causes of teeth mobility: Traumatic occlusion, inflammation of
Periodontal ligament or loss of alveolar bone support.
- Treatment of teeth mobility: Scaling & Motivation of meticulous
oral hygiene. The condition may sometimes require temporary or
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definitive splinting. Persistence of tooth mobility might preclude

using the tooth as abutment.
- Splinting is indicated when:
-All the remaining teeth have reduced support
-Only two or three widely spaced retainable teeth
-The first premolar and all molars have been lost and the
second premolar is to serve as the abutment
- Periodontium:
The health of the PDL is determined by findings that need
periodontal treatment are:
a. Pocket depth exceeds 3 mm
b. Furcation involvement
c. Severe gingivitis
d. Marginal exudate e. Less than 2 mm of attached gingiva

Figure ‎1-4. Counting the number of decayed, missing and filled teeth

to set a DMF score for the patient

Figure ‎1-5 a. Intra-oral periodontal examination, b. Evaluation of pocket depth

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ii. Abutments with Guarded Prognosis:

• If the prognosis of an abutment tooth is questionable, it might be
possible to compensate for its expected loss by a a proper denture
design.
 In questionable single standing posterior abutments
- They can be retained & used at end of the tooth-supported
base or left unused and the case is treated as tooth tissue
supported case.
- When it is extracted, it could be replaced by extending
denture base to denture framework.
Such an original design must include provisions for future
indirect retention, flexible clasping of the future abutment,
and provision for establishing tissue support.
 In Questionable anterior abutments
- This is difficult to manage.
Why? Because, it is difficult to add a new retainer when the original
one is lost.
iii. Oral hygiene and caries susceptibility:
• Patient's oral hygiene should be evaluated as it has direct effect on
prognosis of the patient's treatment.
• Disclosing tablets or solution can be used to detect plaque, which
will indicate the patient motivation towards oral hygiene.
iv. Mucosa:
 The color, condition and the thickness of the mucosa
should be examined.
a. Color of the Mucosa :

 Normal mucosa should have a healthy pink color.

 Red mucosa indicates an inflammatory change.
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 Inflamed tissues should be treated before making

impression.
 White patches might indicate an area of frictional
keratosis
 Palatal papillary hyperplasia, Epulis fissuratum &
Denture stomatitis (Figure ‎1-6) may be due traumatic
occlusion, poor fit of the prosthesis, poor oral hygiene and
continuous wearing of the prosthesis.

.
Figure ‎1-6: Redness of the mucosa due to denture stomatitis

b. Soft tissues covering some bony prominences such as:

 Torus palatinus:
 Torus mandibularis .
 Undercuts and bulbous maxillary tuberosities
Overlying mucosa could be thin, stretched and easily injured
depending on the degree of prominence.
The effect of any bony undercut areas may be minimized by:
 Changing the path of insertion of the RPD in case of
unilateral undercut.
 Relieving the denture base or reducing the length of the
denture border
 Surgical correction of undercuts.
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 Flexible denture base or flexible border

 Changing the design to avoid this bony prominence
c. Soft tissue abnormalities:

 Bulky or highly attached labial frenum.

 Highly attached lingual frenum
 Flabby tissues covering the edentulous area
v. Tongue size & mobility:
The tongue should be examined for Size, movement & coordination
a. Size:
- Large tongue which
 decreases the stability of lower denture
 Interferes with impression making.
 Tongue-biting is common after insertion of the denture.
- Small tongue does not provide adequate lingual peripheral
seal.
b. Tongue Movement & coordination:
- Tongue movements & coordination are important to provide
good peripheral seal
- Necessary to maintain the denture in the mouth during
functional activities like speech, deglutition and mastication, etc.
vi. Occlusal relationships (Figure ‎1-7):
It is the relation between the opposing teeth and between the teeth
and the opposing ridge. It is examined for:
a. Available inter-arch space for placement of artificial teeth.
b. The degree of anterior vertical overlap.
c. Super eruption and tilting of the remaining teeth.
d. Cuspal interference

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a. b.

c.
Figure ‎1-7: Intra-oral examination of the occlusal relation to see

a. drifting of adjacent, super-eruption of opposing teeth and anterior vertical

and horizontal overlap. b. Interarch space, c. Occlusal relation is better
examined on the cast

vii. Quality and quantity of saliva:

a. Dry mouth has no lubricating effect. Saliva substitute should be
used
b. Thick and ropy saliva or copious amounts of serous saliva induce
problems during impression.

viii. Space for mandibular major connector (Figure ‎1-8):

a. The mandibular major connector should be located 3 mm below
the free gingival margins & the inferior border of the connector
should be at or slightly above the position of the active floor of the
mouth. Hence, 7 - 8 mm space should be available if a lingual bar
is to be used.
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b. Available space is measured with a calibrated periodontal probe

with the patient raising the tongue towards the palate.
Measurements are made at several positions; the probe is then used
to transfer the measurements to the cast.

Figure ‎1-8: Distance between the superior border of the major connector

and the ginigival margin should be at least 3-4 mm

3. Radiographic examination of partially edentulous patients:

Radiographic examination may be carried-out through:
A. Complete mouth periapical and bite-wing survey.
B. Panoramic Radiograph.
C. Previous radiographs if possible for comparison.
Importance of Radiographic Examination:
Dental radiographs can be used to supplement the clinical
examination but should not be used as a substitute for it. A critical
evaluation of the following factors should be made:
 Type, location, and severity of bone loss
 Location, severity, and distribution of furcation involvements
 Alterations of the periodontal ligament space;
 Alterations of the lamina dura
 The presence of calcified deposits
 The location and conformity of restorative margins
 Evaluation of crown and root morphologies
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 Root proximity
 Presence of Caries
 Evaluation of other associated anatomic features, such as the
mandibular canal or sinus proximity.
i. Examination of residual ridge to evaluate:
 Presence of any pathologic condition
 Root fragments, unerupted teeth (Figure ‎1-9) or foreign bodies and
to decide whether they should be removed or not
 Quantity of bone.
-Alveolar process.
-Residual ridge.
-Basal bone
 Bone quality and bone Index areas (bone factor):
- The higher the bone density the greater resistance to resorption.
- The bone index area provides assessment of the bone response to
stimulation or irritation. According to Wolff’s law of bone
physiology”Intermittent stimulation can cause bone apposition,
constant stimulation (irritation) causes bone resorption”
- This is made by analyzing bone index areas. These areas are areas
of bony support which disclose the bone reaction due to increased
force. e.g. areas of bone around abutment teeth . This helps in
predicting the future resistance of abutment teeth and ridge to
forces transmitted by an RPD. These areas are compared to areas
of bone around teeth in normal function
- Factors that affect the bone density or quality are
a. Extrinsic bone factors. Localized forces applied to bone.
b. Intrinsic bone factors which may influence the rate of resorption.

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ii. Examination of remaining teeth

Remaining teeth should be carefully examined to evaluate the
following:
 Presence and extent of caries
 Existing restorations (inadequate proximal contours, presence of
deficient margins or recurrent caries).
 Root canal fillings
 Root length, size and form (Multi rooted teeth with will resist
stresses better than teeth with fused or conical roots)
 C/R ratio:
- The radiographic C/R ratio is a commonly used index to evaluate
the degree of abutment teeth support.
- A tooth with C/R ratio of 1:2 is considered a good RPD abutment.
- As tooth with C/R ratio more than 1:1 will unfavorable prognosis
as a RPD abutment.
 PDL space: A thin uniform ligament space is a more favorable
than is a widened, irregular space. Wide PDL space: indicate
trauma, mobility or heavy function.
 Bone loss around teeth, especially interdentally and in the furcation
areas might indicate a periodontal disease
 Lamina dura: -Uneven lamina dura: is seen in tipped teeth due
to uneven forces.
-Partial or total absence of lamina dura may be
found in hyperparathyroidism & Paget disease.
- Thickening of lamina dura: Seen in mobile
tooth under trauma or heavy function.

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a. b.
Figure ‎1-9:a. Severe alveolar bone loss; b. Impacted molar tooth bud

4. DIAGNOSTIC CASTS
 Impressions should be made for making accurate diagnostic casts.
 The diagnostic impression is usually made with alginate in a stock
tray.
 A diagnostic cast should be poured using dental stone ( Strong, not
easily scratched )
 Purposes of accurate diagnostic casts:
i. Analysis of the hard & soft tissue contours
ii. Allow occlusion diagnosis from the lingual & buccal
aspects.
iii. Preliminary design of the RPD .
iv. Determine the need for required surgical correction
v. Topographic survey of the dental arch to be restored by
RPD & draw the proposed design on them.
vi. To determine the need for mouth preparation.
vii. Serves for presenting the treatment plan for placement of
restorations, re-contouring of teeth, and preparation of rest
seats better to the patient.
viii. Custom trays may be fabricated on the diagnostic casts
ix. Used as a constant reference as the work progresses.
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x. Diagnostic casts on a suitable articulator permit analysis of

- Occlusion
- The adequacy of interarch space
- The presence of over erupted or malposed teeth
- The presence of tuberosity interferences.
xi. Unaltered diagnostic casts should become a permanent part
of the patient's records

Figure ‎1-10: Mounted diagnostic casts

 Analysis of mounted diagnostic casts:

The mounted diagnostic casts provide visual access from all directions &
enable the dentist to make a detailed analysis of the patient’s occlusion.
i. Mounting of maxillary cast to articulator
Jaw Relationship Records for Diagnostic Casts (Vertical dimension
of occlusion and centric jaw relation record)to inspect the
following:
Occlusal plane
Occlusion
Tipped or malposed teeth
Traumatic vertical overlap
The presence of tuberosity interferences
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Chapter 1 Diagnosis and Treatment Planning

interarch space
Malrelation of jaws
Diagnostic wax up
- Inter-arch distance
Causes of insufficient interarch distance:
a. Too large maxillary tuberosity
b. Over erupted teeth with their alveolar bone support.
c. Maxillary tuberosity interferences.(undercut on one or both
Sides).
- Occlusal plane
a. Irregular occlusal plane:
Management depends on the degree of extrusion & the condition of the
tooth:
 Enameloplasty,.
 Placement of an extracoronal cast metallic restoration
 Endodontic therapy and crown, when sever reduction to be
made.
 Extruded teeth can also be repositioned through orthodontic tooth
movement procedures.
 Severely extruded teeth should be extracted.
b. Malposed occlusal plane:
Management depends of the amount of super-eruption and
might sometimes require segmental osteotomy.
- Occlusion
• The mounted diagnostic casts are also used for evaluating the
patient’s occlusion.
• The information obtained from the analysis of the occlusion should
be correlated with other clinical findings.
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Chapter 1 Diagnosis and Treatment Planning

- Occlusal interferences:
• Premature occlusal contacts are commonly seen in partially
edentulous patients due lack of continuity of the dental arch.
- Bruxism:
• Severe bruxism may injure teeth, cause them to abrade, traumatize
the periodontium, the TMJ joint causing pain, or discomfort.

- Diagnosis of traumatic occlusion :

• Excessive teeth wear (chipping or teeth fracture may be seen).
• Loss of supporting structures (tooth mobility, migration & pain
after occlusal contact).
• The radiographic signs of traumatic occlusion follows:
 Widening of the PDL space with thick or absent lamina dura.
 Periapical or furcation radiolucency.
 Alveolar bone Resorption.
 Root resorption.
- Management of occlusal interferences and bruxism:
• Occlusal equilibration: Selective grinding or coronal reshaping of
teeth to equalize the occlusal stress,
• Producing simultaneous occlusal contacts, or harmonizing cuspal
relations by restoring missing teeth using the proper occlusal
concept.
THE PATIENT SHOULD BE MADE AWARE OF THE
FOLLOWING.
1. The nature & severity of the existing dental problems.
2. Any limitation in function, phonetics, esthetics, and longevity related
to the prosthesis.
3. The physical aspects of the prosthesis regarding bulk & tissue
coverage.
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Chapter 1 Diagnosis and Treatment Planning

4. Any treatment options that may be considered.

5. The risks, benefits and alternatives related to any treatment plan.
6. Patient must understand & accept responsibility for preventive home
care and professional recall.
TREATMENT PLANNING
 Prosthodontic treatment for partially edentulous patient’s can be
divided into six separate phases or stages.
Phase I
• Collection and evaluation of diagnostic data (e.g. Diagnostic
impressions).
• Treatment of emergency conditions.
 Relief of pain and infection.
• Determining the type of prosthesis to be fabricated.
• Patient motivation.

Phase II
• Pre prosthetic mouth preparation.
• Making the primary impression.
• Patient motivation

Phase III
• Designing the RPD.

Phase IV
• Prosthetic mouth preparation
• Making the final impression
• Patient motivation.

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Chapter 1 Diagnosis and Treatment Planning

Phase V
• Fabrication of the removable partial denture.
Phase VI
• Insertion.
• Post-insertion management.
• Periodic recall and review.

Treatment options for partially edentulous patients:

For partially edentulous patient, there are six alternatives
1. Fixed partial denture.
2. Removable partial denture
3. Complete denture.
4. Any combination.
5. Overdenture
6. Implant prosthesis

1. FIXED BRIDGE:
INDICATIONS:
a. Healthy abutments with suitable c/r ratio.
b. Abutment requires restoration or reshaping.
c. Short span edentulous area.
d. Unfavourable angulations of the teeth for RPD.

2. COMPLETE DENTURE
INDICATIONS:
a. Poor abutment teeth
b. Bad oral hygiene and rampant decay.
c. esthetically un acceptable anterior teeth
d. Rejection of professional advice
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Chapter 1 Diagnosis and Treatment Planning

e. Refusal mouth preparation

f. Poor alignment
g. Radiation therapy

3. REMOVABLE PARTIAL DENTURE INDICATONS

a. Long span edentulous area with well supported abutments
b. free end saddles
c. Multiple missing anterior teeth
d. Weak abutment
e. High increased caries index
f. Need of cross arch stabilization (bracing) of remaining teeth
g. Immediate replacement of missing teeth
h. Excessive bone loss
i. High possibility of future tooth loss
j. Physical or emotional problems of patient.
k. Patient desire (economic and time and preserve of sound teeth )
l. Young patients (< 17 y.) and old age
m. Restore facial contour
n. Alteration vertical dimension of occlusion
o. Transitional prosthesis
p. Palatal cleft obturators
q. Extreme atrophic ridge
r. Severely diabetic patients

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