Coordination of Fixed and Removable

Prosthodontic Treatment

Fixed-Removable Treatment also referred to as “Combination Treatment” because it

combines two types of treatment.

Treatment Options for Replacement of Missing Teeth

1. No treatment

No treatment ( indications )

1. long-standing edentulous space  with little or no drifting or elongation

of the adjacent or opposing teeth

here the question of replacement should be left to the patient’s wishes

2. If the patient have no functional, occlusal, or esthetic impairment (

shortened dental arch )

 replacement according to patient wishes

Ex: a patient that has cancer, done radiotherapy, 10 Functional units

and has a missing 6 I can’t do an implant for him, neither
removable (because of the radiotherapy, the mucosa is dry and thin),
so the ideal treatment? No treatment

2. Implant supported restoration

3. Fixed partial denture(bridge)

4. Removable partial denture (RPD)

 A fixed replacement is usually the preferred treatment of choice.

  Exp 1 :

a healthy 35-year-old male patient , has a missing 6, what’s the treatment option
?

 you shouldn’t list all above treatment options for the patient  you should
choose what is the most suitable for this case

 Exp 2 : a patient with a long span ridge from the canine to 7(missing 4,5,6),

 Fixed bridge  not recommended ( exceptions )  long span

 no treatment  not recommended  (because it is esthetic area),

 best treatment options here  either RPD or implant

Don’t list for the patient all treatment options mentioned above  limit the treatment
options of the patient so he can choose between two options ( not four or five )

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Initial Examination

 What is the patient’s chief complaint?

 What is the patient’s dental history?

 How is the patient’s health?

 Examination of Patient
– Extra-oral
– Intra-oral
– TMJ
– Periodontal
– Dental
– Occlusion using mounted diagnostic casts.
RPD INDICATIONS

1. Long edentulous spans

When we consider it long span that not treated by fixed bridge ??

 it’s debatable  Dr rami said  more than 3?? missing teeth it’s a long span,

but it depends on the case ,

 we can look at
 the patient diet,
 abutment teeth
 opposing arch

for an example a bridge from the canine to the 6 (strong abutments) 

the technician can add 3 teeth (pontic) rather than two teeth if the
distance is big  and you do a 5-unit bridge from the canine to the 6 
it is acceptable

but if bridge was from the canine to the 7 bridge ( replacing 4,5,6 ) 
it’s a long span

we can do it if the opposing arch has an RPD  it’s acceptable (less

force),

but if the patient wants to replace the RPD with implants  it become
not acceptable because the chance of failure is high
 2. Absence of adequate periodontal support

 crown to root ratio

is a measure of the length of tooth occlusal to the alveolar crest of bone

compared with the length of root embedded in the bone

 Ideal ratio: 1:2

 Realistic optimum: 2:3
 Minimum ratio: 1:1  under normal circumstances

‫ مثل الحاالت التالية‬adequate ‫ و اعتبرها‬1:1 ‫ اكتر من‬crown / root ratio ‫في حاالت ممكن يكون‬
o If the opposing occlusion is composed of artificial teeth ( RPD , complete
dentures )  occlusal force will be diminished , with less stress on the
abutment teeth

o abutment tooth with a less than-desirable crown-root ratio  is more

likely to successfully support a fixed partial denture if the opposing
 occlusion is composed of mobile, periodontally involved teeth than if the
opposing teeth are periodontally sound

3. Structurally and anatomically compromised abutments

4. Need for cross-arch stabilization

5. Distal extension ( free end saddle )

6. Need to restore soft and hard tissue contours

 we can add pink porcelain when we have a defect but it has a limit and as it’s
rough it can accumulate the food  so if it wasn’t accessible to good oral
hygiene, the patient will complain from smell, inflammation and progressive
bone loss.
 So we prefer the removable prosthesis
7. Anterior esthetics

 It is often possible to attain a more pleasing appearance by using one or more

denture teeth on a denture base.

 simulate the appearance of diastema , dental crowding , dental rotation

 extreme changes in the soft tissue architecture
 to more effectively satisfy a patient’s phonetic

8. Age and health

patients that have medical issues, I need to do something very quick & don’t need
too much visit)  the removable prosthesis

9. Attitude and desires of patient. &economic reasons

10. Ease of plaque removal

11. Immediate need to replace extracted teeth ( acrylic RPD )

12. Missing canine with two adjacent teeth

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RPD Treatment Planning Required Diagnostic Information

1. Caries diagnosis

2. Periodontal examination

 Periodontal probing depths,

 mobility,
 bone level,
 level of keratinized attached tissue (specially for RPD abutment teeth )

 RPD is a device that collects food so if I already have periodontal disease and
attachment loss,
  I have to make sure that the patient is stable periodontally & in a good
maintenance plan,

 without patient cooperation about maintenance plan  don’t treat him.

3. endo status
 Pulp vitality,
 status of previous endodontic treatment,
 Periapical pathosis,
 presence and state of foundation restorations(build-ups, cast post and cores, etc)

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RPD Treatment Planning

Occlusal Analysis

Occlusal relationship must be evaluated with mounted diagnostic casts to study the
following:

 Occlusal plane
 Amount of interocclusal space
 Horizontal and vertical relationship of anterior teeth
 Occlusal contacts in centric occlusion and maximum intercuspation
 Occlusal eccentric schemes (anterior guidance, group function)

 The above factors play a critical role in designing a removable partial denture.

Confirmative v.s reorganized approach

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Objectives of Modifying Abutment Tooth Contours

Modification should be confined to enamel

1. Develop an acceptable path of insertion for the RPD

2. Promote favorable biomechanical properties.

– Retention

– Stability

– Support
3. Improve Esthetics
4. Enhance Comfort

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Surveyed Crowns as RPD Abutments

When Does One Choose to Fabricate a Crown to Serve as a Removable Partial Denture
Abutment?

1. When correction of unacceptable tooth contours cannot be achieved through enamel

modification alone leading to significant dentine exposure.

 Dentine exposure can cause sensitivity and caries

  For example  If I need to do an adjustment on sever tilted teeth to create a
guide plane to eliminate the undercuts (basically, we need to remove more tooth
structure), but this will lead to significant dentine exposure  so we make
surveyed crowns.

2. When correction of unacceptable tooth contours cannot be achieved through adhesive

restoration such as composite or resin-bonded rest seat.

3. To restore a badly broken down clinical crown

4. To reestablish a proper occlusal plane (e.g. supraerupted teeth )

5. To provide

 proper rests, particularly with anterior teeth,

 and adequate retentive undercuts for direct retainers (I-bar, Cclasp) when
inadequate contours exist.
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Combining Fixed Restorations and Removable prostheses

Treatment Sequence

 Planning the RPD design starts before planning or fabricating the fixed restoration.

 We determine the RPD design to make the required adjustments on the fixed
restoration design (surveyed crown)
  Once the fixed restorations are inserted  the case would be a straight forward case 
as the abutments of RPD will be ready to receive the RPD and their details will be
transmitted through the final impression that will be taken for the fabrication of the
removable restoration.

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Surveyed Crown Fabrication

Treatment Sequence

1. Mounting of study casts with a facebow record preferably in centric relation

2. Surveyed diagnostic wax-up—including guide planes and rest seats

3. Duplication of diagnostic wax-up to generate a stone cast

4. Fabrication of a putty index or vacuum formed matrix (suck down) for

 fabrication of a provisional restoration and

 as a guide for RPD abutment tooth preparation.
5. Preparation and temporization of abutment teeth

Regardless of the type of crown used  preparation should be made to provide the
appropriate depth for the occlusal rest seat.

 This is best accomplished by altering the axial contours of the tooth to the ideal
before preparing the tooth and creating a depression in the prepared tooth at the
occlusal rest area
6. Preparation of all guide planes and rest seats on other RPD abutments based on the
established RPD design

7. Final FULL ARCH impression of abutment teeth preparations ( for surveyed crowns )
and adjacent edentulous areas ( for record block )
8. Facebow record to mount maxillary cast

9. Centric relation or maximum intercuspation record to mount the mandibular cast (Record
bases to be fabricated if inadequate number of teeth remain )

10. Full contour wax-up and wax cut-back if metal ceramic restoration
To accurately assess the contours of the wax pattern, the pattern is dusted with a thin
layer of powdered wax or zinc stearate The height of contour is then marked using the
analyzing rod in the vertical arm of the surveyor
11. Casting  fitting to die  metal try-in to verify fit of casting, occlusion if applicable
12. Porcelain bisque survey and try-in  then verify interproximal contacts, occlusion, fit,
guidance,
Esthetics
13. Porcelain glaze & polish metal, and final cementation

14. Refinement of other RPD abutments (guide planes, rest seats, facial / lingual heights of
contour for retainers) and final RPD framework impression
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