Diagnosis and

Treatment Planning for

Partially Edentulous
Patients
First Appointment
Keys to a successful Interview

• Dentist’s attitude
• Caring
• Understanding
• Respectful
• Phrasing of questions
• Open-ended questions

WE SHOULD MEET THE MIND OF THE PATIENT BEFORE WE MEET

THE MOUTH OF THE PATIENT
Health Questionnaire: Diabetes

• Decrease resistance to
infection
• Patients often display
reduced salivary output.
Health Questionnaire: Arthritis

• If it is in TMJs, may
produce changes in
occlusion
• Very rare in TMJ, and if
it is in TMJ it is usually a
secondary site
Health Questionnaire:
Parkinson’s Disease

• Oral hygiene and

handling of dentures
will be impaired
• Difficult impressions
due to excessive
quantities of saliva
Health Questionnaire:
Paget’s Disease

• Patients may present

enlargement of
tuberosities.
• Frequent recall
program.
• Quite rare
Health Questionnaire:
Acromegaly

• Enlargement of the
mandible
• Frequent exams to
evaluate fit and function
of removable prosthesis
Health Questionnaire: Epilepsy

• Removable dentures may be

contraindicated if they are
small and seizures are
frequent and severe:
choking
• If patient takes phenytoin
(common drug to take),
make sure that RPD does
not irritate gingival tissues.
Health Questionnaire:
Pemphigus Vulgaris

• Common symptoms:
oral discomfort and
dryness.
• Establish smooth and
polished borders to
reduce soft tissue harm.
• Greater follow up is
anticipated.
Health Questionnaire:
Treatment for Cancer
• Most common oral
complications:
• Xerostomia
• Irritations
• Bacterial and fungal
infections
• 40% of patients who have
cancer outside of the mouth
have repercussions inside
the mouth.
Cardiovascular Disease

• Require medical
consultation:
• Acute or recent MI
• Angina pectoris
• Congestive Heart Failure
• Arrhythmia
• Hypertension
• Take blood pressure as soon
as you see patient (180/110
and you shouldn’t see
patient)
Health Questionnaire:
Transmissible Diseases
• Hepatitis
• TB
• Influenza
• HIV

• Make sure impressions are

disinfected
Effects of drugs on treatment

• Anticoagulants (coumadin,
aspirin)
• Post-surgical bleeding
• Antihypertensive agents
• Orthostatic hypotension
• Xerostomia if patient is on diuretics
• Endocrine Therapy
• Xerostomia
Structure of the interview

• Dental History
• How did he/she lose his/her
teeth? Caries? Perio?
• Gather information about existing
dentures.
• Old x-rays.
Structure of the interview

• Diet
• Frequent usage of mints, soft
drinks, sugar-containing products
Structure of the interview

• Habits
• Bruxism and clenching
• Tongue thrusting
Structure of the interview

• Expectations of
treatment, get the chief
complaint
• Questions from patient
Initial Examination

• Problems requiring immediate attention

• Evaluation of oral hygiene. Explain:
• Signs and symptoms of dental disease
• Materials and techniques for home care
• Patient’s responsibilities (you can only do 50% of the job, the patient has to
do the other half, i.e. the OH)
Initial Examination

• Eval. of caries
susceptibility
• Oral prophylaxis to clear
things up
• Radiographs (Pan and
FMS)
• Diagnostic impressions
and casts
Second appointment

• Facebow transfer
• Take centric relation registration
• Take protrusive record
• Mount casts
Centric relation record

• Recommended method
• Recording CR position
• Occlusal vertical
dimension
Centric relation record:
using wax?

• We can also use elastomeric registration materials (wax tends to change

dimension over time and can become brittle)
Centric relation record: Using
Record bases

• If patient does not have

enough teeth to mount
lower cast to upper (i.e.
no posterior teeth),
fabricate record bases.
• Wax-up, take relation in
centric relation.
Setting condylar elements

• Protrusive record: with either wax or elastomeric

material.
• Ask patient to put front teeth edge to edge for
practice, then using PVS ask them to repeat.
Setting condylar elements

Too shallow The condylar setting is… Too steep

Correct
inclination
Diagnostic Wax-up
Definitive Oral Examination:
Caries and existing restorations

• Countours of potential
abutments
• Occlusion
• Possible extractions.
Definitive Oral Examination:
pulpal tissues

• Possible pulp testing in teeth to be used as abutments that have

decay or crowns or extensive work.
• Selection of endodontically treated tooth as abutments is NOT
contraindicated. Better prognosis with full crown coverage
restoration.
Definitive Oral Examination:
tooth mobility
• Unstable occlusion
• Tooth in traumatic
occlusion
• PA abscess
• Acute pulpitis
• Cracked tooth syndrome
Definitive Oral Examination:
tooth mobility
• Trauma of occlusion
• Inflammation of
periodontum
• Loss of bone support

Niether is useful as an abuttment

for a partial Useful for an abuttment for
an overdenture
Definitive Oral Examination

• oral mucosa
• hard tissues abnormalities
• soft tissues abnormalities
• space for mandibular major
connector
Definitive Oral Examination

• radiographic evaluation of prospective abutments

Evaluation of mounted diagnostic
casts

• Interarch distance
• Occlusal plane
• Irregular occlusal plane
• Malpositioned occlusal plane
Evaluation of mounted diagnostic
casts
• Malrelation of arches
• Tipped or malposed
teeth
• Occlusion

Interferences need to be corrected

To treat or not to treat at
centric relation….that is the
question.
• We will construct our prosthesis at CR if:
• CR=MI
• Absence of posterior tooth contacts (tissue- borne)
• Few remaining posterior contacts

Otherwise, we will construct our RPD’s at maximum intercuspation position.

We will not introduce new interferences by a RPD.
Finally….

• Diagnostic wax-up
• Consultation to other
specialties
• Development of
Treatment plan.
?? $ ?? @ … ? &&!

How do I
develop a
Treatment
Plan????
Developing a sequenced
treatment plan
• Phase I:
• evaluation,
• immediate treatment,
• diagnostic mounting, wax-up, partial design,
• referral to other specialties (endo, ortho, etc.),
• patient education (OHI, etc).
Developing a sequenced
treatment plan
• Phase II:
• Removal of caries,
• extractions,
• perio tx,
• occlusal equilibration,
• placement of temporary restorations
(temporary crowns, etc).
Developing a sequenced
treatment plan
• Phase III (continuation of Phase II):
• Pre-prosthetic surgeries,
• root canal therapies,
• definitive restoration of teeth,
• RPD mouth preparation, final impressions, metal try-in, records (if needed).
• Phase IV:
• Delivery of RPD,
• Instruction for patient.
• Phase V: Periodic recall, reinforcement of education.