Prosthodontic Diagnosis

Section 02 - Prosthodontic Diagnosis
Handout
Abstracts
001. Koper, A. The initial interview with complete denture patients !ts structure and strateg". #
Prosthet Dent 2$%&0-%&', 1&'0.
002. (ouse, ). ). *elationship o+ oral e,amination to dental diagnosis. # Prosthet Dent -20--
21&, l&%-.
00$. .aseheart, #. *. /on-ver0al communication in the dentist-patient relationship. # Prosthet
Dent$11-10, 1&'%.
001. .arone, #. 2. Diagnosis and prognosis in complete denture prosthesis. # Prosthet Dent
1120'-21$, 1&31.
00%. Koper, A. 4h" dentures +ail. D5/A -'21-'$1, 1&31.
003. .olender, 5. 6., Swoope, 5. 5., and Smith, D. 7. The 5ornell )edical !nde, as a prognostic
aid +or complete denture patients. # Prosthet Dent 2220-2&, 1&3&.
00'. .ergman, .. , and 5arlsson, 8. 7. 5linical long-term stud" o+ complete denture wearers. #
Prosthet Dent %$%3-31, 1&-%.
00-. *issin, 6., et al. Si, "ear report o+ the periodontal health o+ +i,ed and remova0le partial
denture a0utment teeth. # Prosthet Dent %1131-13', 1&-%.
00&. #ohnson, P. 9., Ta"0os, 8. ). , and 8risius, *. #. Prosthodontics. Diagnostic, treatment
planning, and prognostic considerations. D5/A $0%0$-%1-, 1&-3.
010. 5haconas, S. #., and 8onidis, D. A cephalometric techni:ue +or prosthodontic diagnosis and
treatment planning. # Prosthet Dent %3%3'-%'1, 1&-3.
011. 5ulpepper, 4illiam D. and )oulton, Patricia S. 5onsiderations in 9i,ed Prosthodontics.
012. 6anda, 6.S. Diagnosis and )anagement o+ Partiall" 7dentulous 5ases with a )inimal
/um0er o+ *emaining Teeth. D5/A - 2ol. 2&, /o. 1, #an 1&-%.
01$. 4alton, T.*. A Ten ;ear 6ongitudinal Stud" o+ 9i,ed Prosthodontics 1. Protocol and
Patient Pro+ile. !nt # Prosthodont 1&&'< 10$2%-$$1.
Section 02: Prosthodontic Diagnosis
(Handout)
missing document ......
- Abstracts -
02-001. Koper, A. he initia! inter"ie# #ith co$p!ete denture patients: %ts structure and
strateg&.
!ntroduction The initial interview allows the doctor and patient to meet each other. The
interview is not concluded until a decision regarding treatment and prognosis is made. The
doctor should +ul+ill two 0asic o0=ectives. (e should evaluate the patient emotionall" and
ph"sicall" and he should allow the patient to assess him.
)ethods o+ !nterviewing 7,plore the +ollowing using ver0al, e,traver0al, and nonver0al
methods o+ communication >1?The patients desires +or, or dissatis+actions with, dentures< >2?The
ade:uac" o+ the dentures the patient is wearing< >$?5ondition o+ the oral tissues and associated
perioral structures< >1?The health and living patterns o+ the patient.
The 9irst )eeting @verlooA nothing as the patient enters the operator" or consultation room.
5ompare apparent age to actual age. 6ooA +or signs o+ +ear.
7sta0lishment o+ Trust 8reeting the patient should var" with the age and t"pe o+ individual. Sit
e"e to e"e and let him Anow he has "our undivided attention. (ave a pen and pad out and taAe
notes. )aAe initial small talA with a +ear+ul patient and allow him to evaluate "ou +irst. The
author calls this a Btrust talAB period.
The PatientCs Pro0lems Determine what concerns the patient the most. Know that com+ort,
esthetics, +unction, and retention are the most common areas o+ concern. Allow the patient to
Aeep talAing a0out what 0others him until "ou are sure "ou have heard it all. AsA the patient how
it +elt to loose his natural teeth. AsA to see photos o+ the patient prior to having his teeth
e,tracted. 9inall", get a denture histor" on the patient.
PatientCs (ealth and 6iving Patterns *eview the health histor" and in:uire a0out medications the
patient ma" 0e taAing. Discuss the patientCs occupation and living ha0its. !n:uire a0out his diet.
The oral tissues o+ a malnourished individual are incapa0le o+ 0earing the stress o+ a denture
without pain, soreness, and 0one loss. AsA the patient to descri0e ideal dentures.
@ral 7,amination !nclude the T)#, )asticator" muscles, structures o+ the +ace, as well as the
oral tissues. *ecogniDe the structural, s"stemic, and neuromuscular limitations o+ the patient. .e
gentle, decisive, and thorough.
@ther Sources o+ !n+ormation 5onsult with the patientCs ph"sician. SpeaAing with a +amil"
mem0er ma" 0e help+ul, and i+ necessar" consult with another dentist.
Application o+ the 9indings Decide whether or not it is possi0le to success+ull" construct a set o+
dentures +or the patient. Plan +or the emotional and ph"sical needs o+ the patient.
Summar" 8ather in+ormation and 0ase the treatment plan on that in+ormation. The o0=ectives
are to evaluate the patient emotionall" and ph"sicall" and let the patient evaluate the doctor.
5ommunication is the 0asic tool in the interview and can 0e encouraged 0" esta0lishing trust.
This in+ormation must 0e o0tained to plan the 0est possi0le treatment +or the complete denture
patient.
02-002. House, '. he (e!ationship o) *ra! +,a$ination to Denta! Diagnosis. - Prosthet
Dent, .o! / 101/, 20/-10.
Purpose To discuss the importance o+ per+orming a complete and thorough oral e,amination and
to present a s"stem o+ classi+"ing and accuratel" recording clinical +indings. The need to
care+ull" interpret and relate all data 0e+ore arriving at a +inal diagnosis is reviewed.
)aterials E )ethods .ased on authorCs e,perience, perceptions, and personal philosoph".
Fnre+erenced.
*esults A thorough dental e,amination includes the +ollowing >1? Personal !n+ormation, >2?
5hie+ 5omplaint, >$? Dental (G, >1? 2isual 7,amination, >%? 7,amination 4ith 7,plorer, >3?
Diagnostic 5asts, >'? Transillumination, >-? *adiographs, >&? )o0ilit" Assessment, >10? 2italit"
Tests, >11? Special )edH6a0 Tests P*/, and >12? Pre-e,traction *ecords.
To save time in recording o0servations and to +acilitate the e,amination o+ the edentulous
patient a numeric s"stem o+ classi+"ing 0iologic conditions is suggested using the numerals 1, 2,
and $. >1? is +avora0le or normal, >2? is less +avora0le or medium, and >$? is un+avora0le or poor.
.iologic +actors evaluated include the +ollowing >1? )uscle Tonus, >2? )uscle Development,
>$? Ph"sical SiDe o+ .on" Structure, >1? Arch 9orm >%? *idge *elations, >3? Ph"sical 9orm o+
*esidual *idge, >'? So+t Tissues, >-? .order Tissue, )uscle, and 9renum Attachments, >&?
*etromolar Area, >10? Palatal Throat 9orm, >11? Saliva, >12? Tongue 9orm, >1$? Alveolar
*esorption, >11? Sensitivit" o+ Palate, >1%? Iualit" o+ .one, and >13? 5ondition o+ )ucosa
5onclusion !t is essential that a comprehensive e,amination with an accurate recording o+
+indings and care+ul anal"sis o+ those +indings alwa"s precede a prosthodontic diagnosis and
treatment plan
02-002. Baseheart, J.R., Nonverbal Communication in the Dentist-
Patient Relationship. J Prosthet Dent Vol 34, 1!", 4-1#.
Purpose: Discuss the signifcance of environment, personal space, touching,
and physical behaviors on dentist-patient interaction.
Materials & Methods: Literature revie.
!esults: Dentist-patient interaction can be altered depending on the dentist"s
aareness and response to non-verbal clues.
02-003. 4arone, -... Diagnosis and Prognosis in 5o$p!ete Denture Prosthesis. - Prosthet
Dent 1063713:208-12.
.e+ore denture construction is 0egun it is vital that a diagnosis and then a prognosis 0e made.
Diagnosis:
1. (ealth histor" >clinical interview? The patient is interviewed to determine past medical
and dental e,periences. A list o+ suggested :uestions is given and the impact that the
answers ma" have on the treatment and prognosis is discussed.
2. 5linical e,amination The patient and his e,isting dentures >i+ he has an"? are e,amined
and note is taAen o+ the esthetics, +acial e,pression, +acial vertical dimension, centric
relation, centric occlusion, speech, sta0ilit", retention. Shortcomings +ound in the old
dentures are e,plained to the patient. Stretching e,ercises are prescri0ed to +acilitate 5*
registration at a later appointment.
$. !ntraoral e,amination /ote throat +orm, tongue position, siDe, and shape, character o+
saliva, character o+ the ridge and so+t tissue, ridge relationship, position o+ muscle and
+renum attachments, interarch space, pathosis, as"mmetr" and height o+ lip line.
*adiographs are taAen, as are diagnostic casts >in duplicate? +or later stud".
Prognosis A+ter all the in+ormation collected at the +irst visit is evaluated, the patient returns +or
the second visit. (e is given the prognosis and an e,planation o+ 0one ph"siolog" o+ the
edentulous ridge and patient adapta0ilit" is given in la" terms.
Iuotation o+ the +ee @nl" a+ter diagnosis and estimate o+ prognosis is complete, is the +ee
discussed with the patient. The +ee should re+lect the pro=ected time, care, sAill, and =udgement
that will 0e used in the treatment o+ the patient.
02-001. Koper, A. 9h& Dentures :ai!. D5;A /:821-823, 1063.
!ntroduction The patient is chie+l" responsi0le +or the success o+ the e++ort. /o positive criteria
+or success o+ denture +a0rication are valid +or ever"one. 9re:uentl" a case will 0e unsatis+actor"
+or a patient +or no discerni0le cause. 9or twelve "ears, the 6os Angles 5ount" Dental Societ"
processed over 2,%00 written complaints +rom patients. '0 percent o+ which involved complete
dentures. )an" were =usti+ied in their complaints 0ecause certain +undamentals o+ denture
construction had 0een disregarded in the +a0rication o+ their dentures. There were also numerous
unhapp" denture wearers who appeared +or e,amination with well constructed dentures.
5riteria +or 7valuating Denture 9ailures An unsuccess+ul denture is one which +ails to +ul+ill
an" or all o+ the +ollowing criteria 1. *estore lost natural dentition and associated structures o+
the ma,illae or mandi0le. 2. maintain health o+ the tissues o+ the mouth. $. help to restore
+unction, phonetics, and esthetics. 1. 0e com+orta0le
@+ greater importance are the +ailures o+ which the patient ma" not 0e aware o+, such as
dentures which violate certain 0asic principles o+ denture construction, which ma" permanentl"
damage the supporting oral structures. This article will discuss some o+ the sources o+ error in
denture construction and o++er certain suggestions.
!. !nade:uate Patient 7valuation The most +re:uent points o+ +ailure.
- 9ailure to recogniDe the ps"chological limitations imposed 0" the patient
1. )an" cannot accept the realit" o+ dentures
2. The" ma" have emotional pro0lems which inter+ere with their adaptive capa0ilities.
7,amples are clenchers, grinders, gaggers, oversalivation, those whose mouths 0ecome dr" when
the" wear dentures.
- 9ailure to identi+" the ph"sical limitations o+ the patient
1. Structural a0normalities - resor0ed alveolar ridges, diminutive ma,illa or mandi0le,
tu0erosities, tori e,ostosis, a massive or h"peractive tongue, vi0rating line position ma"
0e more anterior and restrict denture space.
2. S"stemic illness - is re+lected in the tissues o+ the mouth 0" poor tone, low pain threshold,
slow healing, sensitivities, and allergies.
$. 6acA o+ neuromuscular coordination - maAes man" steps o+ denture construction di++icult,
later these patients +ind it di++icult to adapt to dentures.
1. Postsurgical and radiation Se:uelae - man" have swallowing and speaAing di++iculties
which maAe it harder to cope with dentures. *adiation o+ tissues causes pain , sloughing,
and slow repair.
!!. 9ailure o+ the dentist to understand his own limitations
The two most common are
A. interpersonal emotional con+licts
.. insu++icient pro+essional sAill.
- 9ailure to prepare the patient +or dentures Preparation o+ the patient +or dentures is as
important as construction o+ the dentures themselves
1. Ph"sical preparation o+ the patient - tu0erosities, 0on" overgrowths, sharp 0on" spicules
2. 7motional preparation o+ the patient - tr" to determine what dentures mean to the patient,
0ecause the mouth is one o+ the most emotionall" charged areas o+ the 0od".
$. 6imiting the e,pectations o+ the patient - the most universal anticipations are
"outh+ulness and the a0ilit" to use dentures liAe the teeth the" once had.
- 9ailure to o0tain understanding and acceptance o+ the treatment plan and +ee - schedule an
Be,planation and arrangementsB session . De+ine the e,tent o+ services and the time period. The
+ee and method o+ pa"ment should 0e agreed upon. A letter o+ con+irmation addressing the a0ove
issues should 0e sent i+ the spouse is not present. Place an outline in the patients chart and have
them sign it.
!2. 7rrors in denture construction most +re:uent errors are +reewa" space, occlusion, improper
peripheral e,tension, poor adaptation o+ denture 0ase to tissues, poor esthetics.
2. 9ailure to seeA consultation when indicated
consultant should e,amine the patient in the o++ice o+ the doctor re:uesting the consult
consult should 0e returned in writing
patient ma" receive reassurance +rom a third part"
2!. 6acA o+ proper a+tercare it occasionall" happens that more time is spent with the patient
a+ter the dentures are completed than during the construction. 4hen such a contingenc" is
planned +or, no pro0lem occurs. /othing should 0e done that would alter the dentures in such a
wa" as to maAe them unaccepta0le +rom the standpoint o+ good denture construction practices.
Summar" Denture +ailure causes are +re:uentl" due to human +actors as lacA o+ patient
evaluation, emotionall" distur0ed patients, and patients with ph"sical handicaps. The dentist
must Anow his reactions to his patients and Anow his limitations as a therapist. S"stemic and oral
corrective procedures should 0e instituted. Patient e,pectations o+ the dentures discussed.
Treatment plan and +ee agreed upon. 9ul+ill 0asic standards o+ denture construction. 8ive proper
a+ter care.
02-006. 4o!ender, 5.<., S#oope, 5.5. and S$ith, D.+. he 5orne!! 'edica! %nde, as a
prognostic aid )or co$p!ete denture patients.
Purpose To assess the value o+ utiliDing the 5ornell )edical !nde, >5)!? as a method o+
identi+"ing pro0lem denture patients 0e+ore 0eginning treatment.
)aterials and )ethods %13 complete denture patients treated 0" =unior dental students and 21
patients treated 0" the author were administered the 5)! as part o+ the comprehensive
evaluation. The 5)! consist o+ +our pages the +irst three pages evaluate the ph"sical health and
the +ourth page evaluates the emotional health o+ the patient. Three or more B"esB responses on
page +our indicate the patient ma" 0e a potential pro0lem, while seven or more B"esB responses
would normall" preclude them +rom 0eing treated in the Dental school. 12 patients with a page
+our score o+ seven or more were included in the stud" and the liAelihood o+ there 0eing a
pro0lem was discussed with the patient prior to treatment. Surve"s were mailed to the patients
+ollowing treatment allowing them to rate the :ualit" o+ the dentures >si, categories with a
possi0le high score o+ 1- and a low score o+ si,? and indicate the num0er o+ postinsertion
appointments. Three postinsertion visits are re:uired +or the student to get credit +or the denture.
102 :uestioners were returned.
*esults Post insertion visits ranged +rom 0-13 with a mean o+ $.-' +or men and $.&- +or women.
The mean patient satis+action scores were as +ollows 13.$ +or those who had 0-2 positive
responses on page +our o+ the 5)!, 1%.- +or those who had $-3 positive responses on page +our
o+ the 5)!, and 13.1 +or those who had seven or more positive responses on the 5)!. 9or those
who had an overall 5)! score o+ 0-21 the mean patient satis+action score was 13.2, and +or
overall 5)! scores o+ 2% or greater the patient satis+action score was 1%.&.
5onclusions The is no correlation 0etween 5)! scores and postoperative visits. A de+inite
correlation e,ist 0etween an overall 5)! score o+ 2% or greater or a page +our 5)! score o+ $-3,
and a decrease in patient satis+action. There is evidence to support the value o+ education +or high
page +our 5)! scores concerning the relationship o+ emotional pro0lems and denture pro0lems.
02-008. 4erg$an, 4. and 5ar!sson, =.+. 5!inica! <ong-er$ Stud& o) 5o$p!ete Denture
9earers. - Prosthet Dent 12:16-61, 10/1.
Purpose To present clinical +indings in a group o+ patients who received complete dentures +or
one or 0oth =aws 21 "ears ago and to put +orward some o+ their opinions.
)aterials E )ethods $2 patients were e,amined 0" :uestionnaire and clinical and radiographic
e,amination.
*esults Denture +unction was assessed in general as ver" good or +airl" good 0" the patients, 0ut
a0out hal+ o+ the su0=ects also +elt that the dentures needed some attention. The patients generall"
had a high evaluation o+ their chewing a0ilit". The denture :ualit" and tissue health were +ar
+rom optimum according to prosthodontic criteria. ." overall =udgement, 11 patients needed new
dentures and 3 needed relining, occlusal ad=ustment, or repair. Tracing o+ cephalometric
radiographs showed wide variations in 0one resorption among patients.
5onclusion The +unctional state o+ the masticator" s"stem, 0oth according to patient reports and
the clinical signs, were generall" good compared with previousl" pu0lished epidemiologic
studies. *PDCs and overdentures are a valua0le treatment +or patients who can not adapt well to
complete dentures. 6ow +re:uenc" o+ mandi0ular dis+unction was pro0a0l" related to the good
adaptation to wearing dentures +ound in most o+ the group studied.

02-00/. (issin, :e!d$an, Kapur and 5haunce&. Si,->ear (eport o) the Periodonta! Hea!th
o) :i,ed and (e$o"ab!e Partia! Denture Abut$ent eeth. - Prosthet Dent 13, 3, *ct. 10/1.
Purpose 6ongitudinal studies indicate that +i,ed and remova0le partial dentures have 0een
associated with increased gingivitis, periodontitis, and tooth mo0ilit". !t has also 0een
demonstrated that with the proper oral h"giene, minimal periodontal changes develop around
a0utment teeth. Although +i,ed or remova0le partial dentures ma" in+luence the periodontal
health o+ the a0utment teeth, no studies have directl" compared the two +or their e++ects on the
periodontium.
)aterials E )ethods The data was collected +rom a comple, series o+ dental e,aminations o+
1221 health" men 0etween the ages o+ $0 and -0. The e,aminations were repeated at $-"ear
intervals. Teeth supporting +i,ed partial dentures, remova0le partial dentures, and analogous
unrestored edentulous ridges were scored and recorded +or si, measures o+ periodontal health
including pla:ue accumulation, calculus deposition, gingival in+lammation, periodontal pocAet
depth, alveolar 0one lose, and tooth mo0ilit". 7,aminer 0ias and relia0ilit" were determined at
the onset 0" comparing the e,aminerCs results with data +rom other trained investigators.
*esults Although 3-0 partiall" edentulous ma,illar" or mandi0ular :uadrants were initiall"
e,amined, comprehensive longitudinal in+ormation was availa0le +or 2$- :uadrants. The
longitudinal anal"sis o+ 2$- :uadrants, spanning 3 "ears, included 1-% persons with a missing
tooth and no prosthesis, 2% individuals with a remova0le partial denture, and 2- participants with
a +i,ed partial denture.
The longitudinal e++ects o+ the +i,ed or remova0le partial dentures on the periodontium were
similar. There were minimal di++erences noted +or pla:ue accumulation, gingival in+lammation,
and pocAet depth. An increased rate o+ pla:ue accumulation was noted a+ter 3 "ears on the +i,ed
partial denture distal a0utment teeth. *eplacing missing teeth reduced mo0ilit" o+ the a0utment
teeth.
5onclusion 9i,ed and remova0le partial dentures provide long-term periodontal health and
should 0e considered +or the restoration o+ a partiall" edentulous arch. *egardless o+ treatment
modalit", conscientious home care and pro+essional proph"la,is are recommended.
02-000. -ohnson, P.:., a&bos, =.'., and =risius, (.-. Prosthodontics. Diagnostic,
treat$ent p!anning, and prognostic considerations. Dent 5!in ;orth A$. 20:102-11/, 10/6.
Purpose Discussion o+ diagnostic, treatment planning, and prognostic considerations +or
Prosthodontic patient.
)aterials and )ethods @0servation and investigation o+ those conditions needing treatment.
• Diagnosis: The Prosthodontic Patient - compromised condition caused 0" disease or
trauma causing tooth loss. 7,pectations o+ the patientJs esthetic and +unctional
re:uirements. Attitude o+ the patient toward prosthodontic care, i.e. +ear or resentment.
• Specia! considerations )or the Prosthodontic Patient: Aging population have uni:ue
re:uirements. Diminished neural and muscular +unction, decrease sensor" and mental
capa0ilities. Depletion o+ su0cutaneous adipose tissue, loss o+ muscle tone, decrease o+
dermal elasticit", increased loss o+ periodontal attachment and increased crown length.
• Diseases a))ecting treat$ent: S"stemic disease - cardiac and pulmonar" a++ect length o+
appointment. Dia0etes a++ects tissue health. Arthritis and ParAinsonJs disease a++ect
a0ilit" to remove prosthesis and h"giene. )ucosal disease, pathosis, and nutritional
disorders a++ects treatment.
• reat$ent P!anning: 5hoice o+ prosthesis +or each tooth or arch. Selection o+ corrective
and augmentive procedure needed. Selection o+ appropriate materials, design o+ the
prosthesis occlusal scheme, and t"pe o+ articulator needed. Diagnostic 4a, Fp allows
visualiDation o+ the +inal esthetics, anticipate pro0lems utiliDed to maAe vacu+orm splints
+or reduction guides and provisionals.
• reat$ent choice: 9i,ed restorations pre+erred with short edentulous spaces, ade:uate
periodontal support, su++icient coronal structure, ade:uate clearance. *emova0le
restorations pre+erred with increased edentulous spaces, length, periodontal weaAened
teeth, weaA terminal a0utments, mo0ilit" o+ teeth, lacA o+ inter-ridge distance, loss o+
tissue in edentulous area. 7sthetic clasping +or *PDJs using attachments, retentive tissue
0ar, a rotational or dual path *PD.
• *"erdenture Abut$ents Ad"antages: !mproves crown to root ratio, provides
proprioception, ps"chologic 0ene+its, preserves alveolar ridge, retention and sta0ilit".
• 'odi)&ing :actors to a reat$ent P!an: Alternative methods o+ treatment. !+ teeth are
non-restora0le how will it a++ect the treatment plan, T)D, implant therap".
*esults Accurate diagnosis and Anowledge o+ the patient, a thorough understanding o+ treatment
modalities and materials, all a++ect the outcome o+ a patientJs treatment.
5onclusion )ultiple 2aria0les maAe each treatment uni:ue.
02-010. 5haconas, Spiro -. and =onidis, De$itrios. A 5epha!o$etric echni?ue )or
Prosthodontic Diagnosis and reat$ent P!anning. he -ourna! o) Prosthetic Dentistr&, ;o"
10/6, .o! 16, ;u$ 1.
This article reviews the 0asic cephalometric landmarAs and anal"ses, and suggests a method o+
use +or complete denture patients.
Prosthodontic 5ephalometric Anal"sis
SAeletal criteria
1. )a,illar" depth >/A to 9(< K &0 degrees? +ig 1 gives an indication o+ the anteroposterior
position o+ the apical 0ase o+ the ma,illa relative to a horiDontal +acial plane >9(?.
• The angle is larger in a sAeletal class 2, ma,illa is protracted, conve, pro+ile.
• The angle is smaller than normal in a class $, ma,illa is retracted, concave pro+ile.
• !n class 2 or class $ patients, the denture teeth should 0e set with the appropriate
discrepanc" in the horiDontal overlap o+ the incisors.
2. )andi0ular depth >/Po to 9(< average K &0 degrees? +ig % the anteroposterior position o+ the
most anterior point o+ the mandi0le.
• A smaller than normal measurement is a class 2 retrognathic mandi0le.
• A larger than normal measurement is a class $ malocclusion, prognathic mandi0le
$. )a,illomandi0ular relationship >ma,illar" depth less mandi0ular depth? >average K 0 degree?.
• !n adult, the average ma,illar" and mandi0ular depth angles measure &0 degrees. A line
drawn +rom / to Po should pass through point A in a normal adult. This gives a straight
sAeletal and so+t tissue pro+ile >+ig 3 center?.
• A straight pro+ile is less pro0lematic in prosthodontic treatment 0ecause o+ the
harmonious relationship 0etween the ma,illa and mandi0le and the associated muscle
pressures against the dentition.
• !+ point A is anterior to /Po, the patients pro+ile is retrognathic, conve,, class 2 >+ig 3
le+t?.
• The denture teeth would 0e placed in a retrognathic relationship.
• !+ point A is posterior to the /Po line, the ma,illomandi0ular relationship is prognathic,
concave, class $ >+ig 3 right?.
• The denture teeth would 0e placed in a reverse la0iolingual relationship to harmoniDe
with the sAeletal and muscle pattern o+ the patient.
)P angle >)PA? >)P to 9(< average K 2% degrees? >+ig. '?.
• This angle gives an indication o+ the vertical height o+ the mandi0ular ramus.
• This angle is larger in a class 2, div 1, 0ecause the mandi0le has not grown.
• This angle also aids in determining +acial t"pe >+ig -?.
6arger angle - dolicho+acial pattern >+ ig - c?. .ecause o+ the narrow nasal cavities and di++icult"
with nasal 0reathing, the patient will have mouth 0reathing tendencies. The" ma" thrust the
tongue +orward. The tongue thrust must 0e considered in setting the arti+icial teeth to produce
dentures that are sta0le and in harmon" with the neuromuscular +orces. This patient is usuall"
class 2 sAeletall", conve, +ace, sAeletal open 0ite, and the denture teeth should 0e set with the
appropriate horiDontal overlap o+ the incisors. This patient will 0e the most di++icult to treat in
most instances.
6ower angle - 0rach"+acial is associated with a class 2, div 2 t"pe o+ sAeletal malocclusion >+ig -
a?.
The masseter muscle activit" is stronger than normal, resulting in the potential +or more soreness
0eneath dentures. This patient is predisposed to T)# disease 0ecause the mandi0le has a
tendenc" to overclose causing muscle spasm. There+ore it is important to achieve correct vertical
dimension with the occlusal plane as close to the center o+ the ramus as possi0le to insure proper
mandi0ular +unction..
6ower +ace height >A/S -LGi - P)< average K 1' degrees? >+ig &?.
• 6arger angle >dolicho+acial? indicates the presence o+ a sAeletal open 0ite.
• Smaller angle >0rach"+acial? indicates the presence o+ a deep 0ite.
• Determination o+ this angle is one o+ the most scienti+ic methods o+ determining the
correct vertical dimension. This measurement, along with phonetics and esthetics, is
help+ul in determining the divergence o+ the oral cavit" with regard to the vertical
ma,illomandi0ular relationship. This relationship aids in setting denture teeth and helps
the patient in preventing possi0le T)# pro0lems.
Dental 5riteria
1. @cclusal plane >average K -$.%mm to lip em0rasure? >+ig. 10?.
This is a linear measurement to determine the correct vertical position o+ the occlusal plane. The
negative average measurement indicates that the occlusal plane is 0elow the lip em0rasure. This
is important in setting teeth +or proper esthetics. The posterior level o+ the occlusal pane is
important +or mandi0ular +unction and the health o+ the temporomandi0ular structures. There is
strong clinical indication that T)# pro0lems occur when the posterior position o+ the occlusal
plane is the +urthest +rom the center o+ the ramus >Gi point?. There+ore the occlusal plane should
pass through the center o+ the ramus to ensure proper occlusal +unction. This plane will pass
through the superior hal+ o+ the retromolar pad clinicall".
)andi0ular incisor protruson >incisor to Apo< average K 1Mmm0 >+ig.11?.
This measurement determines the anteroposterior position o+ the incisal edge o+ the mandi0ular
central incisor relative to the point +rom line A on the ma,illa to Po on the mandi0le.!n as much
as the position o+ the APo line is an indication o+ the ma,illomandi0ular relationship, this
measurement relates the lower incisor to the ma,illa and mandi0le. 2erticall", the incisal edge o+
the mandi0ular incisor is placed appro,imatel" 1.2% mm a0ove the level o+ the occlusal plane.
The incisal edge o+ the ma,illar" incisor would then 0e placed 1.2% mm 0elow the level o+ the
occlusal plane, giving the patient a normal 2.% mm vertical overlap. !+ the patient is either a 5lass
2, div 1 or a 5lass $ malocclusion t"pe, the incisors are placed to represent an appropriate
amount o+ horiDontal overlap.
Set the incisal edge o+ the lower incisor 1 mm anterior to this A Po line. The position o+ this tooth
ma" 0e Ae" to the denture set up, and all o+ the remaining teeth might 0e positioned in a
s"stematic and almost e++ortless manner. (owever the relative degree o+ resorption o+ the
residual ridge and the need to 0alance tooth position with associated muscle +unction should also
0e considered +or complete denture sta0ilit".
Pro+ile anal"sis 7 line >lower lip to Pn-PoJ line< no average? >+ig 12?. This measurement relates
the lower lip to a line +rom the tip o+ the nose >Pn? to the tip o+ the so+t tissue o+ the chin >PoJ?.
Appearance is most estheticall" pleasing when the lips are relativel" close to the 7 line.
Summar" A review o+ cephalometric landmarAs has 0een discussed and related to the needs o+
complete denture +a0rication. A techni:ue +or use o+ the cephalogram in complete denture
+a0rication is presented.
02-011. 5u!pepper, 9i!!ia$ D. and 'ou!ton, Patricia S. 5onsiderations in :i,ed
Prosthodontics.
!ntroduction Preservation o+ the teeth, the supporting structures, and the residual ridges are the
chie+ concern when providing restorative treatment to the partiall" edentulous patient. Success or
+ailure will 0e in+luenced 0" diagnosis and treatment planning, se:uence o+ treatment, and
patient education. 5ommunication should not 0e neglected.
7ssentials +or Treatment Planning !n addition to the complete oral and e,traoral e,amination the
dentist should review a complete medical histor". A past dental histor" is also help+ul. 9ull
mouth radiographs provide much in+ormation, as well diagnostic cast mounted on an ad=usta0le
articulator.
5oordination o+ Treatment Se:uencing treatment correctl" and utiliDing the other specialties as
indicated will help achieve success. 7ndodontic treatment should 0e completed as necessar" and
the teeth rein+orced to protect them during the restorative phase. Periodontal treatment should 0e
per+ormed to achieve a more predicta0le prognosis. Preprosthetic surger" can 0e completed with
the periodontal therap". @rthodontic care will provide a more predicta0le clinical result.
According to .rehn, teeth which are tipped more than 2% degrees should never 0e utiliDed as an
a0utment. During the restorative phase reevaluate tentative a0utments, speci+icall" tooth mo0ilit"
and crown to root ratio. *eevaluate the occlusion and complete all operative procedures and
caries control prior to 0eginning prosthodontic treatment.
Preparation Design +or A0utment Teeth The preparation design must satis+" the criteria +or the
+i,ed restoration and remova0le prosthesis. Place margins supragingival i+ possi0le. 5aries,
e,isting restorations, short clinical crowns, and esthetic demands ma" necessitate the placement
o+ su0gingival margins. *easons +or restoring a0utment teeth with crowns include e,tensive
deca", large or unservicea0le restorations that should 0e replaced, lacA o+ a naturall" occurring
undercut, or anterior teeth designated +or cingulum rest. The amount o+ reduction should allow
+or the placement o+ rest seats in the crown. 7nsure space e,ist +or the minor connector. A
vacuum +ormed tra" is an e,cellent aid in evaluating reduction. !+ possi0le the line o+ draw +or
the a0utment crown should 0e di++erent +rom the path o+ placement o+ the remova0le partial
denture.
*estoration o+ a 5rown to an e,isting *emoval Partial Denture 5lasp @ccasionall" an a0utment
crown must 0e remade. A techni:ue is presented that recommends +a0ricating an acr"lic coping
over the die, then adding acr"lic to the coping while seated in the mouth with the partial denture
in place to esta0lish the contours under the clasp and rest seat in acr"lic. The remaining contours
and occlusal morpholog" is then completed in wa,, and the crown is +a0ricated in the usual
manner.
FtiliDation o+ )ultiple A0utments @ccasionall" splinting a0utment teeth is necessar". 7,amples
include teeth with loss o+ periodontal support or a lower premolar with a small cone shaped root.
The rational o+ splinting is to improve support, sta0ilit" and +unction. )c5racAen has stated a
lone standing tooth has a more +avora0le prognosis i+ it is splinted to another tooth 0" a +i,ed
0ridge. Periodontal health must not 0e compromised and ample em0rasure space must 0e present
to allow +or proper home care.
Summar" The success o+ remova0le partial denture prosthodontics depends on planning and
coordination o+ treatment. 9i,ed restorations are o+ten the +oundation on which remova0le partial
dentures are constructed, and their contri0ution to the overall success cannot 0e minimiDed.
02-012. <anda, <.S. Diagnosis and 'anage$ent o) Partia!!& +dentu!ous 5ases #ith a
'ini$a! ;u$ber o) (e$aining eeth. D5;A .o!. 20, ;o. 1, -an 10/1.
Purpose To discuss the possi0le solutions to situations in which two, three, or +our teeth remain
in an arch with relativel" poor strategic location. The" usuall" are in less than per+ect periodontal
health and are +re:uentl" in supraocclusion.
4ith the introduction and classi+ication o+ the use o+ man" t"pes o+ intracoronal and
e,tracoronal retainers, remaining teeth can +re:uentl" 0e saved.
)ount diagnostic casts on a semiad=usta0le articulator. FtiliDe occlusion rims where
necessar". *ecord the centric relation record at the given 2D@.
As patients loose teeth over the "ears, +re:uentl" with shi+ting o+ teeth, there is greater than
usual discrepanc" 0etween 5* and 5@. !+ the patient has 0een partiall" edentulous +or a long
period o+ time and has one or more teeth added to an e,isting prosthesis, there ma" also 0e some
+laring o+ anteriors and a slight decrease in vertical dimension.
!deall", centric relation should coincide with centric occlusion, the greater num0er o+
arti+icial teeth in the prosthesis, the more liAel" it is to achieve this ideal. 5onversel", i+ there are
numerous natural teeth with steep cusps or guidance, >posterior or anterior?, it ma" 0e necessar"
to provide treatment in a BconvenienceB relationship.
Anterior *egion
7,. Si, mandi0ular anteriors >+ig 1?.
T, 1. splinting and utiliDing precision or semiprecision attachments is accepta0le, with good
0one and periodontal support. 2. i+ no restorations are to 0e made in the anterior region and the
canine contours are ade:uate, the use o+ conventional circum+erential clasps, with indirect
retention is indicated. $. a swing locA retainer is also indicated.
)andi0ular Anterior *egion .ilateral
*emova0le partial dentures can 0e retained on two +reestanding canines in the mandi0le 0"
• clasp retainers, circum+erential or *P!-t"pe.
• splinting with pontics or a 0ar 0etween teeth and clasps.
• splinting with intracoronal retainers.
• splintng with e,tracoronal retainers.
• overdentures
• over amalgam class 1 restorations
• over individual copings
• over post copings splinted 0" means o+ a 0ar.
The +ollowing 0ars can 0e used
• a round 0ar with one or more clasps
• an ovoid with its retaining mechanism
• a 0ar +a0ricated 0" a technician, cast +rom a wa, +orm . This is utiliDed when no clip or
other +emale t"pe mechanism will 0e used to anchor the overdenture to the 0ar. The
+unction o+ the 0ar is purel" +or its splinting e++ect. A 0ar without clips is used when there
is too little occlusogingival height, it serves to help in anterioposterior sta0ilit". 5ross
arch splinting o+ the canines helps to increase their longevit", which helps maintain
mandi0ular anterior 0one.
Fnilateral
!n situations where a central, lateral, and canine or lateral and canine on the same side remain,
the options are more limited >+ig '?.
!t is possi0le to use clasps or rests >incisal, cingulum? 20 degree +acets, or reciprocating
lingual rests. !t is +re:uentl" advisa0le to use a lingual plate in these situations. Some
practitioners splint, using intracoronal attachments to avoid showing clasps. These patients are
0etter to have an overdenture, with or without attachments. !+ a clip is used , maAe certain that it
lines up with the a,is o+ rotation, and not the line =oining the centers o+ the teeth. !+ there is room,
a 5eAa, 0utton, stud or other simple movement attachment is pre+erred. Ade:uate room is
+re:uentl" a pro0lem in this location, and it is 0etter to sacri+ice retention 0" a clip or other
device in +avor o+ a simple overdenture. The simple overdenture creates less stress on the roots,
which will pro0a0l" result in retaining the roots and alveolar 0one longer.
)a,illar" Anterior *egion
4hen teeth remain on 0oth sides o+ the midline, man" o+ the comments are the same i+ +ive or
si, teeth are to 0e splinted. !+ canines are short, use precision attachments rather than
semiprecision attachments 0ecause the +rictional retention +rom opposing parallel walls is
compromised owing to the wall on the palatal side 0eing shorter than on the la0ial side, and 0oth
walls diverging >+ig -?. This is due to the curvature o+ the lingual anatom" o+ ma,illar" canines.
The indirect retention 0" a precision or semiprecision attachment is e,cellent.
A semiprecision +its less well, the male is cast usuall" +rom co0alt chromium allo" that will
wear the +emale crown. This slow wear and nonparallel walls provide a less stress to a0utments.
!t is recommended that a lingual clasp arm 0e utiliDed with 0oth precision and semiprecision
attachments.
4hen two ma,illar" canines remain, there are two choices
- the" ma" 0e utiliDed as +ree standing canines using rests and conventional
circum+erential clasps or an *P! design.
- anterior pontics or a 0ar +or cross-arch splinting
- the 0ar +ollows the arch and is not utiliDed +or rotation or with an attachment.
!t is rarel" =usti+ied to retain one or two ma,illar" anterior roots +or an overdenture. The"
create an anterior 0ulge o+ the la0ial overdenture +lange, and maAe esthetics di++icult.
!t ma" 0e advantageous to save ma,illar" anterior roots +or an overdenture when ma,
complete dentures oppose a man partial denture with natural anterior teeth. This can result in
settling and rotation o+ 0oth prosthesis over time and a class $ relationship. A +la00",
h"pertrophic ma,illar" anterior ridge results. *etained ma, anterior roots would help preserve
the alveolar ridge.
Posterior *egion
!n the mandi0ular situation, the choice is +le,i0le >ad=usta0le? circum+erential clasps with
occlusal rests.
A single man molar can 0e retained on a temporar" 0asis in the transition to a complete denture.
!n the mandi0ular one molar case there is little need +or indirect retention, and gravit" is a
+avora0le +actor.
!n the ma,illar" arch, there are several considerations
• circum+erential clasps with occlusal rests, however there is little or no indirect retention
>sticA" +oods, gravit"?. The +ulcrum line is 0etween the occlusal rests o+ the molars. The
onl" wa" to get indirect retention is to e,tend the ma, denture 0ase posterior to this
+ulcrum line.
• when crowns are +a0ricated, use mesial semiprecision rests with +le,i0le lingual arms.
There is no need +or posterior e,tension, indirect retention is provided 0" the depth o+ the
semiprecision attachment.
• it is advisa0le to e,tract a single ma, molar, gravit" is the enem", it is ne,t to impossi0le
to achieve indirect retention on a single tooth. This tooth prevents peripheral seal.
Premolar region Patients who have one or two teeth in the mandi0le or ma,illa are +aced with a
class 1 lever s"stem acting around the rest on the teeth. This soon causes loosening and
premature loss o+ the teeth. These >and a single mandi0ular molar? are almost the onl" t"pes o+
cases that should 0e constructed as tissue 0orne cases without occlusal rests. 6ong guide planes
are placed on the lingual, mesial, and distal sur+aces. A hal+ round passive wrought wire clasp is
used on the 0uccal.
5anine and Two Premolars Fnilaterall"
- !n the ma,illa Splint with crowns, use semiprecision attachments. This will give +rictional
retention and indirect retention. 5over as much o+ the palate to resist occlusal +orces.
- !n the mandi0le Splinting and semiprecision attachments is not an option, 0ecause there is no
palate to resist occlusal +orces. !t is 0etter to institute endo, maAe copings with or without
attachments and treat the occlusion as one would with a set o+ complete dentures.
Summar" 4henever possi0le, the minimal num0er and simplest attachments should 0e used.
02-012. 9a!ton, .(. A en >ear <ongitudina! Stud& o) :i,ed Prosthodontics: 1. Protoco!
and Patient Pro)i!e. %nt - Prosthodont 10087 10:221-221.
Purpose !nitial report o+ a ten "ear stud" o+ all +i,ed Prosthodontic treatment per+ormed in a
specialist Prosthodontic practice in Australia.
)aterials and )ethods A total o+ $11 patients with 111 treatment episodes which included '3-
crowns and $13 +i,ed partial dentures occurring 0etween #anuar" 1&-$ and Decem0er 1&&2. All
treatment provided 0" author with standardiDed management protocol +ollowed throughout the
treatment period. 5ases were mounted on arcon articulators and the same commercial la0orator"
+a0ricated all the restorations. @cclusal design 0ilateral contacts and centric, anterior
disocclusion, 0alancing contacts eliminated, occlusal plane +lat as possi0le. @utcome o+
treatment separated into categories success+ul >no retreatment?, surviving >re+erring dentist
con+irmed no retreatment?, unAnown, dead, retreatmentHrepaired >original marginal integrit"
intact?, and retreatmentH+ailed >part or all o+ prosthesis lost?. )inimum time 0etween review and
patient treatment was 12 months.
*esults The $11 patients ranged in age +rom 1$ to '1 "ears with 3$N +emale and $'N male.
There was an -1.%N recall rate +or this stud". The reasons the patients re:uested treatment were
esthetics >13N?, improved +unction >22N?, and replacement o+ *PDJs >22N?. T)D s"mptoms
+ound in 1$N prior to restoration with -1N +emale. 2N developed s"mptoms a+ter treatment.
@cclusal vertical dimension increased in 2$N. .ecause a re+erral 0ased Prosthodontic practice
concentrates on di++icult and +ailed restorations, mean service time o+ +ailed restorations was
eight "ears. Per+oration o+ a prosthesis +or root canal therap" was not considered in the
retreatment categor". -.%N o+ prosthesis re:uired retreatment over the surve" period, $N were
a0le to 0e repaired, and %.%N +ailed.
5onclusion An Australian Prosthodontist conducted a 10 "ear stud" o+ +i,ed prosthodontic
treatment in his practice with -1.%N recall rate. -.%N o+ treatment episodes re:uired some +orm
o+ retreatment. %.%N +ailed and $N were a0le to 0e repaired. 9emales sought treatment 2 to 1
over males. 7sthetic desires was the most common reason +or patients seeAing crowns and +ailed
prosthesis was the predominant reason +or seeAing 9PDJs.