1.Presented by: Dr . Azeem khan MDS 2nd year

2. INTRODUCTIONINTRODUCTION A meaningful treatment embodiesA meaningful treatment embodies four different processes:four different processes: 1.1. Ascertaining a patients dentalAscertaining a patients dental needs.needs. 2.2. Relating the patients desires orRelating the patients desires or wants to needs.wants to needs. 3.3. Developing a treatment plan relevantDeveloping a treatment plan relevant to these wants and needs, andto these wants and needs, and 4.4. Executing the treatment.Executing the treatment. 3. OBJECTIVES OF PROSTHODONTIC TREAMENTOBJECTIVES OF PROSTHODONTIC TREAMENT 1.1. Elimination of the disease.Elimination of the disease. 2.2. The preservation of the health and relationshipThe preservation of the health and relationship of teeth and the health of the remaining oralof teeth and the health of the remaining oral tissues, which will enhance the removabletissues, which will enhance the removable partial denture design, andpartial denture design, and 3.3. The selected replacement of lost teeth and theThe selected replacement of lost teeth and the restoration of function in an esthetically pleasingrestoration of function in an esthetically pleasing manner.manner. 4. Diagnosis and Treatment Planning for oralDiagnosis and Treatment Planning for oral rehabilitation must take into consideration somerehabilitation must take into consideration some or all of the following procedures:or all of the following procedures: 1.1. The establishment of good periodontalThe establishment of good periodontal health.health. 2.2. The restoration of individual teeth.The restoration of individual teeth. 3.3. The restoration of harmonius occlusalThe restoration of harmonius occlusal relationships.relationships. 4.4. The replacement of missing teeth by fixedThe replacement of missing teeth by fixed restorations.restorations. 5.5. The replacement of other missing teeth byThe replacement of other missing teeth by means of removable partial dentures.means of removable partial dentures. 5. Treatment plan should precede earlier treatment soTreatment plan should precede earlier treatment so that abutment teeth and other areas in the mouththat abutment teeth and other areas in the mouth can be prepared to support and retain the partialcan be prepared to support and retain the partial denture.denture. Diagnostics casts for designing and planningDiagnostics casts for designing and planning partial denture treatment must be made beforepartial denture treatment must be made before definitive treatment is undertaken.definitive treatment is undertaken. 6. Diagnosis is the determination of the natureDiagnosis is the determination of the nature of the disease.of the disease. Diagnosis can be classified as:Diagnosis can be classified as: A.A. Clinical diagnosisClinical diagnosis -- includes personalityincludes personality evaluation ,clinical examination andevaluation ,clinical examination and radiographic examinationradiographic examination.. B.B. Post clinical or derived diagnosisPost clinical or derived diagnosis -- dealsdeals with the evaluation of patients conditionwith the evaluation of patients condition using the diagnostic data collected duringusing the diagnostic data collected during the clinical diagnosisthe clinical diagnosis 7. IMPORTANCE OF DIAGNOSTIC PHASE OFIMPORTANCE OF DIAGNOSTIC PHASE OF TREATMENTTREATMENT Failure in RPD treatment can be traced to inadequate diagnosisFailure in RPD treatment can be traced to inadequate diagnosis and an incomplete treatment plan.and an incomplete treatment plan. Essential diagnostic data are obtained from a patientsEssential diagnostic data are obtained from a patients interview , radiographs , mounted and surveyed diagnosticinterview , radiographs , mounted and surveyed diagnostic casts, a definitive oral examination including periodontalcasts, a definitive oral examination including periodontal probing, percussion , vitality tests and consultations withprobing, percussion , vitality tests and consultations with medical and dental specialists when appropriate.medical and dental specialists when appropriate. 8. ORGANIZING THE EXAMINATIONORGANIZING THE EXAMINATION A.A. Health questionnaire-to assess the patientsHealth questionnaire-to assess the patients general health.general health. B.B. Patients interview Patients interview i.i. Establishing a rapport.Establishing a rapport. ii.ii. Gaining insight into psychological makeup of theGaining insight into psychological makeup of the patient-patient- In 1950 Dr. M M House classified patientsIn 1950 Dr. M M House classified patients into the following four psychological type :into the following four psychological type : PhilosophicalPhilosophical ExactingExacting HystericalHysterical IndifferentIndifferent 9. OShea et alOShea et al characterized ideal dental patient as :characterized ideal dental patient as : compliant ,sophisticated and responsive.compliant ,sophisticated and responsive. WinklerWinkler described traits that characterized the idealdescribed traits that characterized the ideal patients response:patients response: Realizes the need for the prosthetic treatment.Realizes the need for the prosthetic treatment. Wants the prosthesis.Wants the prosthesis. Accepts the prosthesis.Accepts the prosthesis. Attempts to use the prosthesis.Attempts to use the prosthesis. WHY THE HOUSE CLASSIFICATION REQUIRESWHY THE HOUSE CLASSIFICATION REQUIRES REEVALUATION?REEVALUATION? Terminology is antiquated, falling out of use, noTerminology is antiquated, falling out of use, no longer carries the same meaning within psychiatry.longer carries the same meaning within psychiatry. The classification pertains to the patients inThe classification pertains to the patients in isolation.isolation. 10. PROPOSED CLASSIFICATIONPROPOSED CLASSIFICATION INDIVIDUAL ADAPTATION TO THE ROLE OF PATIENTINDIVIDUAL ADAPTATION TO THE ROLE OF PATIENT The proposed classification is based on 2 factors:The proposed classification is based on 2 factors: 1.1. The level and quality of the engagement orThe level and quality of the engagement or involvement of the patient toward the dentistinvolvement of the patient toward the dentist {including issues as domination, submission,{including issues as domination, submission, idealization and devaluation of the dentist }idealization and devaluation of the dentist } 2.2. The level of willingness to submit (trust) to theThe level of willingness to submit (trust) to the dentist.dentist. Patient type:Patient type: IDEAL, SUBMITTER , RELUCTANT ,IDEAL, SUBMITTER , RELUCTANT , INDIFFERENT , RESISTANT.INDIFFERENT , RESISTANT. 11. IDEAL a patient who accepts whatever treatment isIDEAL a patient who accepts whatever treatment is given to him by the dentist but after his query hasgiven to him by the dentist but after his query has been answered. He is engaged in his treatment andbeen answered. He is engaged in his treatment and trusts the dentist.trusts the dentist. SUBMITTER a patient who submits to what theSUBMITTER a patient who submits to what the dentist says without any questions asked.dentist says without any questions asked. RELUCTANT a patient who feels that no person canRELUCTANT a patient who feels that no person can help him and reluctantly follows instructions.help him and reluctantly follows instructions. INDIFFERENT a patient who is not engaged in theINDIFFERENT a patient who is not engaged in the treatment and does not follow the dentiststreatment and does not follow the dentists instructions.instructions. RESISTANT a patient who challenges the dentistRESISTANT a patient who challenges the dentist and feels that the dentist is incompetent and willand feels that the dentist is incompetent and will cheat him.cheat him. 12. iii.iii. Evaluating effect of physical problems onEvaluating effect of physical problems on treatmenttreatment Systemic disturbances can have significance:Systemic disturbances can have significance: DiabetesDiabetes-- small oral abscesses and poor tissue tone.small oral abscesses and poor tissue tone. - reduced salivary output which reduces the ability of- reduced salivary output which reduces the ability of patient to wear prosthesis.patient to wear prosthesis. ArthritisArthritis changes in the TMJ , jaw relation record can be difficult.changes in the TMJ , jaw relation record can be difficult. Pagets diseasePagets disease patients may have enlargement of maxillarypatients may have enlargement of maxillary tuberosities.tuberosities. AcromegalyAcromegaly-- patients may have enlargement of the mandiblepatients may have enlargement of the mandible.. 13. Parkinsons diseaseParkinsons disease patient has severe rhythmic contractionspatient has severe rhythmic contractions of the muscles which prevents the patient to insert andof the muscles which prevents the patient to insert and remove RPD. Impressions are compromised due to excessiveremove RPD. Impressions are compromised due to excessive amount of saliva.amount of saliva. Pemphigus vulgarisPemphigus vulgaris disease begins with formation of bullae indisease begins with formation of bullae in the oral cavity. Symptoms are painful oral cavity and dryness ofthe oral cavity. Symptoms are painful oral cavity and dryness of the mouth.the mouth. EpilepsyEpilepsy a grand mal seizure may result in the fracture anda grand mal seizure may result in the fracture and aspiration of the prosthesis.If the patient is on Dilantin sodiumaspiration of the prosthesis.If the patient is on Dilantin sodium then care should be taken that the RPD should not irritate thethen care should be taken that the RPD should not irritate the gingival tissues.gingival tissues. Cancer-Cancer- oral symptoms are effects of radiation and chemotherapyoral symptoms are effects of radiation and chemotherapy which include mucosal irritations, xerostomia and bacterial andwhich include mucosal irritations, xerostomia and bacterial and fungal infections which will complicate the construction andfungal infections which will complicate the construction and wear of the prosthesis.wear of the prosthesis. 14. XerostomiaXerostomia patients susceptibility to mucosalpatients susceptibility to mucosal ulcerations and fungal infections mayulcerations and fungal infections may increase due to decreased salivary flow.increase due to decreased salivary flow. iv.iv. Evaluating effects of drugs onEvaluating effects of drugs on treatmenttreatment IIncreasing age usually means an increase in:ncreasing age usually means an increase in: The need for some type of prosthodonticThe need for some type of prosthodontic treatment.treatment. The use of prescribed and over the counterThe use of prescribed and over the counter drugs.drugs. 15. Some of the frequently prescribed drugs that can affectSome of the frequently prescribed drugs that can affect prosthodontic treatment are :prosthodontic treatment are : 1.1. AnticoagulantsAnticoagulants: post surgical bleeding could be a: post surgical bleeding could be a problem for patients receiving anticoagulants whoproblem for patients receiving anticoagulants who undergo extractions or soft tissue or osseousundergo extractions or soft tissue or osseous surgery.surgery. 2.2. Antihypertensive drugsAntihypertensive drugs: side effect of: side effect of antihypertensive drugs is postural or orthostaticantihypertensive drugs is postural or orthostatic hypertension which may result in syncope whenhypertension which may result in syncope when patient assumes an upright position. The treatmentpatient assumes an upright position. The treatment for hypertension includes prescription of a diureticfor hypertension includes prescription of a diuretic agent , which can contribute to a decrease inagent , which can contribute to a decrease in saliva which is associated to dry mouth.saliva which is associated to dry mouth. 16. 3.3. Endocrine therapy :Endocrine therapy : patients may develop sorepatients may develop sore mouth, they may blame the prosthesis for causingmouth, they may blame the prosthesis for causing the discomfortthe discomfort.. 4.4. Saliva-inhibiting drugs :Saliva-inhibiting drugs : methantheline bromide ,methantheline bromide , atropine are used to control excessive saliva toatropine are used to control excessive saliva to make accurate impressions, these drugs shouldmake accurate impressions, these drugs should not be used for patients with cardiacnot be used for patients with cardiac diseases,prostatic hypertrophyand glaucoma.diseases,prostatic hypertrophyand glaucoma. AIDS FOR SUCCESSFUL INTERVIEW :AIDS FOR SUCCESSFUL INTERVIEW : a)a) Dentists attitude and behaviourDentists attitude and behaviour b)b) Phrasing of questionsPhrasing of questions c)c) Expectations of treatmentExpectations of treatment d)d) Questions from patient.Questions from patient. 17. Dentists attitude and behaviorDentists attitude and behavior a.a. Dentist should make eye contact with the patient ,Dentist should make eye contact with the patient , looking directly at the patient and displayinglooking directly at the patient and displaying complete attention rather than studyingcomplete attention rather than studying radiographs or writing.radiographs or writing. b.b. He should maintain a relaxed and attentiveHe should maintain a relaxed and attentive physical posture. The dentist should face thephysical posture. The dentist should face the patient , preferably at the same level and shouldpatient , preferably at the same level and should appear relaxed and unhurried.appear relaxed and unhurried. c.c. Dentist should employ appropriate head nodding ,Dentist should employ appropriate head nodding , verbal following and verbal reflection.verbal following and verbal reflection. 18. STRUCTURE OF INTERVIEWSTRUCTURE OF INTERVIEW i.i. DENTAL HISTORY:DENTAL HISTORY: Reason as to why teeth have been lost , and careReason as to why teeth have been lost , and care should be taken to preserve the remaining teeth byshould be taken to preserve the remaining teeth by improving patients oral hygiene and dietaryimproving patients oral hygiene and dietary intake.intake. If teeth have been lost due to periodontal disease ,If teeth have been lost due to periodontal disease , effort must be made to discover and eliminate theeffort must be made to discover and eliminate the cause.cause. ii.ii. DIET:DIET: Sugar and /or sugar containing products should beSugar and /or sugar containing products should be controlled if taken continuously throughout thecontrolled if taken continuously throughout the day as the prosthesis shields the microorganismsday as the prosthesis shields the microorganisms from the cleansing and buffering action offrom the cleansing and buffering action of patients saliva.patients saliva. 19. iii.iii. HABITS:HABITS: 1.1. Bruxism and clenchingBruxism and clenching 2.2. Tongue thrustingTongue thrusting PATIENTS PHYSICAL CHARACTERISTICS:PATIENTS PHYSICAL CHARACTERISTICS: If the patient has a speech problem , the problem should beIf the patient has a speech problem , the problem should be corrected and recognized as these patients require a longercorrected and recognized as these patients require a longer period to learn a good speech with new prosthesis.period to learn a good speech with new prosthesis. Some patients may exhibit poor coordination hence it willSome patients may exhibit poor coordination hence it will be difficult to maintain an adequate level of hygiene of thebe difficult to maintain an adequate level of hygiene of the oral cavity and prosthesis.oral cavity and prosthesis. Patients with short or highly mobile lips may be problematicPatients with short or highly mobile lips may be problematic as esthetics will be compromised as most or all of the claspas esthetics will be compromised as most or all of the clasp arms , denture borders , and other components will showarms , denture borders , and other components will show when the patient speaks or smiles.when the patient speaks or smiles. 20. Oral examination should precede anyOral examination should precede any mouth rehabilitation procedures andmouth rehabilitation procedures and should include :should include : 1.1. a visual and digital examination ofa visual and digital examination of the teeth and the surroundingthe teeth and the surrounding tissues with mouth mirror, explorer,tissues with mouth mirror, explorer, periodontal probe,periodontal probe, 2.2. a complete intraoral radiographica complete intraoral radiographic survey,survey, 3.3. vitality tests for critical teeth andvitality tests for critical teeth and 4.4. an examination of casts correctlyan examination of casts correctly oriented on an adjustable articulator.oriented on an adjustable articulator. 21. During examination it is important toDuring examination it is important to restore and maintain the remaining oralrestore and maintain the remaining oral structures in a state of healthstructures in a state of health The primary objectives are:The primary objectives are: It should include the prevention ofIt should include the prevention of tooth migration and the correction oftooth migration and the correction of traumatic influences.traumatic influences. Should consider the best method toShould consider the best method to restore lost function within the limits ofrestore lost function within the limits of tissue tolerance of the patient.tissue tolerance of the patient. To maintain or improve the appearance ofTo maintain or improve the appearance of the mouth.the mouth. 22. SEQUENCE OF ORAL EXAMINATIONSEQUENCE OF ORAL EXAMINATION I.I. Visual examinationVisual examination includesincludes looking for:looking for: caries susceptibiltycaries susceptibilty number of restored teethnumber of restored teeth evidence of decalcificationevidence of decalcification periodontal diseaseperiodontal disease gingival inflammationgingival inflammation gingival recessiongingival recession II.II. Relief of pain and discomfortRelief of pain and discomfort and placement of temporaryand placement of temporary restorations.restorations. 23. III.III. Complete intraoral radiographic surveyComplete intraoral radiographic survey Objectives of a radiographic examination are:Objectives of a radiographic examination are: 1.1. To locate areas of infection and other pathosisTo locate areas of infection and other pathosis that may be present.that may be present. 2. To reveal the presence of root2. To reveal the presence of root fragments,foreign objects, bone spicules andfragments,foreign objects, bone spicules and irregular ridge formations.irregular ridge formations. 3. To reveal the presence and extent of caries and3. To reveal the presence and extent of caries and the relation of carious lesions to the pulp.the relation of carious lesions to the pulp. 24. 4.4. To reveal the presence of root canalTo reveal the presence of root canal fillings and to permit their evaluation as tofillings and to permit their evaluation as to future prognosis.future prognosis. 5. To permit evaluation of existing5. To permit evaluation of existing restoration as to evidence of recurrentrestoration as to evidence of recurrent caries, marginal leakage and overhangingcaries, marginal leakage and overhanging gingival margins.gingival margins. 25. 6.6. To permit evaluation of periodontalTo permit evaluation of periodontal conditions present and to establish the needconditions present and to establish the need and possibilities for treatment.and possibilities for treatment. 7. To evaluate the alveolar support of abutment7. To evaluate the alveolar support of abutment tooth , their number , the supporting lengthtooth , their number , the supporting length and morphology of their roots, the alveolarand morphology of their roots, the alveolar support remaining.support remaining. IV.IV. A thorough and complete oral prophylaxisA thorough and complete oral prophylaxis 26. V.V. The exploration of teeth and investing structuresThe exploration of teeth and investing structures includes:includes: Determination of tooth mobility andDetermination of tooth mobility and Examination of occlusal relationships.Examination of occlusal relationships. VI.VI. Vitality tests of remaining teethVitality tests of remaining teeth VII.VII. Determination of height of the floor of the mouth to locateDetermination of height of the floor of the mouth to locate inferior borders of the lingual mandibular majorinferior borders of the lingual mandibular major connectorsconnectors VIII.VIII. Impressions for making accurate diagnostic castsImpressions for making accurate diagnostic casts 27. DIAGNOSTIC CASTSDIAGNOSTIC CASTS A Diagnostic cast should beA Diagnostic cast should be an accurate reproduction ofan accurate reproduction of the teeth and adjacentthe teeth and adjacent tissues.tissues. A diagnostic cast is made ofA diagnostic cast is made of dental stone because of itsdental stone because of its strength and it is lessstrength and it is less abraded than dental plaster.abraded than dental plaster. Impression is made withImpression is made with irreversible hydrocolloidirreversible hydrocolloid (alginate).(alginate). 28. PURPOSES OF DIAGNOSTIC CASTSPURPOSES OF DIAGNOSTIC CASTS To supplement the oralTo supplement the oral examination by permitting a viewexamination by permitting a view of the occlusion from theof the occlusion from the lingual ,as well as buccal aspect.lingual ,as well as buccal aspect. Possibilities for improvementPossibilities for improvement either by occlusal adjustmenteither by occlusal adjustment and /or occlusal reconstructionand /or occlusal reconstruction with the help of diagnosticwith the help of diagnostic waxing which helps the dentistwaxing which helps the dentist to plan ahead.to plan ahead. To permit a topographic surveyTo permit a topographic survey of the dental arch to be restoredof the dental arch to be restored by a removable partial denture.by a removable partial denture. 29. A cast surveyor determines the parallelism of theA cast surveyor determines the parallelism of the tooth surfaces and to establish the influence on thetooth surfaces and to establish the influence on the design of the partial denture.design of the partial denture. To permit a logical and comprehensiveTo permit a logical and comprehensive presentation to the patient of present and futurepresentation to the patient of present and future restorative needs as well as of the hazards ofrestorative needs as well as of the hazards of further neglect.further neglect. 30. Occluded and individualOccluded and individual diagnostic casts can bediagnostic casts can be used to point out to theused to point out to the patient:patient: a.a. Evidence of toothEvidence of tooth migration and the result ofmigration and the result of the same.the same. b.b. Effects of further toothEffects of further tooth migration.migration. c.c. Loss of occlusal supportLoss of occlusal support and its consequences.and its consequences. d.d. Hazards of traumaticHazards of traumatic occlusal contacts.occlusal contacts. e.e. Cariogenic and periodontalCariogenic and periodontal implications of furtherimplications of further neglect.neglect. 31. Individual impression trays can beIndividual impression trays can be fabricated. For wax blockouts duplicatefabricated. For wax blockouts duplicate diagnostic casts can be used.diagnostic casts can be used. Diagnostic casts may be used as a constantDiagnostic casts may be used as a constant reference as the work progresses.reference as the work progresses. Unaltered diagnostic casts should become aUnaltered diagnostic casts should become a permanent part of the patients records ofpermanent part of the patients records of conditions existing before treatment.conditions existing before treatment. 32. MOUNTING DIAGNOSTIC CASTSMOUNTING DIAGNOSTIC CASTS Diagnostic casts may be occluded by hand ,butDiagnostic casts may be occluded by hand ,but occlusal analysis is better accomplished by using anocclusal analysis is better accomplished by using an adjustable articulator.adjustable articulator. Casts if mounted in relation to the axis-orbital planeCasts if mounted in relation to the axis-orbital plane permit better interpretation of the plane of occlusionpermit better interpretation of the plane of occlusion in relation to the horizontal plane.in relation to the horizontal plane. The objective of diagnostic mounting is to positionThe objective of diagnostic mounting is to position the casts of the dental arches on an articulator sothe casts of the dental arches on an articulator so that the casts have the same relationship as do thethat the casts have the same relationship as do the mandible and maxilla in the patients skull.mandible and maxilla in the patients skull. 33. There are three distinct phases to this procedure:There are three distinct phases to this procedure: 1.1. Orientation of the maxillary cast to the condylar elements ofOrientation of the maxillary cast to the condylar elements of the articulator by means of a face bow transfer.the articulator by means of a face bow transfer. 2. Orientation of the mandibular cast to the maxillary cast at2. Orientation of the mandibular cast to the maxillary cast at the patients centric jaw relation by means of an accuratethe patients centric jaw relation by means of an accurate centric jaw relation record.centric jaw relation record. 3. Verification of these relationships by means of an additional3. Verification of these relationships by means of an additional centric jaw relation records and comparison of occlusalcentric jaw relation records and comparison of occlusal contacts on the articulator with those in the mouth.contacts on the articulator with those in the mouth. 34. ARBITRARY HINGE AXISARBITRARY HINGE AXIS The selection depends on the type of face-bow such as theThe selection depends on the type of face-bow such as the whip-Mix and Hanau Spring-Bow placed into each externalwhip-Mix and Hanau Spring-Bow placed into each external auditory meatus.auditory meatus. A convenient point to use isA convenient point to use is Beyron's pointBeyron's point, located 13 mm, located 13 mm anterior to the posterior margin of the tragus of the ear on aanterior to the posterior margin of the tragus of the ear on a line to the outer canthus of the eye.line to the outer canthus of the eye. 35. Anterior Point of ReferenceAnterior Point of Reference The infraorbital notch is selected when aThe infraorbital notch is selected when a Hanau face-bow is used with the Hanau WideHanau face-bow is used with the Hanau Wide Vue articulator.Vue articulator. The plane contacting the anterior referenceThe plane contacting the anterior reference point and the two external auditory meatus ispoint and the two external auditory meatus is parallel with the Frankfort horizontal plane ofparallel with the Frankfort horizontal plane of the maxillary cast to the condylar elements ofthe maxillary cast to the condylar elements of the articulator.the articulator. 36. Technique:Technique: 1.1. Preparation of bite fork.Preparation of bite fork. 2.2. Orientation of face-bow to bite fork andOrientation of face-bow to bite fork and reference points.reference points. 3.3. Orientation of face-bow to articulator.Orientation of face-bow to articulator. 4.4. Attachment of maxillary cast toAttachment of maxillary cast to articulator.articulator. 37. Preparation of Bite forkPreparation of Bite fork One sheet of baseplate wax is thoroughly softened over theOne sheet of baseplate wax is thoroughly softened over the Bunsen burner, formed into a cylinder, and adapted aroundBunsen burner, formed into a cylinder, and adapted around both sides of the bite fork.both sides of the bite fork. A cake of red modeling compound softened in a water bath isA cake of red modeling compound softened in a water bath is equally effective. While the compound is still soft, the bite forkequally effective. While the compound is still soft, the bite fork is positioned in the mouth with the projecting attachment armis positioned in the mouth with the projecting attachment arm to the left side of the patient, and the midline of the patient.to the left side of the patient, and the midline of the patient. Imprints of the maxillary teeth are accurately recorded.Imprints of the maxillary teeth are accurately recorded. The mandibular teeth are allowed to close lightly into the softThe mandibular teeth are allowed to close lightly into the soft compound to stabilize the face-bow.compound to stabilize the face-bow. The compound is allowed to cool in the mouth, removed andThe compound is allowed to cool in the mouth, removed and chilled with cold water. Then the face-bow record is trimmed sochilled with cold water. Then the face-bow record is trimmed so that only indentations of the maxillary cusp tips remain and allthat only indentations of the maxillary cusp tips remain and all soft tissue contacts are removed.soft tissue contacts are removed. 38. Orientation of the Face-bow to Bite fork and ReferenceOrientation of the Face-bow to Bite fork and Reference PointsPoints The bite fork with its record in position is seated inThe bite fork with its record in position is seated in the maxillary teeth and supported by the mandibularthe maxillary teeth and supported by the mandibular teeth.teeth. A convenient point to use has been described byA convenient point to use has been described by Beyron. Beyron's point is located 13 mm anterior toBeyron. Beyron's point is located 13 mm anterior to the posterior margin of the center of the tragus ofthe posterior margin of the center of the tragus of the ear on a line to the outer acanthus of the eye. Athe ear on a line to the outer acanthus of the eye. A line running through these marks is theline running through these marks is the arbitraryarbitrary hinge axis.hinge axis. If the third point of reference is desired the orbitalIf the third point of reference is desired the orbital pointer is released and rotated toward the patient sopointer is released and rotated toward the patient so that the tip approximates the infraorbital notchthat the tip approximates the infraorbital notch below the patient's right eye. This anterior referencebelow the patient's right eye. This anterior reference completes thecompletes the Frankfort horizontal plane.Frankfort horizontal plane. 39. Jaw Relationship Records for Diagnostic CastsJaw Relationship Records for Diagnostic Casts The maxillary cast is correctly oriented to theThe maxillary cast is correctly oriented to the opening axis of the articulator by means of face bowopening axis of the articulator by means of face bow transfer and becomes spatially related to the uppertransfer and becomes spatially related to the upper member of the articulator in the same relationshipmember of the articulator in the same relationship that the maxilla are related to the hinge axis and thethat the maxilla are related to the hinge axis and the Frankfort plane.Frankfort plane. When a centric relation record is made at anWhen a centric relation record is made at an established vertical dimension, the mandible is in itsestablished vertical dimension, the mandible is in its most retruded relation to the maxilla.most retruded relation to the maxilla. When the maxillary cast is correctly oriented to theWhen the maxillary cast is correctly oriented to the axis of the articulator, the mandibular cast becomesaxis of the articulator, the mandibular cast becomes correctly oriented to the opening axis, whencorrectly oriented to the opening axis, when attached to and mounted with an accurate centricattached to and mounted with an accurate centric relation record.relation record. 40. Materials available for recording centricMaterials available for recording centric relationrelation :: 1)1) WaxWax 2)2) Modeling plasticModeling plastic 3)3) Quick setting impression plasterQuick setting impression plaster 4)4) Metallic oxide bite registration pasteMetallic oxide bite registration paste 5)5) Polyether impression materialsPolyether impression materials 6)6) Silicon impression materials.Silicon impression materials. 41. Roentgenographic interpretation:Roentgenographic interpretation: The quality of the alveolarThe quality of the alveolar support of an abutment toothsupport of an abutment tooth is important because theis important because the tooth will withstand greatertooth will withstand greater stress loads in supporting astress loads in supporting a dental prosthesis.dental prosthesis. Abutment teeth adjacent toAbutment teeth adjacent to distal extension bases aredistal extension bases are subjected not only to verticalsubjected not only to vertical and horizontal forces, but toand horizontal forces, but to torque as well because of thetorque as well because of the movement of the tissuemovement of the tissue supported base.supported base. 42. Value of Interpreting bone density:Value of Interpreting bone density: Abnormal stresses, may create a reduction inAbnormal stresses, may create a reduction in the size of the trabecular pattern, particularlythe size of the trabecular pattern, particularly in that area of bone directly adjacent to thein that area of bone directly adjacent to the lamina dura of the effected tooth.lamina dura of the effected tooth. Such bone changes usually indicatesSuch bone changes usually indicates stresses that should be relieved because ifstresses that should be relieved because if the resistance of the patient decreases, thethe resistance of the patient decreases, the bone may exhibit a progressively lessbone may exhibit a progressively less favorable response in future radiographs.favorable response in future radiographs. 43. Index Areas:Index Areas: Index areas are those areas of alveolar supportIndex areas are those areas of alveolar support that disclose the reaction of bone to additionalthat disclose the reaction of bone to additional stress.stress. The reaction of the bone to additional stressesThe reaction of the bone to additional stresses in these areas may be either positive bonein these areas may be either positive bone factor with evidence of a supporting trabecularfactor with evidence of a supporting trabecular pattern, a heavy cortical layer, and a densepattern, a heavy cortical layer, and a dense lamina dura, or the reverse response orlamina dura, or the reverse response or negative bone factor with a poor prognosisnegative bone factor with a poor prognosis because the additional stresses caused by thebecause the additional stresses caused by the RPD may hasten destructive processes andRPD may hasten destructive processes and cause failure of the abutment teeth.cause failure of the abutment teeth. Other index areas are those around teeth thatOther index areas are those around teeth that have been subjected to abnormal occlusalhave been subjected to abnormal occlusal loading, that have been subjected to diagonalloading, that have been subjected to diagonal occlusal loading caused by tooth migration,occlusal loading caused by tooth migration, and that have reacted to additional loading,and that have reacted to additional loading, such as around existing FPD abutments.such as around existing FPD abutments. Positive response Negative response 44. Alveolar Lamina Dura:Alveolar Lamina Dura: The lamina dura is a thin layer of hard corticalThe lamina dura is a thin layer of hard cortical bone that normally lines the sockets of allbone that normally lines the sockets of all teeth.teeth. When a tooth is in the process of being tipped,When a tooth is in the process of being tipped, the centre of rotation is not at the apex of thethe centre of rotation is not at the apex of the root but in the apical third.root but in the apical third. Resorption of bone occurs where there isResorption of bone occurs where there is pressure, and apposition occurs where there ispressure, and apposition occurs where there is tension. Therefore during the active tippingtension. Therefore during the active tipping process the lamina dura is uneven, withprocess the lamina dura is uneven, with evidence of both pressure and tension on theevidence of both pressure and tension on the same side of the root.same side of the root. When systemic disease is associated withWhen systemic disease is associated with faulty protein metabolism and when the abilityfaulty protein metabolism and when the ability to repair is diminished, bone is resorbed andto repair is diminished, bone is resorbed and the lamina dura is disturbed.the lamina dura is disturbed. 45. Third MolarsThird Molars:: Unerupted third molars should be considered asUnerupted third molars should be considered as prospective future abutments to eliminate the need forprospective future abutments to eliminate the need for a distal extension RPD.a distal extension RPD. Root Length, size, and FormRoot Length, size, and Form Teeth with large or long roots are more favorableTeeth with large or long roots are more favorable abutment teeth because of the greater potential areaabutment teeth because of the greater potential area for periodontal ligament support.for periodontal ligament support. Tapered or conical roots are unfavorable becauseTapered or conical roots are unfavorable because even a small loss of bone height can greatlyeven a small loss of bone height can greatly diminish the attachment area.diminish the attachment area. Multi- rooted teeth whose roots are divergent orMulti- rooted teeth whose roots are divergent or curved are stronger abutment teeth .curved are stronger abutment teeth . 46. The position of roots of adjacent teeth is alsoThe position of roots of adjacent teeth is also important. If the roots of the approximating teeth areimportant. If the roots of the approximating teeth are close together with little interproximal boneclose together with little interproximal bone separating them, even moderate irritation or forceseparating them, even moderate irritation or force may be destructive.may be destructive. Crown /Root RatioCrown /Root Ratio It can be defined as "the physical relationship betweenIt can be defined as "the physical relationship between the portion of the tooth with in the alveolar bonethe portion of the tooth with in the alveolar bone compared with the portion not with in the alveolarcompared with the portion not with in the alveolar bone, as determined radiographically".bone, as determined radiographically". If the crown/root ratio is greater than 1:1 or ifIf the crown/root ratio is greater than 1:1 or if furcation involvement of a multirooted tooth isfurcation involvement of a multirooted tooth is present, the tooth has a poor prognosis as anpresent, the tooth has a poor prognosis as an abutment tooth.abutment tooth. 47. Periodontal Ligament SpacePeriodontal Ligament Space A widening of the periodontal ligament space with aA widening of the periodontal ligament space with a thickening of the lamina dura indicates mobility,thickening of the lamina dura indicates mobility, occlusal trauma, and heavy function.occlusal trauma, and heavy function. Evaluation of PeriodontiumEvaluation of Periodontium Examination findings that indicate possible need forExamination findings that indicate possible need for periodontal treatment include the following :periodontal treatment include the following : Pocket depth in excess of 3 mm.Pocket depth in excess of 3 mm. Function involvement.Function involvement. Marginal exudates.Marginal exudates. 48. Deviations from normal color and contour inDeviations from normal color and contour in gingival, indicating gingivitis.gingival, indicating gingivitis. Potential abutment teeth with less than 2 mm ofPotential abutment teeth with less than 2 mm of attached gingival.attached gingival. Pulling of muscle or frena on attached gingiva.Pulling of muscle or frena on attached gingiva. The wear of an ill-fitting prosthesis or continuousThe wear of an ill-fitting prosthesis or continuous wear of a removable partial denture coupled with in-wear of a removable partial denture coupled with in- adequate oral hygiene frequently contributes toadequate oral hygiene frequently contributes to accumulation of redundant tissue on the proximalaccumulation of redundant tissue on the proximal surfaces of the abutment teeth.surfaces of the abutment teeth. The initiation of good oral hygiene measures andThe initiation of good oral hygiene measures and tissue rest 6 to 8 hours per day (preferably at night)tissue rest 6 to 8 hours per day (preferably at night) will usually allow some resolution of the redundantwill usually allow some resolution of the redundant tissuetissue.. 49. Evaluation of Oral Mucosa: PathologicEvaluation of Oral Mucosa: Pathologic ChangesChanges Any ulceration, swelling, or color change thatAny ulceration, swelling, or color change that might indicate malignant or premalignantmight indicate malignant or premalignant changes should be recognized and properlychanges should be recognized and properly evaluated through biopsy or referral. Heavyevaluated through biopsy or referral. Heavy smokers and drinkers (the oral cancer high-smokers and drinkers (the oral cancer high- risk group) are particularly vulnerable torisk group) are particularly vulnerable to these tissue changesthese tissue changes.. 50. Evaluation of Caries and Existing RestorationsEvaluation of Caries and Existing Restorations The simple two-surface intracoronal restoration mayThe simple two-surface intracoronal restoration may be adequate for restoring a carious tooth.be adequate for restoring a carious tooth. If the tooth has extruded above the occlusal planeIf the tooth has extruded above the occlusal plane because of the lack of an antagonist, the choice maybecause of the lack of an antagonist, the choice may be an extra coronal restoration to improve thebe an extra coronal restoration to improve the occlusal plane.occlusal plane. If a tooth that does not possess adequate contoursIf a tooth that does not possess adequate contours for clasping is to serve as an abutment, a fullfor clasping is to serve as an abutment, a full coverage restoration may be necessary.coverage restoration may be necessary. If the tooth requires a restoration, the choice ofIf the tooth requires a restoration, the choice of restorative material is a metallic casting.restorative material is a metallic casting. 51. Evaluation of Sensitivity to PercussionEvaluation of Sensitivity to Percussion The following conditions can contribute to the irritationThe following conditions can contribute to the irritation of the periodontal ligament fibers, making the toothof the periodontal ligament fibers, making the tooth sensitive to percussion testing:sensitive to percussion testing: Tooth movement caused by prosthesis or theTooth movement caused by prosthesis or the occlusionocclusion A tooth or restoration in traumatic occlusionA tooth or restoration in traumatic occlusion Periapical or pulpal abscessPeriapical or pulpal abscess Acute pulpitisAcute pulpitis Gingivitis or preiodontitisGingivitis or preiodontitis Cracked tooth syndromeCracked tooth syndrome A removable partial denture should not beA removable partial denture should not be constructed until the cause is discovered and theconstructed until the cause is discovered and the sensitivity is eliminatedsensitivity is eliminated 52. Evaluation of Hard Tissue abnormalitiesEvaluation of Hard Tissue abnormalities Torus PalatinusTorus Palatinus Torus palatinus is a benign, slowly growingTorus palatinus is a benign, slowly growing protuberance of the palatine processes of the maxilla.protuberance of the palatine processes of the maxilla. Removal of a torus palatinus is not necessary unless itRemoval of a torus palatinus is not necessary unless it is so large that it interferes with the design andis so large that it interferes with the design and construction of the prosthesis.construction of the prosthesis. Usually a major connector can be selected andUsually a major connector can be selected and designed to circumvent the torus.designed to circumvent the torus. If removal of the torus is deemed necessary, an acrylicIf removal of the torus is deemed necessary, an acrylic resin surgical splint should be constructedresin surgical splint should be constructed preoperatively.preoperatively. TORUS PALATINUS 53. Torus MandibularisTorus Mandibularis -- The torus mandibularis usually occursThe torus mandibularis usually occurs bilaterally, on the lingual surface of the bodybilaterally, on the lingual surface of the body of the mandible. Mandibular tori should beof the mandible. Mandibular tori should be removed if the patient is to wear a removableremoved if the patient is to wear a removable partial denture with any degree of comfort .partial denture with any degree of comfort . TORUS MANDIBULARIS 54. Exostoses and UndercutsExostoses and Undercuts Undercut areas may be minimized by a change in the path ofUndercut areas may be minimized by a change in the path of insertion of a removable partial denture. Surgical correctioninsertion of a removable partial denture. Surgical correction of undercuts should be accomplished if relieving the dentureof undercuts should be accomplished if relieving the denture base or reducing the length of the denture border would:base or reducing the length of the denture border would: o Significantly reduce the support for and stability of theSignificantly reduce the support for and stability of the prosthesis.prosthesis. o Create a bothersome food impaction area, orCreate a bothersome food impaction area, or o Cause a denture border to be so far away from theCause a denture border to be so far away from the underlying tissue that it may affect function, compromiseunderlying tissue that it may affect function, compromise esthetics, or cause discomfort for the patient.esthetics, or cause discomfort for the patient. EXOSTOSES 55. Evaluation of Quantity and Quality of SalivaEvaluation of Quantity and Quality of Saliva If the mouth is dry, the patient will probably beIf the mouth is dry, the patient will probably be uncomfortable wearing a removable partial denture.uncomfortable wearing a removable partial denture. The denture bases will drag across the tissuesThe denture bases will drag across the tissues during placement and removal if the lubricatingduring placement and removal if the lubricating effect of the saliva is not present.effect of the saliva is not present. Nervousness, age drugs, systemic disturbances, andNervousness, age drugs, systemic disturbances, and radiation can markedly reduce the salivary output.radiation can markedly reduce the salivary output. A lubricating saliva substitute can help make theA lubricating saliva substitute can help make the prosthesis more tolerable for the patient. Thick andprosthesis more tolerable for the patient. Thick and ropy saliva or copious amounts of serous salivaropy saliva or copious amounts of serous saliva present problems in the impression procedure.present problems in the impression procedure. 56. Evaluation of space for Mandibular Major connectorEvaluation of space for Mandibular Major connector A properly constructed lingual bar major connector isA properly constructed lingual bar major connector is approximately 5 mm wide from its inferior to its superior border.approximately 5 mm wide from its inferior to its superior border. The superior margin of the connector should be located 3 mmThe superior margin of the connector should be located 3 mm below the free gingival margins of the mandibular teeth to avoidbelow the free gingival margins of the mandibular teeth to avoid damage to the gingival tissues. The inferior border of thedamage to the gingival tissues. The inferior border of the connector should be positioned at or slightly above the positionconnector should be positioned at or slightly above the position of the active floor of the mouth to prevent interference with theof the active floor of the mouth to prevent interference with the functional movements of the floor of the mouth and to helpfunctional movements of the floor of the mouth and to help avoid the packing of food under the major connector. Thereforeavoid the packing of food under the major connector. Therefore a minimum of 7 to 8 mm of space should be available, a linguala minimum of 7 to 8 mm of space should be available, a lingual plate major connector should be used if less than 7 mm ofplate major connector should be used if less than 7 mm of space is available.space is available. Mandibular lingual bar major connector 57. Evaluation of Mounted Diagnostic CastsEvaluation of Mounted Diagnostic Casts Inter arch Distance:Inter arch Distance: Lack of sufficient interarch distance is a commonLack of sufficient interarch distance is a common finding for the placement of artificial teeth.finding for the placement of artificial teeth. The problem is caused by a maxillary tuberosity thatThe problem is caused by a maxillary tuberosity that is too large in vertical height or too bulbous. Theis too large in vertical height or too bulbous. The surgical reduction of the vertical height of thesurgical reduction of the vertical height of the tuberosity and at times the adjacent residual ridge istuberosity and at times the adjacent residual ridge is necessary if satisfactory replacement of the missingnecessary if satisfactory replacement of the missing teeth is to be accomplishedteeth is to be accomplished.. 58. Irregular Occlusal PlaneIrregular Occlusal Plane Enameloplasty can effectively reduce a moderatelyEnameloplasty can effectively reduce a moderately extruded tooth. At times the reduction of a singleextruded tooth. At times the reduction of a single cusp improves the occlusal plane.cusp improves the occlusal plane. If the extrusion is greater than 1 or 2 mm or if theIf the extrusion is greater than 1 or 2 mm or if the tooth does not lend itself to enameloplasty, thetooth does not lend itself to enameloplasty, the placement of an extracoronal cast metallicplacement of an extracoronal cast metallic restoration is indicated.restoration is indicated. Traumatic Vertical OverlapTraumatic Vertical Overlap Clinical symptoms of traumatic vertical overlapClinical symptoms of traumatic vertical overlap include abrasion, mobility, and migration of theinclude abrasion, mobility, and migration of the teeth, as well as inflammation and ulceration of theteeth, as well as inflammation and ulceration of the gingival and palatal mucosa.gingival and palatal mucosa. 59. Akerly (1977) has classified traumatic verticalAkerly (1977) has classified traumatic vertical overlap into four basic types:overlap into four basic types: Type 1Type 1 the mandibular incisors extrude and impinge the mandibular incisors extrude and impinge into the palate.into the palate. Type 2Type 2 the mandibular incisors impinge into the the mandibular incisors impinge into the gingival sulci of the maxillary incisors.gingival sulci of the maxillary incisors. Type 3Type 3 both maxillary and mandibular incisors incline both maxillary and mandibular incisors incline lingually with impingement of the gingival tissues oflingually with impingement of the gingival tissues of each arch.each arch. Type 4Type 4 - the mandibular incisors move or extrude into- the mandibular incisors move or extrude into the abraded lingual surfaces of the maxillary anteriorthe abraded lingual surfaces of the maxillary anterior teeth.teeth. 60. o A treatment prosthesis that plates the lingualA treatment prosthesis that plates the lingual surfaces of the maxillary anterior teeth can be usedsurfaces of the maxillary anterior teeth can be used to prevent further extrusion of the mandibularto prevent further extrusion of the mandibular incisors.incisors. o If a maxillary removable partial denture is indicated,If a maxillary removable partial denture is indicated, the major connector can be extended onto thethe major connector can be extended onto the lingual surfaces of the anterior teeth with a thin platelingual surfaces of the anterior teeth with a thin plate of metal. This will provide a vertical stop to preventof metal. This will provide a vertical stop to prevent further eruption of the mandibular anterior teeth.further eruption of the mandibular anterior teeth. o The plating should cover the cingula of the teethThe plating should cover the cingula of the teeth with projections extending to the contact points.with projections extending to the contact points. o If only a mandibular removable partial denture isIf only a mandibular removable partial denture is required for replacement of teeth, a lingual platerequired for replacement of teeth, a lingual plate major connector can be designed to preventmajor connector can be designed to prevent continued eruption of the anterior teeth.continued eruption of the anterior teeth. 61. Tipped or Malposed TeethTipped or Malposed Teeth A posterior tooth tends to drift forward into theA posterior tooth tends to drift forward into the space created by the removal of the tooth mesial tospace created by the removal of the tooth mesial to it.it. Limited orthodontic procedures for minor toothLimited orthodontic procedures for minor tooth movement can be used to upright the tipped tooth tomovement can be used to upright the tipped tooth to allow the placement of an artificial tooth of moreallow the placement of an artificial tooth of more normal size.normal size. OcclusionOcclusion Partially edentulous patients have an even greaterPartially edentulous patients have an even greater probability of having premature occlusal contactsprobability of having premature occlusal contacts because of the drifting and migration of teeth thatbecause of the drifting and migration of teeth that usually accompany the loss of continuity of theusually accompany the loss of continuity of the dental archdental arch .. 62. Role of Occlusal EquilibrationRole of Occlusal Equilibration Occlusal equilibrations is the selective grinding or coronalOcclusal equilibrations is the selective grinding or coronal reshaping of teeth with the intent of equalizing occlusal stress,reshaping of teeth with the intent of equalizing occlusal stress, producing simultaneous occlusal contacts, or harmonizingproducing simultaneous occlusal contacts, or harmonizing cuspal relations.cuspal relations. Extensive occlusal equilibration should never be initiated on aExtensive occlusal equilibration should never be initiated on a patient with acute temperomandibular joint dysfunction.patient with acute temperomandibular joint dysfunction. Balancing side or non chewing side interferences, which areBalancing side or non chewing side interferences, which are usually the most destructive eccentric interferences, shouldusually the most destructive eccentric interferences, should always be eliminatedalways be eliminated.. 63. TREAT AT CENTRIC JAW RELATION OR CENTRICTREAT AT CENTRIC JAW RELATION OR CENTRIC OCCLUSIONOCCLUSION The following clinical situations indicate constructionThe following clinical situations indicate construction of the prosthesis at centric jaw relation:of the prosthesis at centric jaw relation: Coincidence of centric jaw relation and centricCoincidence of centric jaw relation and centric occlusion.occlusion. Absence of posterior tooth contacts because theAbsence of posterior tooth contacts because the opposing arch is completely edentulous ofopposing arch is completely edentulous of because of the pattern of the missing teeth.because of the pattern of the missing teeth. Situation in which all posterior tooth contacts areSituation in which all posterior tooth contacts are to be restored with cast restorations.to be restored with cast restorations. Only a few remaining posterior contacts.Only a few remaining posterior contacts. 64. 5.5. Minimum alveolar support for all the teeth that canMinimum alveolar support for all the teeth that can be made acceptable with minimum occlusalbe made acceptable with minimum occlusal equilibration.equilibration. 6.6. Anterior slide from centric jaw relation andAnterior slide from centric jaw relation and symptoms of traumatic occlusion of the anteriorsymptoms of traumatic occlusion of the anterior teeth.teeth. 7.7. Clinical symptoms of occlusal trauma.Clinical symptoms of occlusal trauma. In the absence of these indications , the removableIn the absence of these indications , the removable partial denture should be constructed at centricpartial denture should be constructed at centric occlusion.occlusion. 65. Indications for RPD:Indications for RPD: o Distal extension situationsDistal extension situations o After Recent ExtractionsAfter Recent Extractions o Long SpanLong Span o Need for Bilateral StabilizationNeed for Bilateral Stabilization o Excessive Loss of Residual BoneExcessive Loss of Residual Bone o Unusually Sound Abutment TeethUnusually Sound Abutment Teeth o Abutments with Guarded PrognosisAbutments with Guarded Prognosis o Economic ConsiderationsEconomic Considerations 66. Treatment Planning: -Treatment Planning: - Phase IPhase I a.a. Collection and evaluation of the diagnosticCollection and evaluation of the diagnostic data, including a diagnostic mounting and thedata, including a diagnostic mounting and the analysis and design of diagnostic casts.analysis and design of diagnostic casts. b.b. Immediate treatment to control pain or infection.Immediate treatment to control pain or infection. c.c. Biopsy of referral of patient.Biopsy of referral of patient. d.d. Development of a treatment plan.Development of a treatment plan. e.e. Initiation of education and motivation of patient.Initiation of education and motivation of patient. 67. Phase IIPhase II a.a. Removal of deep caries and placement of temporaryRemoval of deep caries and placement of temporary restorations.restorations. b.b. Extirpation of inflamed or necrotic pulp tissues.Extirpation of inflamed or necrotic pulp tissues. c.c. Removal of non retainable teeth.Removal of non retainable teeth. d.d. Periodontal treatment.Periodontal treatment. e.e. Construction of interim prosthesis for function orConstruction of interim prosthesis for function or esthetics.esthetics. f.f. Occlusal equilibration.Occlusal equilibration. g.g. Reinforcement of education and motivation of patientReinforcement of education and motivation of patient 68. Phase IIIPhase III a.a. Preprosthetic surgical procedures.Preprosthetic surgical procedures. b.b. Definitive endodontic procedures.Definitive endodontic procedures. c.c. Definitive restoration of teeth, includingDefinitive restoration of teeth, including placement of cast metallic restorations.placement of cast metallic restorations. d.d. Fixed partial denture construction.Fixed partial denture construction. e.e. Reinforcement of education andReinforcement of education and motivation of patient.motivation of patient. 69. Phase IVPhase IV a.a. Construction of removable partial denture.Construction of removable partial denture. b.b. Reinforcement of education andReinforcement of education and motivation of patient.motivation of patient. Phase VPhase V a.a. Post insertion carePost insertion care b.b. Periodic recallPeriodic recall c.c. Reinforcement of education andReinforcement of education and motivation of patientmotivation of patient 70. BIBLIOGRAPHYBIBLIOGRAPHY Benedict Rich :New paradigms in prosthodontic Treatment planning :Benedict Rich :New paradigms in prosthodontic Treatment planning : The Journal of Prosthetic Dentistry, volume 88 number 2,(208-212);The Journal of Prosthetic Dentistry, volume 88 number 2,(208-212); August 2002.August 2002. Kenneth L.Stewart: Clinical Removable Partial Prosthodontics:2ndKenneth L.Stewart: Clinical Removable Partial Prosthodontics:2nd edition,(117-221):Ishiyaku euroamerica,inc,publishersedition,(117-221):Ishiyaku euroamerica,inc,publishers.. McCrackens Removable Partial Prosthodontics:9McCrackens Removable Partial Prosthodontics:9thth edition, (213-edition, (213- 259):Harcourt brace and company asia pte ltd.259):Harcourt brace and company asia pte ltd. Simon Gamer : M M House Mental classification: The Journal ofSimon Gamer : M M House Mental classification: The Journal of Prosthetic Dentistry, volume 89 number 3,(297-300); March 2003.Prosthetic Dentistry, volume 89 number 3,(297-300); March 2003. Susan K Hummel:Quality of removable partial dentures worn by theSusan K Hummel:Quality of removable partial dentures worn by the adult U.S population :The Journal of Prosthetic Dentistry, volume 88adult U.S population :The Journal of Prosthetic Dentistry, volume 88 number 1,(37-43); July 2002number 1,(37-43); July 2002 Yoav Grossman : The prosthodontic concept of crown to rootYoav Grossman : The prosthodontic concept of crown to root ratio:The journal of prosthetic dentistry, August 2006.ratio:The journal of prosthetic dentistry, August 2006.