Prosthodontic Restoration 2021

313
13
Prosthodontic Restoration
Diagnosis and Treatment Planning
CHAPTER MENU
13.1 Documenting Patient Health Histories, 313

13.2 Documenting Clinical, Radiographic, and Photographic Findings, 315
13.3 Designing Prosthodontic Treatment Plans, 320
Develop a Problem List and Diagnostic Summary, 322
Use a Prosthodontic Diagnostic Index for Referral, 322
Survey and Design Removable Partial Dentures for the Partially Edentulous Patient, 325
Fabricate Radiographic Stent for Implants for the Partially and Completely Edentulous Patient, 327
Discuss Prognosis and Alternative Treatments with Patient, 328
Design a Properly Sequenced Comprehensive Treatment Plan, 330
Educate Patient Regarding Appointment Sequence, 331
Treatment Plan and Appointment Sequence for Prosthodontic Reconstruction of a Complex
Patient, 333
Educate Patient Regarding Costs of Treatment, 334
Treatment Plan – By Description, 338
13.4 Summary, 338
References, 340
13.1 Documenting Patient achieve favorable prosthodontic outcomes (see

Health Histories Figure 13.9).
Figures 13.1–13.5 show a completely eden-
Optimal prosthodontic restorative treatment tulous male patient who exhibits normal
for a dental patient can be provided only after anterior–posterior residual ridge relations
the clinician has obtained and reviewed the intraorally, but has excessive loss of vertical
medical, social, and dental histories of the dimension and a prognathic facial profile with
patient and documented them in the patient’s old dentures in place. The patient expressed
dental record. A patient’s needs, desires, and dissatisfaction with his appearance when wear-
attitudes concerning prosthodontic restoration ing dentures saying that they made him look
of their oral cavity (Figures 13.1–13.8) for form, “ape-like.” Unfortunately, the patient allowed
function, and esthetics should also be inter- this negative personal image of himself to affect
preted by the clinician and documented in the his ability to interact socially withdrawing from
patient’s dental record (Jahangiri et al. 2011). friends and family members. Figures 13.6–13.8
A truthful assessment and documentation of a show the same patient who now exhibits an
patient’s personality, psychological state, and orthognathic facial profile after a significant
expectations is of paramount importance to increase in the vertical dimension of occlusion
Physical Evaluation and Treatment Planning in Dental Practice, Second Edition.

Géza T. Terézhalmy, Michaell A. Huber, Lily T. García and Ronald L. Occhionero.
© 2021 John Wiley & Sons, Inc. Published 2021 by John Wiley & Sons, Inc.
Companion Website: www.wiley.com/go/terezhalmy/physical
314 Physical Evaluation and Treatment Planning in Dental Practice
Figure 13.1 Pre-treatment lateral facial view of

complete denture patient with excessive loss of
vertical dimension of occlusion and prognathic
profile.
Figure 13.3 Completely edentulous patient shown

in Figure 13.1 with old dentures in maximum
intercuspation showing Class III anterior tooth and
maxillomandibular denture relations.
Figure 13.4 Intraoral frontal view of completely

edentulous patient in Figure 13.1 showing normal
ridge relations with mandible at physiologic rest
position.
and prosthodontic restorative treatment to

Class I ridge and occlusal relations with new
maxillary and mandibular complete dentures.
Figure 13.2 Extraoral facial measurement of
vertical dimension of patient in Figure 13.1 with The restoration of the patient’s lower face
old complete dentures in maximum intercuspation height and characterization of the acrylic
(66 mm). resin denture teeth allowed the patient to feel
Prosthodontic Restoration 315
Figure 13.5 Intraoral frontal view of patient with

old dentures in maximum intercuspation showing
significant posterior tooth wear, and Class III
anterior tooth and bilateral posterior cross bite
relations.
Figure 13.7 Extraoral facial measurement of

vertical dimension of patient in Figure 13.1 with
new complete dentures in maximum
intercuspation (75 mm).
Figure 13.6 Post-treatment lateral facial view of

complete denture patient with vertical dimension
of occlusion restored with new complete dentures.
much better about his personal appearance

and dramatically improved his outlook on
life allowing him once again to socialize and
connect with others. Figure 13.8 Intraoral frontal view of new complete
dentures showing elimination of Class III anterior
tooth and bilateral posterior crossbite relations
13.2 Documenting Clinical, due to proper restoration of vertical dimension of
occlusion.
Radiographic, and Photographic
Findings soft and hard tissues, existing teeth, occlusal
relations, and edentulous areas should be com-
In order to properly evaluate a dental patient pleted and all pathologic and non-pathologic
for prosthodontic treatment, very thorough problems documented and charted in the
clinical and radiographic examinations of all patient’s dental record. The prosthodontic
Figure 13.9 Written interview form to aid in the evaluation of a patient’s personality, psychological state,
and expectations regarding removable prostheses.
evaluation form for partially and completely patient requiring prosthodontic restorations
edentulous patients shown in Figure 13.10 can by making diagnostic impressions and max-
provide an organized way to approach these illomandibular records. In this manner, the
clinical activities. diagnostic casts can allow for extraoral visual-
In addition to radiographs, utilization of ization of tooth alignment and positions, ridge
intraoral and extraoral photographs can doc- form, interarch and interocclusal relationships
ument the patient’s facial form, face height, of the patient’s dentition and edentulous areas
supporting teeth, edentulous areas, occlu- and be used to treatment plan fixed and remov-
sion, and dental conditions that will help the able prosthodontic restorations and survey and
clinician arrive at a correct diagnosis and design removable partial dentures. As seen in
treatment plan. Critical information can also Figures 13.11–13.16, the patient’s functional
be gathered at the initial assessment of the and esthetic demands, as well as financial
Figure 13.10 Prosthodontic diagnosis form used for pretreatment evaluation of partially and completely
edentulous patients.
Figure 13.11 Partially edentulous patient with Figure 13.14 Frontal and occlusal views of
missing mandibular anterior teeth and no right surveyed and color-coded design drawn on
side canine guidance due to loss of long span fixed mandibular diagnostic cast for rotational path RPD.
partial denture #22–27.
Figure 13.15 Frontal view of completed maxillary

and mandibular RPDs.
Figure 13.12 Patient with survey crown #27 and

mandibular Class IV rotational path RPD restoring
right side canine guidance and missing anterior
teeth.
Figure 13.16 Occlusal view of mandibular

rotational path RPD.
constraints, often times result in a choice of

removable prostheses rather than fixed partial
dentures or implant-supported prostheses for
restoration of long span edentulous spaces.
Figure 13.13 Frontal and occlusal views of
surveyed and color-coded design drawn on A prerequisite to diagnosis and treatment
mandibular diagnostic cast for rotational path RPD. planning different prosthodontic treatment
Figure 13.17 Evaluation form to assess dental students for their diagnosis and treatment planning of
removable partial dentures.
options and a key to the success of any SUBJECTIVE (S):

dental treatment is a well-organized and
Chief Complaint: 34-year old Caucasian female
well-performed data-gathering process (Hol-
wants her painful upper teeth removed
lender et al. 2003). For example, as an aid
today.
to determine if conventional removable
Meds: none.
prosthodontic therapy would be better for
ADE: NKDA; NKADE (Adverse Drug Experi-
a partially edentulous patient than fixed or ences: No Known Drug Allergies; No Known
implant prosthodontic therapy, a standard- Adverse Drug Experiences)
ized form can help “put it all together” for PMHx: Childbirth × 4.
dental students and licensed practitioners PDentHx: Multiple extractions of carious
as they diagnose, treatment plan, and sur- posterior teeth. Patient states that she
vey and design a removable partial denture cannot afford extensive alloy and/or com-
(Figure 13.17). posite restorations, root canals, crowns, or
The comprehensive examination of a patient implants.
in need of prosthodontic restoration should FamHx: Mother had breast cancer.
include the clinician’s extraoral, intraoral, SocHx: Denies use of alcohol, reports pack/day
and periodontal findings; interpretation of smoking habit.
radiographs; and consultations with dental
specialists. A problem-focused systematic OBJECTIVE (O):
approach that employs a Subjective, Objective, Vital Signs: BP – 130/75.
Assessment, Plan (SOAP) format for chart Clinical Findings: Multiple missing teeth and
entries will insure that proper assessments grossly decayed teeth # 6, 7, 8, 9, 10, 11, 15,
and documentation are completed in a log- 21, 22.
ical, legal, and timely manner (Terezhalmy Radiographs: Panoramic radiograph taken
et al. 2009). The following SOAP progress three months previous to appointment
notes with blue and italicized headings is (Figure 13.1) shows teeth #3, 4, 5, 14, 15,
an example of how to properly document the 21, 22 present. Periodontal problems and
evaluation, diagnosis, and treatment plan- healing extraction sites noted in maxillary
ning for the partially edentulous patient in and mandibular arches.
Figures 13.18–13.22. Photographs: Intraoral, extraoral frontal,
and occlusal digital images recorded after
healing of extraction sites.
Diagnostic Casts: Color-coded survey and
design completed for Kennedy Class I
mandibular bilateral distal extension
Removable Partial Dentures (RPD). I-bar
retentive clasps and cingulum rests selected
based on fit, function, and esthetics.
13.3 Designing Prosthodontic

Treatment Plans
Treatment planning for a prosthodontic patient
can be viewed as the development of a series of
Figure 13.18 Extraoral frontal view of partially dental procedures that are necessary to main-
edentulous patient. tain health or to restore a diseased dentition
Figure 13.19 Pretreatment panoramic radiograph of partially edentulous patient in Figure 13.18.
Figure 13.20 Intraoral frontal view of partially

edentulous patient in Figure 13.18. Figure 13.21 Survey of mandibular diagnostic cast
for RPD.
to a state of health. In order to accomplish
these goals, clinicians should develop detailed disease; (iii) restoring function; (iv) restoring
dental discipline oriented treatment plans esthetics; (v) preventing future disease; and
for every patient undergoing comprehensive (vi) providing cost-effective care.
prosthodontic care. It is also important that The actual treatment planning process
a systematic approach is utilized to complete for fixed and/or removable prosthodontic
all necessary dental procedures in the fewest procedures should involve using a problem
number of patient visits. list as a guide, integrating risk assessment,
With that in mind, clinicians should addressing each problem, determining priori-
establish goals for treatment planning a ties for treatment, examining the relationship
prosthodontic patient based on (i) addressing between problems, establishing a prognosis,
the patient’s chief complaint; (ii) eliminating and presenting alternatives to the patient.
of maxillary and mandibular removable

prostheses in accordance with accepted
treatment plan.
PLAN (P):
Treatment Plan options for the restoration of
form, function, and esthetics should take in
to account the patient’s expectations, dental
IQ, financial constraints, and compliance
with maintenance protocols for fixed and
Figure 13.22 Intraoral frontal view of immediate removable prostheses. The patient should be
removable prostheses. informed of the prognosis and the risks and
benefits of optional therapy and no therapy,
Develop a Problem List and Diagnostic in other words, “No treatment” as an option
Summary would be included in this section.
After the initial patient assessment and clini- Option #1 – Maxillary and Mandibular Imme-
cal, radiographic, and photographic findings diate Complete Dentures with extraction
are well documented, then a problem list of all remaining teeth at time of delivery of
should be developed to help aid in diagnosis, prostheses. Good to Fair Prognosis.
treatment planning, and prognostic inter- Option #2 – Maxillary Immediate Complete
pretation for prosthodontic treatments. The Denture opposing Mandibular Removable
assessments (A) and treatment plan options Partial Denture (RPD). Extract #21 and 22
(P) provided to the patient in Figure 13.19 and fabricate mandibular metal RPD and
should be entered in the patient’s dental restore #23-F and #27-F with composite
record, following the SOAP format, after entry resin to establish retentive undercuts for
of the Subjective information (S) and Objective I-bar clasp and restore #22-L and #27-L for
findings (O). cingulum rest seats for vertical support of
metal framework. Extract remaining maxil-
ASSESSMENT (A):
lary teeth at time of simultaneous delivery
Problem List: See Figures 13.18, 13.20, and of maxillary immediate complete denture
13.21 for clinical, radiographic, and pho- and mandibular bilateral distal extension
tographic findings to document patient’s RPD. Excellent to Good Prognosis.
dental conditions by teeth, tooth surfaces, Patient chose Option #2 based on her desire
and edentulous spaces. to keep some mandibular teeth for function
Diagnostic Summary: List and summa- and esthetic reasons, the minimal cost for
rize problems by medical and dental composite resin restorations on RPD abut-
disciplines – Systemic; Oral Pathology; Pre- ment teeth compared to surveyed crowns,
ventive; Occlusion/TMJ; Periodontics; Oral and both final prostheses are removable.
and Maxillofacial Surgery; Endodontics;
Operative Dentistry; Fixed Prosthodon-
Use a Prosthodontic Diagnostic Index
tics; Implant Prosthodontics; Removable
for Referral
Prosthodontics and Orthodontics.
Assessment: Extract symptomatic teeth #7, Based on the education, training, experience,
8, and 15 immediately due to pain and and practice location of some clinicians, den-
retain teeth # 6, 9, 10, and 11 to main- tal patients that require complex treatment
tain vertical dimension of occlusion for may need referral to a prosthodontist. Upon
maxillomandibular relations for fabrication completion of Figures 13.9 and 13.10, it would
be appropriate to discuss with the patient that

referral to a specialist for prosthodontic restora-
tive care is indicated due to the complexity
of the proposed dental treatment, a high-risk
prognosis, and the availability of specialty care.
The American College of Prosthodontists
(ACP) developed Prosthodontic Diagnos-
tic Index (PDI) classification systems for
completely edentulous, partially edentulous,
and completely dentate patients based on
diagnostic findings and the severity of their
pretreatment dental conditions (McGarry et al. Figure 13.23 Precision-milled metal framework
1999; McGarry et al. 2002; McGarry et al. 2004). with locator attachment for retention of
implant-assisted maxillary Class IV RPD.
The guidelines in each of the ACP classifica-
tion systems were designed and are intended
to help diagnose and determine appropriate
treatments for patients seeking dental care.
As an example, four categories are defined in
the ACP PDI for partially edentulous patients,
Class I to Class IV, with Class I representing
a simple, uncomplicated clinical situation
(favorable prognosis) and class IV repre-
senting a highly complex clinical situation
(unfavorable prognosis). Each class of partially
edentulous patients is differentiated by specific
diagnostic criteria. Figure 13.24 Wax try-in of removable partial
Benefits of the PDI classification systems for overdenture in Figure 13.23 to assess fit, function,
clinicians include: phonetics, and esthetics.
(1) Improved treatment planning. 13.24). Proper prosthodontic diagnosis allows

(2) Improved professional communication. for anticipating and acknowledging the com-
(3) Insurance reimbursement commensurate plexity of treatment options and it provides the
with complexity of care. best possible dental care for the patient.
(4) Improved screening tool for dental school The following diagnostic criteria are
admission clinics. designed to help in treatment planning par-
(5) Standardized criteria for outcomes assess- tially edentulous patients:
ment and research.
• Location and extent of edentulous areas.
(6) Enhanced diagnostic consistency.
• Abutment tooth condition.
(7) Simplified aid in the decision to refer a
• Occlusal scheme.
patient.
• Residual ridge.
It should also be noted that the PDI classifica- • Conditions creating a guarded prognosis.
tion and diagnosis for the partially edentulous
Some of the indications for referral of partially
patient is independent of the proposed treat-
edentulous patients to a prosthodontist for
ment meaning that the index is not limited
restorative care include:
to only conventional RPDs, but may include
fixed and/or implant-supported removable (1) Changes to the occlusal plane.
partial denture prostheses (Figures 13.23 and (2) Changes to the occlusal vertical dimension.
(3) Multiple adjunctive procedures are neces- or more teeth plus a canine. Abutment teeth
sary. unable to retain coronal restorations; require
(4) Very high esthetic concerns. local adjunctive therapy that may include peri-
(5) Refractory patient (stubborn or unman- odontics, endodontics, and/or orthodontics.
ageable – not yielding or resistant to Class I molar/skeletal relations but requires
treatment). equilibration and/or enameloplasty. Residual
ridge displays a loss of vertical and horizontal
Based on anatomical, functional, systemic, and
hard and soft tissue support (Figures 13.27 and
psychological conditions of a patient, the PDI
13.28).
would classify the following partially edentu-
lous patients as Class I, II, III, or IV:
Class III Missing three or more adjacent teeth
Class I Single arch missing two maxillary or in any arch. Abutment teeth are not able to
four incisors, and/or missing two posterior support intracoronal or extracoronal restora-
teeth. No pre-prosthetic surgery needed. Class tions and require extensive adjunctive therapy,
I molar/skeletal relations (stable maximum which may include periodontics, endodon-
intercuspation position). Adequate residual tics, and/or orthodontics. Class II or Class
ridge bone height, soft tissue support, and III molar/skeletal relations, malocclusion,
attached mucosa (Figures 13.25 and 13.26). but no need to alter occlusal vertical dimen-
sion. Extensive loss of hard and soft tissue of
Class II Both arches missing two maxillary
or four mandibular incisors, or missing two
Figure 13.27 PDI Class II partially edentulous

patient.
Figure 13.25 PDI Class I partially edentulous
patient.
Figure 13.26 PDI Class I partially edentulous Figure 13.28 PDI Class II partially edentulous
patient. patient.
Figure 13.31 PDI Class IV partially edentulous

Figure 13.29 PDI Class III partially edentulous patient.
patient.
Figure 13.32 PDI Class IV partially edentulous

Figure 13.30 PDI Class III partially edentulous patient.
patient.
residual ridge requires pre-prosthetic surgery

(Figures 13.29 and 13.30).
Class IV Long span with multiple missing

teeth in both arches resulting in extruded
teeth. Severely compromised or missing strate-
gic abutment teeth in four or more sextants.
Need to re-establish entire occlusion with
alteration of occlusal vertical dimension. Defi-
cient hard and soft tissue support requires
pre-prosthetic surgery. Systemic, functional,
and/or psychological impairments creating a
Figure 13.33 Color-coded design drawn on
guarded prognosis (Figures 13.31 and 13.32).
diagnostic cast for a maxillary distal extension
RPD.
Survey and Design Removable Partial and tooth alterations for a definitive remov-
Dentures for the Partially Edentulous
able partial denture can be drawn on the
Patient
surveyed diagnostic cast using a color-coded
In order to enhance communication with design (Figures 13.33 and 13.34). The dentist
the patient and the dental laboratory, the should also draw a design on the laboratory
definitive metal and acrylic resin components work authorization form that coincides with
who needed extensive endodontic and oral

surgical procedures before prosthodontic
rehabilitation with a maxillary complete over-
denture and a mandibular Class I removable
partial overdenture (Figures 13.35–13.41).
Figure 13.34 1/2 T-bar clasp assembly drawn on

maxillary left premolar to retain and support left
side of a maxillary distal extension RPD.
the written description of the RPD and its Figure 13.36 Pre-treatment left lateral view of
components. The color-coded diagnostic cast mounted diagnostic casts.
can be used chairside by the dentist as a
“blueprint” for the preparation of abutment
teeth for guide planes, retentive undercuts,
rest seats, and occlusal clearance.
Mounted diagnostic casts and the survey and
design of removable partial dentures should
be an integral part of the physical evaluation,
diagnosis, and treatment planning process
for the partially edentulous patient (Phoenix
et al. 2003). When utilized, these adjunctive
diagnostic procedures can help improve the
prognosis and outcome of the prosthodontic Figure 13.37 Occlusal view of abutment teeth for
treatment for the complex multidisciplinary support of mandibular removable partial
phased-treatment patient such as this patient overdenture.
Figure 13.35 Pre-treatment right lateral view of Figure 13.38 Post-treatment occlusal view of
mounted diagnostic casts. mandibular partial overdenture.
Fabricate Radiographic Stent

for Implants for the Partially
and Completely Edentulous Patient
In addition to designing an RPD for a partially
edentulous patient, it may also be necessary to
fabricate a radiographic stent to determine if
dental implants are a viable treatment option.
The radiographic stent is fabricated on the
patient’s diagnostic cast. The patient wears
the radiographic stent when a cone beam
Figure 13.39 Frontal view of abutment teeth for computerized tomogram (CBCT) is made to
maxillary complete overdenture. determine if adequate bone is available for
placement of implants based on the form,
function, and esthetics of the replacement
teeth (Figures 13.42–13.44).
Figure 13.40 Post-treatment view of maxillary

complete overdenture opposing mandibular
bilateral distal extension removable partial
overdenture.
Figure 13.42 Occlusal view of a partially
edentulous patient.
Figure 13.41 Post-treatment frontal view of Figure 13.43 Maxillary diagnostic cast of patient
patient wearing maxillary complete overdenture in Figure 13.42 with radiographic stent fabricated
and mandibular partial overdenture. for CBCT.
and restorative dentist can accurately measure

the bucco-lingual dimension and height of
bone available for the implant fixture based on
where the implant crown will be positioned for
esthetics and function (Figures 13.46–13.49).
Discuss Prognosis and Alternative

Treatments with Patient
For ethical and legal reasons, it is essential
that the patient be informed of the different
Figure 13.44 Lateral view of radiographic stent
showing aluminum foil placed mesiodistally for prosthodontic options for dental treatment and
each tooth to be restored with an implant. also provided an estimate of the overall cost,
prognosis, and anticipated longevity/viability
Clinicians will often find that the use for each alternative therapy (Ozar and Sokol
of a panoramic radiograph for treatment 2002). Clinicians should offer at least two
planning dental implants is limited as treatment plan options to the patient before
it can only be viewed in one dimension both dentist and patient agree upon the final
(Figure 13.45). Computerized tomography treatment. The options may include only fixed,
provides a three-dimensional view of the par- removable, or implant options or a combina-
tially edentulous area for treatment planning tion of these types of prostheses, especially if
dental implants (Rose et al. 2004). It is impor- missing teeth are to be replaced. One of the
tant to center the radiographic marker (strip proposed plans could be the ideal treatment
of aluminum foil) mesiodistally in the edentu- plan and the other an alternate treatment
lous space for each tooth that will be restored plan, with both focused on what is “best”
with an implant crown. The marker allows for the patient. A copy of the itemized and
for the CBCT to be sectioned so the surgeon signed final treatment plan should be given
Figure 13.45 Panoramic radiograph of patient missing upper right 1st molar treatment planned for a single
tooth implant.
Radiographic
3 Marker
Site #3
Figure 13.46 CBCT image in lower right shows outline of radiographic marker placed mesiodistally on
tooth #3 in radiographic stent. CBCT images show different views of width and height of bone available for
implant placement in extraction site #3.
Figure 13.48 Periapical radiograph of implant

fixture surgically placed at #3 site.
the benefits of treatment and the risks of no

Figure 13.47 Intraoral occlusal view of healing
abutment on implant at #3 site. treatment thoroughly explained to the patient
(Terezhalmy et al. 2009).
to the patient and the original kept on file The clinician must also determine if the
in the dentist’s office for insurance purposes results of the proposed prosthodontic therapy
and medico-legal reasons. The option to do is important and applicable to the patient. In
“no treatment” should also be presented with order to provide a clinically significant therapy
include elimination of pain, difficulty with

mastication, esthetics, and quality of life.
Prosthodontics has traditionally recom-
mended proactive treatment to avoid poor
outcomes, such as crowning teeth with cracked
enamel or large amalgam restorations and
replacing all missing teeth. The question for the
dentist to consider is: Which of these outcomes
is clinically relevant and how likely are these
outcomes with or without intervention? Making
a prediction of outcome (prognosis) becomes
Figure 13.49 Final complete crown for restoration an important clinical skill. The astute clinician
of implant at #3 site. should recognize that decisions to intervene
are crucial and in some cases may be less
and provide the patient with a prognosis, desirable to patients (Newman et al. 2006).
one should distinguish the importance and
meaning of results of therapy reported in the
Design a Properly Sequenced
dental literature so the patient can make an
Comprehensive Treatment Plan
informed decision. The prognosis for a specific
therapy must go beyond “statistics” and take There are five phases of dental treatment that
into account the patient’s preferences, values, should be recognized as necessary to prop-
and circumstances in combination with the erly sequence a comprehensive treatment
clinician’s experience and judgment. The key plan for a patient (Terezhalmy et al. 2009).
to providing the “best” prosthodontic treat- Phase I is emergency treatment to alleviate
ment is to be able to translate research findings pain, bleeding, or swelling. Phase II is the
into practice to help the patient and clinician removal and control of pathologic conditions
make informed dental care decisions (Forrest that need periodontal, endodontic, surgical,
et al. 2009). and/or operative dentistry therapy. Phase III
Patients are often treatment planned with is the prosthodontic repair or replacement
the understanding that certain therapies will of non-pathologic dental conditions, such as
have better long-term outcomes than others. severely worn, fractured, and/or missing teeth.
Prosthodontics is a treatment-oriented spe- Phase IV is the re-assessment of pathologic and
cialty and has traditionally provided dental non-pathologic conditions once all dental ther-
treatment for patients with two activities: apies have been completed. And, finally, Phase
replace defective and/or missing teeth and V is maintenance dental therapy and periodic
restore dental arches to an “ideal” occlusion. recall evaluations to assess the outcomes of
Unfortunately, in certain situations, these out- treatment.
comes may be at odds with patient preferences. As an example of a properly sequenced
Other outcomes, not advocated by traditional comprehensive treatment plan, a clinician
clinicians, should be considered when making would take into account that a grossly carious
prosthodontic treatment decisions. Certain molar tooth cannot be planned for endodontic
pathologies, such as caries and periodontal therapy and subsequently repaired with a core
disease may have significant outcomes for the build-up and a complete coverage crown if
success of prosthodontic therapies, includ- the tooth is non-restorable or has a guarded
ing loss of tooth structure, pocket formation, to hopeless periodontal prognosis. Although
mobility, abscess formation, and tooth loss. not an emergency situation, extraction of the
Other outcomes of significant relevance to tooth is indicated and the “best” option for the
partially and completely edentulous patients patient would be a fixed, removable, or implant
lesions, or destructive parafunctional habits

that the patient may not find important to
address before they receive their “new” crowns
or prosthesis. For this reason, it is incumbent
upon the dentist to educate the patient from
the very beginning of dental therapy about
the proper “sequence” of appointments based
upon a phased approach to dental treatment.
The five different “phases” of dental treat-
ment that can assist the clinician in sequencing
Figure 13.50 Partially edentulous patient with dental appointments are:
extensive dental problems.
Phase I: Emergency treatment.
Phase II: Removal of disease (gingivitis, peri-
odontitis, caries, pulpal and periapical
pathology, oral surgery, etc.)
Phase III: Replacement and final restoration
of teeth (fixed, removable, and implant-
supported prostheses).
Phase IV: Re-assessment
Phase V: Recall and maintenance.
The following complex patient treatment

plan is an example of the different “steps” for
Figure 13.51 Wax-up to aid in the diagnosis and replacement and final restoration of teeth that
treatment planning of interdisciplinary dental care can assist the clinician in sequencing dental
for patient in Figure 13.50. appointments based on the delivery of major
disciplines of prosthodontic care. When the
prosthesis offered as Phase III treatment after final treatment plan is presented to the patient,
Phase II surgical therapy. the clinician should always discuss the type of
Diagnostic wax-ups of the proposed restora- restorations, restorative materials, fixed and
tions should also be completed and shown to removable prostheses, esthetic expectations,
the more complex patient when discussing the complications, limitations, and oral hygiene
need for a properly sequenced comprehensive requirements (Figures 13.52–13.60).
treatment plan that involves interdisciplinary
care and referral to specialists (Figures 13.50
and 13.51).
Educate Patient Regarding Appointment

Sequence
The first appointment after a prosthodontic
treatment plan has been finalized should
start with trying to resolve the patient’s chief
complaint, such as a decayed, fractured, or
mobile tooth. Unfortunately, on many occa-
sions, the clinician will find it necessary to
Figure 13.52 Pre-treatment intraoral view of
focus on resolving other dental conditions, partially edentulous patient with severe wear of
such as active periodontal disease, carious natural dentition.
Figure 13.53 Post-surgical intraoral view of Figure 13.56 Diagnostic mounting and wax-up for
patient showing crown lengthened maxillary complete mouth reconstruction. Custom incisal
anterior teeth. guide table insures anterior guidance designed in
wax-up will be transferred to the final maxillary
and mandibular metal-ceramic anterior crowns.
Figure 13.54 Maxillary occlusal view of patient

with erosion of lingual surfaces of anterior teeth Figure 13.57 Pre-treatment frontal view of
due to acidic insult and fractured right first molar. diagnostic wax-ups showing short clinical crown
lengths on maxillary anterior teeth and need for
periodontal crown lengthening.
Figure 13.55 Mandibular occlusal view of patient Figure 13.58 Pre-treatment extraoral view of
with missing right molars and severe wear of teeth patient before periodontal crown lengthening of
due to bruxism. maxillary anterior teeth.
4. Survey and design of a mandibular unilat-

eral distal extension RPD.
5. Referral to oral surgeon for extraction
of severely fractured, non-restorable
maxillary right first molar.
6. Referral to periodontist for maxillary ante-
rior tooth crown lengthening.
7. Replacement of defective amalgams
and/or composite resins to establish
sound foundations for complete crowns
and fixed partial dentures.
Figure 13.59 Post-treatment extraoral view of 8. Construction of an occlusal splint to stabi-
patient after full mouth reconstruction. lize anterior teeth after crown lengthening,
increase patient’s vertical dimension of
occlusion (VDO), and evaluate mutually
protected occlusal scheme.
9. Preparation of teeth for complete cov-
erage crowns and fixed partial denture
(FPD) and wear of full mouth provisional
restorations.
10. Re-evaluation in four to six weeks of new
VDO and mutually protected occlusal
scheme, and molar extraction site healing.
11. Master impression of all prepared teeth
for fabrication of permanent crowns and
FPDs.
Figure 13.60 Post-treatment intraoral view of
patient after full mouth reconstruction with 12. Fabrication, try-in, adjustment of occlu-
maxillary crowns, maxillary fixed partial dentures, sion, and cementation of maxillary
mandibular surveyed crowns, and mandibular metal-ceramic crowns and FPDs and
unilateral distal extension RPD.
mandibular surveyed crowns.
13. Master impression of mandibular arch
Treatment Plan and Appointment with new surveyed crowns for unilateral
Sequence for Prosthodontic distal extension RPD.
Reconstruction of a Complex Patient 14. Framework try-in, altered cast impression,
wax try-in, and delivery of metal-based
1. Preventive procedures to improve oral unilateral distal extension mandibular
hygiene and periodontal condition, includ- RPD.
ing scaling, root planning, prophylaxis, 15. Fabrication of hard acrylic maxillary
and oral hygiene instruction. occlusal guard for nocturnal bruxism.
2. Referral for psychiatric and dietary coun- 16. Deliver occlusal guard, provide wear and
seling based on enamel loss and a medical care instructions for fixed and remov-
history of anorexia. able prostheses, and review oral hygiene
3. Occlusal evaluation, including diagnostic instructions.
casts, facebow transfer, maxillomandibu- 17. Re-evaluation, recall, and periodontal
lar records, articulation of casts, and maintenance appointments scheduled at
diagnostic wax patterns. three-month intervals.
Educate Patient Regarding Costs replace 3 missing teeth from the upper right
of Treatment 2nd molar to the upper right canine because
of the patient’s heavy wear due to bruxism,
As mentioned earlier, the success or failure
high caries risk, and/or the length of span
of prosthodontic clinical procedures often
of a fixed partial denture. If implants are not
depends upon the assessment of a patient’s
affordable to the patient, the patient is a poorly
personality, as well as, risk management of
controlled diabetic, or a chronic smoker,
their dental problems. It is not uncommon
then a maxillary Kennedy Class III tooth
for prosthodontic care and treatment of a
borne RPD may be a relatively inexpensive
patient in a dental office to take multiple
compromise and provide acceptable esthet-
visits at great expense to the patient. Some
ics, phonetics, and function for this patient
patients may even have certain expectations
(Nesbit et al. 2007).
for the delivery of dental care and should be
informed that during the course of treatment
unexpected complications or new conditions
may arise that may result in higher costs. Case 13.1 Diagnostic Summary and Treatment
Before initiating any prosthodontic proce- Planning for a Patient
dures, it is important to educate the patient
The diagnostic summary documents the prob-
regarding the appropriate sequence of visits,
lem list and diagnosis of your clinical and
the necessity for and cost of consultations
radiographic examination of your patient.
and specialty care, the cost of each appoint- In addition it also documents the following
ment and the total cost for the treatment items:
planned, and the time needed for each appoint-
ment to properly manage all of their dental 1. Explanation of treatment plan options.
conditions. 2. Risks and benefits of all options.
At times, a patient with dental disease that 3. Patient’s choice of treatment plan choice.
has been stabilized with Phase II treatment 4. Documentation of patient’s acceptance of
may have their prosthodontic care produced treatment plan.
in “stages” whereby not all of the fixed, 5. Comments made by the patient regarding
removable, and/or implant prostheses in the treatment plan alterations.
treatment plan are fabricated at the same time. 6. Your recommendations if alterations are
This allows for financially challenged patients made (especially if they are contrary to
to afford and pay for parts of the prosthodontic treatment options recommended).
treatment plan over an extended period of time 7. Assistance with continuity of care for your
(Nesbit 2007). For example, a partially eden- patients. As patients are treated and possi-
tulous patient that needs multiple surveyed bly relocate, it documents the reasoning for
crowns and maxillary and mandibular RPD a specific treatment plan.
can be offered a sequenced treatment plan to
The diagnostic summary can be written in a
do the surveyed crowns in one year and the
SOAP format. It includes:
RPDs in the next year.
In some situations, not only will diag- 1. Subjective and objective findings.
nostic criteria, but also patient modifiers, 2. Assessment and problem list categorized
in addition to financial constraints require by dental disciplines.
alternative treatment planning that result 3. Documentation of treatment plan and
in lower cost to the patient. For example, a options explained to the patient.
definitive metal-base removable partial den- 4. Explanation of risks and benefits for all
ture may have to be treatment planned to treatment plans and options.
5. Patient’s choice of treatment and that all S: Chief Complaint (in patient’s own words).
questions regarding treatment, including Review Medications, Adverse Drug Experi-
its risks and benefits are fully understood ences, Medical History, Dental History, Family
by the patient, and that the patient had all History, and Social History.
questions answered. What should you know about the patient’s
medical, dental, family, and social history? Why
The following is the recommended format is it important for you as a clinician to have
of a Diagnostic Summary for the complex this information? Answer: NEVER TREAT A
patient in Figures 13.61–13.65: STRANGER!
Figure 13.61 Pre-treatment panoramic radiograph for Case 1 patient.
Figure 13.62 Pre-treatment periapical radiographs for Case 1 patient.

involvements, tooth mobility, supragingival

plaque, supragingival and subgingival calculus.
Phase II: Removal of dental disease (gingivi-
tis, periodontitis, caries, pulpal and periapical
pathology, oral surgery, etc.) completed before
Phase III: Prosthodontic replacement and
restoration of teeth.
A: List and summarize problems by dental
disciplines. Problems listed in sequential order:
(1, 2, 3, etc.).
Systemic: List medical problems that could
influence your proposed treatment. Provide
Figure 13.63 Maxillary diagnostic cast for Case 1 summary of patient’s medications, past med-
patient. ical history, past dental history, social history,
and family history. Provide ASA risk status and
dental management considerations.
Example: Type II Diabetes – degree of blood
sugar control with oral insulin medications
varies weekly, thus delayed healing may be
experienced; allergic to Penicillin and latex. ASA
II. Patient cleared for routine dental care with
modifications based on blood sugar levels at
time of treatment. Do not prescribe Penicillin.
Use nitrile gloves and avoid patient contact with
latex dental products.
Oral Pathology: Summarize any head
or neck lesions and provide a differential
diagnosis if possible.
Figure 13.64 Mandibular diagnostic cast for Example: Small, irregular areas of dekera-
Case 1 patient.
tinization of filiform papillae on dorsal surface
of tongue. (1) Appearance is consistent with
O: Record vital signs. List the significant benign migratory glossitis (geographic tongue).
extraoral and intraoral findings including Observation indicated.
pathologic and non-pathologic conditions, Preventive: Summarize level of risk based
existing restorations, and prostheses. All clin- upon caries, cancer risk, and nutritional assess-
ical, radiographic, and periodontal findings ments.
should be charted on an odontogram in the Example: Xerostomia associated with poor
patient’s dental health record. This can be control of diabetes (or due to prescription med-
completed as part of a patient’s electronic ications) and chewing of mint lozenges places
health record (EHR) or completed on a form patient at moderate risk for cervical caries. (2)
that is maintained in a patient’s paper chart. Occlusion/TMJ: Summarize TMJ assess-
What clinical findings should be recorded ment and occlusal problems.
to diagnose periodontal disease? When should Example: Class III occlusion – noncontri-
definitive periodontal therapy be initiated butory. Also can list canine or group function
for a patient? Answer: Probing depths, gin- guidance, if any loss of vertical dimension due
gival margin level, mucogingival junction to occlusal attrition, and any symptoms with
level, bleeding on probing/purulence, furcation TMJs.
Figure 13.65 Charting of clinical, radiographic, and periodontal findings on odontogram in paper-based
chart.
Periodontics: Summarize assessment of mobility #21. Prognosis #4, 14, and 15 is guarded
gingivitis and periodontitis. with #15 supra-erupted beyond occlusal plane.
Example: Chronic generalized moderate (4) #21 has hopeless prognosis. (5)
periodontitis all quadrants with moderate to Oral and Maxillofacial Surgery: Summa-
heavy supragingival and subgingival calculus. rize problems for tooth and soft and/or hard
(3) Localized severe periodontitis with Class III tissue removal.
Example: #15 supraerupted below occlusal portion of treatment, reviewed risks and bene-
plane affects placement of mandibular dis- fits of accepted treatment or no treatment with
tal extension RPD. (4) #21 localized severe patient, patient had all questions answered.
periodontitis, Class III mobility, and hopeless Final treatment plan signed and dated by
periodontal prognosis. (5) patient.
Endodontics: Summarize pulpal and peri-
apical problems. Treatment Plan – By Description
Example: Non-contributory.
A sequential numbering system in the Problem
Operative Dentistry: Summarize character
List in the A portion of the SOAP format can be
of caries and defective restorations.
used to document the phase, tooth/surfaces,
Example: Caries #1-L (6) #4-D incipient (7)
diagnosis, procedure code, and treatment
#5-M (8) #8-M recurrent (9) #9-M recurrent
planned for the patient.
(10) #11-M (11) #14-M (12) #15-M and D (13)
Additional problem numbers can be added
Cervical erosion #4-F (14) #5-F (15) #14-F (16)
sequentially among or after those listed as in
#15-F (17) #21-F (18) #22-F (19) and #28-F
the example below. It should be noted that
(20)
dental discipline treatment was “phased” for
Fixed Prosthodontics: Summarize prob-
this patient based on clinical, radiographic,
lems necessitating crown and bridge treat-
and photographic findings and the diag-
ment.
noses of both pathologic and non-pathologic
Example: #4 needs MOD core build-up neces-
conditions. See Table 13.1 and Figure 13.66.
sitating PFM survey crown (21) and #14 has
large amalgam build-up necessitating PFM
survey crown. (21)
Implant Prosthodontics: Summarize
problems and rationales for implant treatment. 13.4 Summary
Example: Maxillary and mandibular implant
placement options discussed, but removable This chapter provides a review of tradi-
prosthetic treatment is less expensive option due tional clinical concepts for the diagnosis
to financial constraints of patient. and treatment planning of fixed, remov-
Removable Prosthodontics: Describe able, and implant prosthodontic procedures.
problems and rationale for removable pros- Although published “indices” for prosthodon-
thetic treatment. tic diagnosis have been presented and should
Example: Missing #2, 3, 7 (space closed), 13, be followed, it is noteworthy that excellent
and 16, maxillary arch needs tooth supported clinical care for completely dentate and
RPD (21) Missing #17, 18, 19, 20, 29, 30, 31, partially edentulous patients may be achieved
and 32, mandibular arch needs bilateral distal with classic treatment approaches as well as
extension RPD. (22) new evidence-based therapies. It is hoped that
Orthodontics: Summarize problem and the diagnosis and treatment planning guide-
rationale for orthodontic treatment. lines and principles presented in this chapter
Example: #7 missing but space closed. #15 will improve the fit, function, and esthetics
supra-erupted to be extracted. Non-contributory. of dental prostheses provided by clinicians
P: Explanation of treatment options, risks and insure the best possible sequencing and
and benefits discussed, patient accepted treat- quality of restorative care for simple, as well
ment plan (by description) or patient rejects as, complex patients.
Table 13.1 List identifying problem, phase, tooth/surfaces, diagnosis, and procedure code for the dental
treatment planned for this patient.
Problem Phase Tooth/Surfaces Diagnosis Procedure Code Treatment Description
1 2 Tongue Glossitis Monitor benign condition

2 2 All Caries Risk 1204 Fluoride application
2 2 All Caries Risk 1303 Oral hygiene instruction
3 2 UR Mod Perio 4341 SCRP
3 2 UL Mod Perio 4341 SCRP
3 2 LL Mod Perio 4341 SCRP
3 2 LR Mod Perio 4341 SCRP
4 2 15 Supra-erupted 7110 Extraction
5 2 21 Hopeless Perio 7110 Extraction
6 2 1-L L Caries 2140 Amalgam, 1 surface
7 2 4-MOD D Caries 2950 Amalgam, Core build-up
8 2 5-MO M Caries 2150 Amalgam, 2 surface
9 2 8-ML M Caries 2331 Resin, 2 surface anterior
10 2 9-ML M Caries 2331 Resin, 2 surface anterior
11 2 11-L L Caries 2330 Resin, 1 surface anterior
12 2 14-MOD M Caries 2950 Amalgam, Core build-up
13 No treatment, see Problem 4.
14 4-F Cervical Erosion 2385 Resin, 1 surface posterior
15 2 5-F Cervical Erosion 2385 Resin, 1 surface posterior
16 No treatment, see Problem 21
19 2 22-F Cervical Erosion 2330 Resin, 1 surface anterior
20 2 28-F Cervical Erosion 2385 Resin, 1 surface posterior
21 3 4 RPD Abutment 2750 PFM Survey Crown
21 3 14 RPD Abutment 2750 PFM Survey Crown
21 3 Max Arch 5213 RPD, maxillary Class III
22 3 Mand Arch 5214 RPD, mandibular Class I
3 4 Perio Reassessment
All 4 Case Reassessment
All 5 Recall
Prosthodontic restorative treatment is identified as Phase 3 in the sequential planning of delivery of care.
Figure 13.66 Recommendation form with preliminary designs for RPDs summarizes the diagnosis and
planning of Phase I and II dental discipline treatment needed before Phase III fixed and removable
prosthodontics treatment.
References
Forrest, J.L., Miller, S.A., Overman, P.R., and Hollender, L.G., Arcuri, M.R., and Lang, B.R.
Newman, M.G. (2009). Evidence-Based (2003). Chapter 3 diagnosis and treatment
Decision Making, 127–132. Philadelphia: planning. In: Osseointegration in Dentistry: An
Lippincott Williams & Wilkins. Overview, 2e (eds. P. Worthington, B.R. Lang
and J.E. Rubenstein), 19–29. Chicago: (eds. S.J. Stefanac and S.P. Nesbit), 200–209.
Quintessence Publishing Co., 86–87. Philadelphia: Mosby, Inc.
Jahangiri, L., Moghadam, M., Choi, M., and Newman, M.G., Takei, H.H., and Klokkevold,
Ferguson, M. (2011). Case 1 Treatment of an P.R. (2006). Carranza’s Clinical Periodontology,
Edentulous Patient with Conventional Denture 10e, 38–39. St. Louis: WB Saunders.
Prostheses. In: Clinical Cases in Prosthodontics, Ozar, D.T. and Sokol, D.J. (2002). Dental Ethics at
9–14. Singapore: Blackwell Publishing Ltd. Chairside. Professional Principles and Practical
McGarry, T.J., Nimmo, A., Skiba, J.F. et al. Applications, 2e, 57. Washington: Georgetown
(1999). Classification system for complete University Press, 291.
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McGarry, T.J., Nimmo, A., Skiba, J.F. et al. (2003). Stewart’s Clinical Removable Partial
(2002). Classification system for partial Prosthodontics, 3e, 127. Chicago: Quintessence
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McGarry, T.J., Nimmo, A., Skiba, J.F. et al. Rose, L.F., Mealey, B.L., Genco, R.J., and Cohen,
(2004). Classification system for completely D.W. (2004). Periodontics: Medicine, Surgery,
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73–82. Terezhalmy, G.T., Huber, M.A., and Jones, A.C.
Nesbit, S.P. (2007). The motivationally or (2009). Physical Evaluation in Dental Practice,
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313

13.1 Documenting Patient Health Histories, 313

13.1 Documenting Patient achieve favorable prosthodontic outcomes (see

Physical Evaluation and Treatment Planning in Dental Practice, Second Edition.

Figure 13.1 Pre-treatment lateral facial view of

Figure 13.3 Completely edentulous patient shown

Figure 13.4 Intraoral frontal view of completely

and prosthodontic restorative treatment to

Figure 13.5 Intraoral frontal view of patient with

Figure 13.7 Extraoral facial measurement of

Figure 13.6 Post-treatment lateral facial view of

much better about his personal appearance

Figure 13.15 Frontal view of completed maxillary

Figure 13.12 Patient with survey crown #27 and

Figure 13.16 Occlusal view of mandibular

constraints, often times result in a choice of

options and a key to the success of any SUBJECTIVE (S):

13.3 Designing Prosthodontic

Figure 13.20 Intraoral frontal view of partially

of maxillary and mandibular removable

be appropriate to discuss with the patient that

(1) Improved treatment planning. 13.24). Proper prosthodontic diagnosis allows

Figure 13.27 PDI Class II partially edentulous

Figure 13.31 PDI Class IV partially edentulous

Figure 13.32 PDI Class IV partially edentulous

residual ridge requires pre-prosthetic surgery

Class IV Long span with multiple missing

who needed extensive endodontic and oral

Figure 13.34 1/2 T-bar clasp assembly drawn on

Fabricate Radiographic Stent

Figure 13.40 Post-treatment view of maxillary

and restorative dentist can accurately measure

Discuss Prognosis and Alternative

Figure 13.48 Periapical radiograph of implant

the benefits of treatment and the risks of no

include elimination of pain, difficulty with

lesions, or destructive parafunctional habits

The following complex patient treatment

Educate Patient Regarding Appointment

Figure 13.54 Maxillary occlusal view of patient

4. Survey and design of a mandibular unilat-

Figure 13.61 Pre-treatment panoramic radiograph for Case 1 patient.

Figure 13.62 Pre-treatment periapical radiographs for Case 1 patient.

involvements, tooth mobility, supragingival

Problem Phase Tooth/Surfaces Diagnosis Procedure Code Treatment Description

1 2 Tongue Glossitis Monitor benign condition

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