1. 1. THE CLINICAL GUIDE SERIES JC Davenport, R M Basker, J RHeath, J P Ralph & P 0 Glantz A CLINICAL GUIDE TO REMOVABLE PARTIAL DENTURES The authoritat ive reference fo r dental pract itioners and st udents
2. 2. Contents Preface Acknowledgements Part I -Patient assessment Need and demand for treatment v VI 3 52 The removable partial denture equation 3 Management options for the partially dentate patient 4 RPDs and the elderly 5 The anatomy of the denture-bearing areas 6 Jaw relationships 7 Information gathering: history, examination, diagnosis and treatment planning 8 Preliminary impressions 9 Articulators 15 21 25 33 39 47 53 Part 2 - Preparation of the mouth 57 10 Initial prosthetic treatment 11 Surgery 12 Periodontal treatment 13 Orthodontic treatment 14 Conservative treatment 15 Tooth preparation 59 69 71 75 77 81 Part 3 - Prosthetic treatment 89 16 Working impressions 17 Recording the jaw relationship 18 Trial insertion of the metal framework 19 Altered cast technique 20 Trial insertion of waxed -up dentures 21 Insertion of the completed denture 22 Review 91 99 107 111 115 123 129 Further reading Index 133 137
3. 3. Part1 Patientassessment art 1 of this book opens by making the important distinction between the need Pand the demand for removable partial denture (RPD) treatment. A discussion of the advantages and disadvantages that can result from fitting an RPD (chapter 2),and an account of the various management options for the partially dentate patient (chapter 3) follow. The increasingly pertinent subject of RPDs and the elderly is con sidered next (chapter 4), followed by a reminder of the relevant aspects of intra-oral anatomy, and jaw and occlusal relationships (chapters 5 and 6). By applying this knowledge during the history taking and examination of the patient, information is obtained to develop a diagnosis and a provisional treatment plan (chap ter 7). However, before the latter can be finalised, it is necessary to examine study casts obtained from preliminary impressions of the patient's mouth (chapter 8). These casts may need to be mounted on an articulator (chapter 9).
4. 4. Needanddemandfor Thave, whilst 'demand' refers to the treatment requested by he term 'need' is commonly used to describe the amount of treatment that dentists judge their patients ought to the patients themselves. Most studies of prosthetic need and demand show that the former is larger than the latter. The many reasqns for this difference can be considered under the following headings. Availability of treatment. Acceptability of treatment. Accessibility of treatment. Availability Availability refers to numbers of dentists, their particular skills, their accessibility to the public and the economic realities of the community in which they practise. Acceptability Acceptability describes the attitudes of people to different forms of treatment. These attitudes are influenced by such matters as education, personal finance, and cultural background. Accessibility Accessibility highlights important differences between people. For example, a particular form of prosthetic treatment may be equally Figure 1.1 Whether or not a removable partial denture (RPD) is worn by the patient is dependent upon self-motivation. In a UK survey people were asked, 'If you had several missing teeth at the back would you prefer to have an RPD or manage without?' The chart shows that most people would prefer to manage without and that the preference grows stronger with increasing age. It is almost as if the longer the person has managed to avoid dentures the stronger is the wish to do without them. available to young and old patients, but the latter may find that the effort needed to seek out that treatment is just too great. Recognizing the difference between need and demand prompts the question, 'How many teeth must be lost before a patient seeks prosthetic replacement?' Experience suggests that the answer can vary greatly. On the one hand, the loss of one anterior tooth is usually a powerful motivator for the patient, whereas another patient may have had many posterior teeth extracted before they seek the advice and help of a dentist. Although the restoration of appearance can be a powerful motivating factor, not every patient will seek treatment follow ing the loss of an anterior tooth. A study of elderly men living in an area where dental treatment was readily available and afford able showed that one in five had at least one unrestored space towards the front of the mouth. In another study, dentists rated the dental appearance of a group of elderly people as less attrac tive than did the subjects themselves. The dentist must therefore avoid preconceptions and consider the thoughts and wishes of the individual patient before recommending the provision of a denture. The time, effort and understanding taken to make this judgement are likely to prevent unnecessary treatment. There can thus be a large difference between the perception of need and demand for a prosthesis as an aid to chewing efficiency. Nutritional status is affected by psychological, sociological and economic factors as well as by the effectiveness of the dentition. 100% 90% 80% 60% 50% 40% 30% 20% 10% .!!lr:: ..a.. 16-24 25-34 35-44 45-54 Age (Yrs) 55-64 65 and over Have RPD (%) 121Manage without (%) 3
5. 5. A clinical guide to removable partial dentures 100% 90% 80% 70% 60% 50%!!!c GI :;:; aO ..I 30% 10% 0% 16-24 25-34 35-44 45-54 55-64 65 and Age (Yrs) over Very upsetting D A little upsetting IZlNot at all upsetting For missing posterior teeth, the concept of the shortened dental arch (SDA) is relevant. Here the needs for oral health and 90 80 70 Ill