Introduction to Clinical Removable Partial Denture Prosthodontics - PDF

Clinical Partial Denture Prosthodontics A lecture By: Dr. Rabie M El huni. BDS, MSc, Advanced Education in Implant Dentistry. Assistant Professor at Department of Prosthodontics, Faculty of Dentistry Benghazi University....

Clinical Partial Denture Prosthodontics A lecture By: Dr. Rabie M El huni. BDS, MSc, Advanced Education in Implant Dentistry. Assistant Professor at Department of Prosthodontics, Faculty of Dentistry Benghazi University. Dr. Rabie El huni 1  Clinical Partial Denture prosthodontics Course Description  The Prosthodontic approach to the management of the partially edentulous conditions will be presented in the form of lectures and clinical phases of this course.  The student will be exposed to the training of prosthodontic therapeutic techniques. The development of skills in clinical practice will be limited to the procedures that are expected to be performed as part of an integrated, comprehensive care of the patients from a general dentistry standpoint.  However, emphasis will continue to be placed on gaining proficiency in basic techniques of removable partial denture prosthodontics Dr. Rabie El huni 2  Professional Performance Standards At the end of the course the student is expected to be able to: 1) Identify, manipulate and understand properties of all the materials to be used in the performance of various clinical and laboratory steps. 2) Follow a complete diagnostic procedure, plan a course of treatment which includes any pre-prosthetic management as the case warrants. 3) Perform basic clinical steps like impression making, mouth preparation, recording jaw relations, try in, insertion procedures and management of post insertion problems. 4) Perform all those laboratory procedures related with the clinical steps. 5) Evaluate and sum up the results of the performed treatment of different steps. 6) Evaluate patient through various means in the maintenance and care of the prosthesis and the oral tissues. Dr. Rabie El huni 3  Course Topics 1. Examination of partially edentulous patients. 12. Try-in of metal framework, inter-maxillary relation 2. Primary Impressions and Diagnostic Casts (Recording Jaw Relations) for R.P.Ds 3. Indications an contraindications of Removable 13. Selection and arrangement of artificial teeth, try- Partial Dentures. in of waxed-up partial dentures. 4. Surveying Procedures 14. Insertion of partial dentures, advice to R.P.D patients, adjustment, and follow-up procedures. 5. Designing the work authorization and instructions to laboratory technicians. 15. Repair of R.P.Ds and addition of clasps. 6. Principles of partial denture designing including 16. Harmful effects of R.P.Ds designing: a) Clasps B) Major & minor connectors C) 17. Special, un-conventional R.P.Ds Rests. 18. Prosthetic aspects of dental implants. 7. Management of distal-extension base partial 19. Implant Removable Partial Dentures dentures Kennedy Class I and II. 20. Implant retained complete overdentures. 8. Management of class III and IV. 21. Implant retained fixed detachable complete 9. Mouth preparation to receive R.P.Ds dentures. 10. Modification of Abutment tooth contours 22. Maxillofacial Prosthodontics. 11. Definitive impressions for R.P.Ds. Dr. Rabie El huni 4 Effect of Tooth Loss Dr. Rabie El huni 5  Partial Denture Prosthodontics  This involves the replacement of the dentition for patients who have lost some of their natural teeth, or are soon to lose them.  Partial dentures must be designed and constructed with an emphasis on the preservation of remaining associated oral structures. Dr. Rabie El huni 6 Removable Partial Denture Treatment Objectives  Preserve remaining associated oral structures.  Provide adequate masticatory function.  Restore natural appearance.  Restore normal speech.  Enhance patient’s quality of life, Dr. Rabie El huni 7  Limitations of Removable Partial Dentures  The essential difference between natural and artificial teeth is that the former are firmly rooted in the bone of the jaws.  On the other hand, artificial dentures are economical prosthodontic solution involving sound abutment teeth for increased retention.  Removable Partial Dentures help maintain teeth of strategic value if other options, e.g. implants are not an option.  The prosthetic flange can also maintain facial fullness.  However, abutment teeth for removable partial dentures are at high risk for both caries and periodontal disease. Dr. Rabie El huni 8  Limitations of Removable Partial Dentures  Compared to fixed partial dentures (FPDs) or dental implants, the stated advantages of RPDs include lower cost and easier oral hygiene procedures.  RPDs are complex devices and many technical errors may lead to clinical complications. However, Biological, mechanical, esthetic, and psychological factors are related to Patients’ perceptions and acceptance of the prosthesis and, consequently, to the success of treatment.  Patient age, previous experience, and replaced tooth position may influence self-reported satisfaction outcomes. Dr. Rabie El huni 9 R.P.Ds Complications Dr. Rabie El huni 10 R.P.Ds Complications Dr. Rabie El huni 11 Alternative Treatment Options Dr. Rabie El huni 12 Shortened Dental Arch Concept Dr. Rabie El huni 13  Shortened Dental Arch Concept  The literature indicates that dental arches comprising the anterior and premolar regions meet the requirements of a functional dentition.  However, functional demands, and the number of teeth to satisfy such demands, vary with the individual and, consequently, dental treatment must be tailored to each individual’s needs and adaptive capability.  By offering the partially dentate patient a treatment option that ensures oral functionality, improved oral hygiene, comfort, and possibly reduced costs, the shortened dental arch (SDA) treatment approach appears to provide an advantage without compromising patient care. Dr. Rabie El huni 14  Diagnosis and Treatment Planning  Diagnosis is the examination of the physical state, evaluation of the mental or psychological make-up, and understanding the needs of each patient to ensure a predictable results.  Diagnosis and treatment planning for oral rehabilitation of partially edentulous mouths must take into consideration the following:  Control Of Caries And Periodontal Disease,  Restoration Of Individual Teeth,  Provision Of Harmonious Occlusal Relationships,  And The Replacement Of Missing Teeth By Fixed (Using Natural Teeth and/or Implants) Or By Removable Prostheses. Dr. Rabie El huni 15  Diagnosis and Treatment Planning  Because these procedures are integrally related, the appropriate selection and sequencing of treatment should precede all irreversible procedures. Diagnosis and treatment planning History Pre-extraction Examination Investigations taking records Examination of Extraorally Intraorally existing restoration Patient Medical Dental Prosthesis data history history history Study Casts Photographs Dr. Rabie El huni 16  History taking  History taking consists of communicating with the patient in order to obtain essential personal details, including chief complaint, desire and expectations, and health information: 1. Patient Data: Name, address, & telephone number, age, sex, and occupation. 2. Chief Complaint: the pt.’s reason for seeking dental treatment and level of motivation towards the maintenance of oral and denture hygiene. 3. Medical History 4. Dental History 5. Prosthesis History; Satisfactory or Unsatisfactory Dr. Rabie El huni 17  Medical History  A thorough and accurate medical history must be obtained during the diagnostic phase of partial denture treatment and must be updated as necessary.  The patient’s past medical history and current medical status should be reviewed with particular attention to known allergies, current medications, drug interactions, and bleeding tendencies.  The successful replacement of missing teeth could be affected by some local or systemic conditions which can be broadly divided into: Dr. Rabie El huni 18  Medical History A. Cardiovascular diseases: atherosclerosis, hypertension, chronic heart failure and atrial fibrillation. A recent myocardial infarction, stroke and cardiovascular surgery B. Bleeding disorders: haemophilia, intake of blood thinning medications C. Poorly controlled Diabetes Mellitus D. Osteoporosis E. Chronic Obstructive Pulmonary Disease F. Psychological conditions G. Medications. Dr. Rabie El huni 19  Dental & Prosthesis History  The history of the patient’s dental condition should include the beginning and severity of the dental disease and the patient’s reaction to dental treatment.  Information regarding the teeth extractions should always be sought.  Radiographic investigation should be asked for following a history of difficult extraction to exclude any possible over-retained roots or other pathologies.  Sufficient time should elapse after teeth extractions to allow for healing and ridge stability. Dr. Rabie El huni 20  Dental & Prosthesis History  The possibility of utilizing a temporary appliance may need to be considered.  Previous prosthetic experience should be noted.  The number of appliances and the time duration each denture has been worn may influence anticipated prognosis. Dr. Rabie El huni 21  Observation of the patient  General appearance. Complexion: the natural color (fair or dark), texture, and appearance of a person’s skin, specially of the face.  Mental attitude classification: A. Philosophical patient: A patient with a rational, sensible, calm and composed disposition. B. Exacting patient: Who likes to know every procedure in detail. 22 Dr. Rabie El huni  Observation of the patient C. Indifferent patient: Who is least bothered about the treatment being offered, uninterested person who may pay no attention to dentist’s instructions, uncooperative, and may blame the dentist for poor dental health D. Hysterical patient: Who has an unhealthy fear about the treatment, emotionally unstable, excitable, and excessively apprehensive person. 23 Dr. Rabie El huni  Mental Attitude patient  Dr. Ewell Neil, in his 1932 textbook entitled "Full Denture Practice" Neil E. Full Denture Practice. 1932. Nashville, Tennessee, Marshall & Bruce. appears to be the first to describe a mental attitude system that came to be widely used in removable prosthodontics.  This system classified patients’ mental attitude into one of four categories: Philosophical, Exacting, Hysterical or Indifferent. It is important to point out that while the introduction of the system has traditionally been credited to Dr. M. M. House, it actually was Dr. Neil who should be recognized as the actual developer of the system as noted in a 2005 publication. Winkler S. House mental classification system of denture patients: The contribution of Milus M. House. J Oral Implantol 2005;31:301-303.  Crediting the system to House likely occurred because of the profession's lack of familiarity with the contents of Neil's 1932 textbook. Meanwhile, House's presentation of the classification in a 1958 dental journal article House MM. The relationship of oral examination to dental diagnosis. J Prosthet Dent 1958;8:208-219. described the relationship of oral examination to dental diagnosis and likely was more widely read, recognized and put to use in the dental profession. Dr. Rabie El huni 24  Cross-Infection Control  All procedures to ensure the safety of the patient and the operating personnel including the dentist, assistants, laboratory technicians etc. must be adhered to.  This includes appropriate cross infection barriers, and sterilization and immunization protocols. Dr. Rabie El huni 25  Clinical and Laboratory Disinfection  Immunization.  Barrier system  Hand washing with antimicrobial soap.  Use of personal protection equipment i.e. gloves, mask, protective eyewear, chin-length face shield, protective clothing ( i.e. , lab coats or gowns).  Instrument sterilization and/or disinfection  Users' demands regarding dental safety glasses. Combining a quantitative approach and grounded theory for the data analysis. Lönnroth EC, Shahnavaz H Int J Occup Saf Ergon. 2001; 7(1):49-59  Recommended Infection Control Practices  Gloves should be worn in treating all patients.  Masks should be worn to protect oral and nasal mucosa from splatter of blood and saliva.  Eyes should be protected with some type of covering to protect from splatter of blood and saliva.  Sterilization methods known to kill all life forms should be used on dental instruments.  Sterilization equipment includes steam autoclave, dry heat oven, chemical vapor sterilizers, and chemical disinfectants. Dr. Rabie El huni 27 Barrier System Dr. Rabie M El huni Dr. Rabie M El huni  Recommended Infection Control Practices  Attention should be given to cleanup of instruments and surfaces in the operatory. This includes scrubbing with detergent solutions and wiping down surfaces with iodine or chlorine (diluted household bleach solutions).  Contaminated disposable materials should be handled carefully and discarded in plastic bags to minimize human contact.  Sharp items, such as needles and scalpel blades, should be contained in puncture- resistant containers before disposal in the plastic bags. Dr. Rabie El huni 30 Denture Stomatitis Dr. Rabie M El huni  Prosthetic Appliances International Journal of Dental Hygiene. May 2018: 16(2): 179-201 Dr. Rabie M El huni  Observation of the patient  Facial examination: Frontal Profile  Lips Dr. Rabie El huni 33  Clinical Examination  A thorough clinical examination and careful acquisition of data represent critical findings needed to arrive at an accurate diagnosis and appropriate treatment plan.  Examination of the maxillofacial extra- and intra-oral hard and soft tissues, appropriate preliminary impressions, accurate records required to articulate maxillary and mandibular casts, and routine radiographs and photographs represent vital information that should be carefully collected. Dr. Rabie El huni 34  Extra-oral Examination  Examination should begin with an extra-oral assessment of the facial form and symmetry, jaw movements, and palpation of T.M.Js and muscles of mastication. Neuromuscular skills or coordination: Muscle tone: Good, fair, or poor Temporomandibular joint : Deviation,Tenderness, Clicking, Dislocation Lymph nodes Dr. Rabie El huni 35 Extra-oral Examination Dr. Rabie El huni 36  Extra-oral Examination Esthetic risk assessment (ERA) o Low lip line = no exposure of papilla. o Medium lip line = exposure of papilla. o High lip line = full exposure of mucosa margin. Dr. Rabie El huni 37 Extra-oral Examination Dr. Rabie El huni 38 Dr. Rabie El huni 39 Dr. Rabie El huni 40 Intra-oral Examination Denture Bearing Area Dr. Rabie El huni 41 Intra-oral Examination Denture Bearing Area Dr. Rabie El huni 42 Intra-oral Examination Denture Bearing Area Dr. Rabie El huni 43 Intra-oral Examination Denture Bearing Area Dr. Rabie El huni 44  Intra-oral Examination  Preliminary visual inspection of the mouth will indicate the basic standard of oral hygiene, the level of caries susceptibility, and the quality of existing restorations.  Special attention should be directed to areas of specific complaint where it may be necessary to institute emergency intervention to relief pain.  Detailed examination should commence with examining the soft tissues covering the lips, cheeks, tongue, palate and floor of the mouth to exclude any pathology.  The presence of gingival or mucosal inflammation in areas covered by a previous denture (Denture Stomatitis) should be noted so an appropriate treatment may be initiated. Dr. Rabie El huni 45 Intra-oral Examination Dr. Rabie El huni 46  Intra-oral Examination  The individual dental arches should be carefully inspected, the location of edentulous spaces noted and the distribution and alignment of remaining teeth carefully assessed in relation to edentulous spaces. Dr. Rabie El huni 47  Intra-oral Examination  The form of the residual ridge and the compressibility of soft tissues in the edentulous area should be assessed visually and by palpation since incompressible areas may have to be avoided by denture margins. Dr. Rabie El huni 48  Intra-oral Examination  The integrity of existing restorations should be carefully checked and carious cavities charted. Dr. Rabie El huni 49  Intra-oral Examination  The health of periodontium should be determined. Standards of plaque control should be assessed and plaque scores may be recorded.  Pocket depths should be measured and charted and any mobility of remaining teeth sholud be noted especially if they are potential abutment teeth. Dr. Rabie El huni 50  Intra-oral Examination  Determination of the floor of the mouth position and border tissue attachments may influence the decision to use removable appliances to replace missing teeth. Dr. Rabie El huni 51 Dr. Rabie El huni 52  Intra-oral Examination  Evaluation of denture foundation should report if any torus palatinus or mandibular tori may need to be surgically removed before preceding or specific types of major connectors will by-pass the torus. Dr. Rabie El huni 53  Intra-oral Examination  The dental arches should then be examined in occlusion and a very critical assessment of: Maximum inter-cuspation, eccentric mandibular movements, vertical dimension of occlusion, tooth wear, over-eruption, tilting or drifting in relation to the opposing arch. Dr. Rabie El huni 54  Intra-oral Examination  Occlusal indicator wax, articulating paper or tape, and then metal foil (Shimstock) may be helpful in clinical assessment of occlusion.  It is also helpful to remember that mounting casts on articulators will help evaluate occlusal schemes and interferences. Dr. Rabie El huni 55  Intra-oral Examination  Existing R.P.Ds should be examined carefully.  The design, quality of construction, fitting to mucosal tissues and tooth contacts and the appearance should be noted and any associated problems should be carefully evaluated and reported. Dr. Rabie El huni 56 Clinical Oral Dryness Score Dr. Rabie El huni 57 Clinical Oral Dryness Score Dr. Rabie El huni 58 Clinical Oral Dryness Score Dr. Rabie El huni 59  Radiographic Evaluation A very important part of diagnosis is determining if the adjacent teeth and bone are free from pathology. The minimum radiographs needed to permit a proper diagnosis include a panoramic, bite wings and/or periapical radiographs. Dr. Rabie El huni 60  Radiographic Evaluation Radiographs should be obtained to check for new or recurrent carious lesions which may not have been revealed by clinical inspection. X-rays are also helpful to reveal the extent of any bone loss and to identify any pathological changes within the jaws. Dr. Rabie El huni 61 Dr. Rabie M El huni Radiographic Evaluation Dr. Rabie El huni 63  Preliminary Impressions Preliminary impressions of a patient’s mouth are obtained in stock impression trays. The resulting study casts are needed for planning treatment, including the designing of partial dentures, and for the construction of individual custom trays which will be used to obtain more accurate definitive impressions required for the fabrication of R.P.Ds. Stock trays are available in variety of sizes and shapes. They may be perforated or plain, metal or plastic, of simple box design or shaped to fit bilateral free-end saddles. Dr. Rabie El huni 64 Preliminary Impressions Dr. Rabie El huni 65  Preliminary Impressions The size of tray is selected so that the teeth sit centrally within the tray. If possible, there should be a space of about 4 mm between the flange of the tray and the buccal and labial surfaces of the teeth. X Dr. Rabie El huni 66  Preliminary Impressions Utility wax can be used to extend tray borders to cover vestibules. There may be regions where the tray is poorly adapted to the underlying structures such as the palate or the saddle areas. In such cases the dead space should be filled by placing impression compound or putty PVS in the appropriate area. The compound will then need to be molded in the mouth. Dr. Rabie El huni 67 Preliminary Impressions Dr. Rabie El huni 68  Preliminary Impressions Once modification of the stock tray has been completed, a thin layer of adhesive is applied and allowed to dry before it is loaded with alginate. The tray is then seated in the mouth and the impression is made. Dr. Rabie El huni 69  Disinfection of Impressions  Impressions should be rinsed to remove saliva, blood and debris and then disinfected before being sent to the laboratory.  Immersion disinfection has been preferred to spraying. Immersion is more likely to assure exposure of all surfaces of the impression to the disinfectant for the recommended time.  Spraying disinfectants onto the surface of the impression reduces the chance of distortion, especially in the case of alginate and polyether materials, but may not adequately cover areas of undercuts. Infection control recommendations for the dental office and the dental laboratory. ADA Council on Scientific Affairs and ADA Council on Dental Practice. J Am Dent Assoc 1996;127:672-80. Matyas J, Dao N, Caputo AA, Lucatorto FM. Effects of disinfectants on dimensional accuracy of impression materials. J Prosthet Dent 1990;64:25-31 Dr. Rabie M El huni  Disinfection of Impressions  After the recommended contact time, the item is rinsed and handled in an aseptic manner for transfer to the laboratory production area.  Iodophors, chlorine solutions, glutaraldehydes or phenols are all acceptable for this step.  All items disinfected in the dental office should be labeled indicating that such items have been decontaminated using an accepted disinfection routine. Dr. Rabie M El huni  Disinfecting Impression Trays Plastic disposable stock trays are used then discarded (if non-autoclavable). Sodium hypochlorite can be used as a disinfectant on aluminium- or chrome- plated trays. But these trays should be monitored for corrosion. Impression trays can also be heat-sterilized.  Diagnostic Casts A diagnostic cast should be an accurate reproduction of all the potential features that aid diagnosis. These include:  The teeth locations, contours, and occlusal plane relationship;  The residual ridge contour, size, and mucosal consistency; and  The oral anatomy determining the prosthesis extensions. Dr. Rabie El huni 73  Diagnostic Casts Information provided by appropriate cast mounting includes: 1. Occlusal plane orientation and the impact on the opposing arch; 2.Tooth-to-palatal soft tissue relationship; 3.Tooth-to-ridge relationship, both vertically and horizontally. Dr. Rabie El huni 74  Mounting For diagnostic purposes, casts should be related on an anatomically appropriate articulator to best understand the role occlusion may have in the design and functional stability of the removable partial denture. This becomes increasingly more important as the prosthesis replaces more teeth. Dr. Rabie El huni 75 Dr. Rabie El huni 76  Occlusal Records If all the remaining posterior teeth occlude very precisely it may be possible to locate the casts in the inter-cuspal position. The casts must then be securely located together before being mounted on the articulator. Alternatively, the relationship may be recorded using a wax template. Dr. Rabie El huni 77  Occlusal Records If there are insufficient teeth remaining for a record of this type to be used successfully, it will be necessary to construct wax record blocks. Dr. Rabie El huni 78  Diagnosis If the reason for the patient’s initial attendance was centered on his/her chief complaint, then the ultimate stage of the history and examination phase is to establish a diagnosis from which a treatment plan will be concluded. Complaints will come in many forms and may be related to pain in the teeth, facial pain, difficulty in eating, a deteriorating appearance or an existing R.P.D that is unsatisfactory. However, findings from the history, examination and requested investigations should provide sufficient evidence for the cause to be established. Dr. Rabie El huni 79  Treatment Plan If necessary, emergency treatment should be undertaken. Impressions should be taken, casts obtained, and if necessary mounted on articulators. The initial treatment plan should be drawn up and discussed with the patient in addition to alternative treatment options. If R.P.D is considered, then an explanation of the possible pre-prosthetic mouth preparation procedures involved. Treatment options may include: No treatment. Extraction of the remaining teeth and providing complete dentures. Dr. Rabie El huni 80  Advantages and Disadvantages of Treatment Options Removable Prostheses Advantages Replace multiple teeth in multiple sites Can be used to replace teeth in growing patients. Generally do not require extensive preparation of abutment teeth May be designed to accommodate future tooth loss Can be used to replace missing soft tissue Can provide good lip support by incorporating labial flanges Aesthetics may be very good The least expensive of restorations Dr. Rabie M El huni Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Removable Prostheses Disadvantages Removable prostheses may not be liked by patient and may reduce self- confidence Connectors cover soft tissue such as the palate and gingiva In subjects with less than ideal oral hygiene they may compromise the health of the periodontal tissues and promote caries around abutment teeth. Retentive elements such as clasps may spoil aesthetics Moderate maintenance requirements and durability Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Fixed Prostheses Fixed prostheses fall into two main categories: 1) Resin bonded bridgework 2) Conventional partial or full coverage bridgework Dr. Rabie M El huni Resin Bonded Bridgework Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Resin Bonded Bridgework Advantages Minimal or no preparation required + supra-gingival margins Reduced chair-side time Good aesthetics if ideal spacing exists and abutment teeth are satisfactory Less expensive than conventional bridges Consequences of failure are relatively small caries is readily diagnosed in most instances. Cantilever designs for single tooth replacements minimize potential problems Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Resin Bonded Bridgework Disadvantages Lack of predictability: de-cementation leading to loss of retention or caries under one of the retainers — average life span 5 to 7 years. Dependent upon meticulous technique and available enamel surface area for bonding May interfere with occlusion, particularly incisal guidance Patients may feel sense of insecurity with restoration, especially if their bridge has debonded previously Change in color/translucency of abutment teeth due to presence of retainer Dr. Rabie M El huni Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Conventional Partial or Full Coverage Bridgework Advantages Fixed Good appearance, including that of abutment teeth if they need to be improved/ harmonized Medium term predictability is good for short span bridges Good control of occlusion possible Minimally compromise oral hygiene Dr. Rabie M El huni Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Conventional Partial or Full Coverage Bridgework Disadvantages Involve considerable tooth preparation which sometimes result in pulpal sequelae Failure due to de-cementation and caries of abutment teeth may lead to further tooth loss Moderately expensive Highly operator dependent requiring exacting techniques both clinically and technically Requires lengthy clinical time and temporary restorations Irreversible Dr. Rabie M El huni Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Implant retained prostheses Advantages Fixed or removable Independent of natural teeth — can provide fixed restoration where no abutment teeth exist Immune to dental caries High level of predictability Good maintenance of supporting bone Dr. Rabie M El huni  Advantages and Disadvantages of Treatment Options Implant retained prostheses Disadvantages Dependent upon presence of adequate bone quantity and quality Involves surgical procedure(s) Highly operator/ technique dependent High initial expense and lengthy treatment time Moderate maintenance requirements especially for removable or extensive fixed prostheses Dr. Rabie M El huni  Treatment Choice In situations where all types of prosthesis are possible, the final choice may rest with the patient, and is largely dependent upon their expectations/desires, financial budget and willingness to undergo treatment. It is important that the patient’s expectations are realistic and achievable. However, some factors may dictate that a certain type of restoration is not feasible or is undesirable. Dr. Rabie M El huni  Summary The patient should be presented with the treatment alternatives and an indication of their respective advantages and disadvantages in their particular case. The treatment plans should be outlined in writing and an estimate of the relative costs given. Complex treatment plans require more detailed descriptions and a projected timetable for completion and costing. It is important to ensure that the patient understands the proposals and is given the opportunity to clarify any matters. A written consent to the agreed treatment plan is advisable. Dr. Rabie M El huni R.P.D Design Dr. Rabie El huni 97