diagnosis and treatment plan of complete denture

1

If we wait until we are ready, we will

be waiting for the rest of our life

DIAGNOSIS AND TREATMENT

PLANNING OF COMPLETE

DENTURE

2

Presented by – Dwij M. Kothari

1st year P.G.

Darshan Dental College & Hospital

CONTENTS:

Introduction

Definition

General introduction to the patient

Principles of perception & Diagnostic procedure

Oral – Systemic interactions

Physical examination

Extraoral

Intraoral

Radiographic examination

3

Temporomandibular disorders and orofacial pain

Pretreatment records

Preprosthetic surgery

Treatment planning

Conclusion

References.

4

INTRODUCTION:

When people reach middle age they suffer from a variety of infirmities to which younger bodies are not victim.

Many of these illnesses were once thought to be inevitable consequences of old age, but now it is known that certain of them, such as nutritional deficiencies and tooth loss, are coincidental rather than incidental to increased age.

Aging is a variable process.

Elders create a need which must be met by the health professions and many of these patients need complete dentures.

5

Successful complete denture therapy begins with a

thorough assessment of the patient’s physical and

psychological condition and determining a treatment that

will deliver a functional complete denture that will

satisfy the expectations of the patient.

6

DEFINITIONS:

7

8

• Prosthodontics is the dental specialty pertaining to the

diagnosis, treatment planning, rehabilitation and maintenance of

the oral function, comfort, appearance and health of patients with

clinical conditions associated with missing or deficient teeth

and/or maxillofacial tissues using biocompatible substitutes.

According to GPT – 8TH ED. -

PROSTHODONTICS

DIAGNOSIS :-

According to HEART WELL

Diagnosis is the act or process of deciding the nature of

the diseased condition by examination

A careful investigation of facts to determine the nature

of a thing

The determination of the nature, location and causes of

a disease.

9

According to BOUCHER

Diagnosis consists of planned observations to determine

and evaluate the existing conditions, which lead to

decision making based on the conditions observed.

10

• According to GPT – 8TH ED.

The determination of the nature of a disease.

11

Treatment plan :-

According to SHELDON WINKLER

Treatment planning means developing a course of

action that encompasses the ramifications and sequelae of

treatment to serve the patient’s needs.

According to GPT- 8th ed. –

The sequence of procedures planned for the treatment of a

patient after diagnosis.

In short, DIAGNOSIS & TREATMENT PLAN can be

summarized as:

Recognizing the problem

Formulating the plan

Carrying out the necessary examination

Finally, interpreting the result.12

GENERAL INTRODUCTION

TO THE PATIENT:

First appointment most important time

Fact finding

Development of mutual trust & understanding

Familiar with the overall condition of the patient.

14

New patients + patients with previous experience

complete history taking & thorough examinations in

which perceptive abilities of the dentist play an

important role.

15

PRINCIPLES OF

PERCEPTION:

Detection: noticing something

Discrimination: distinguish which we have noticed from

something else.

Recognition

Identification

Judgement

16

DIAGNOSTIC

PROCEDURES

Preferably carried out in two appointments:

THE FIRST APPOINTMENT:

Acquainted with the patient

Beginning of evaluation of the process involved in

diagnosis & treatment plan

17

Obtain essential information from the patient:

18•Radiographic survey •Diagnostic casts

•Thorough history

Since success & failure of treatment depends greatly

on mutual confidence & rapport between the dentist &

patient, the first appointment is extremely important.

THE SECOND APPOINTMENT

The dentist discusses the proposed treatment plan

The sequence in which the treatment will be carried out

19

A THOROUGH HISTORY SHOULD INCLUDE:

Personal Data:

Name

Age

Sex

Race

Occupation

Cosmetic index: Class I- High cosmetic index

Class II - Moderate cosmetic index

Class III- Low cosmetic index

Personality (House ).20

Medical History

General health

Pathology

Dental History

Chief complaint

Expectation

Edentulism

Previous denture/s.

Existing or current dentures

Pre extraction records

Clinical evaluation 21

THE HOUSE CLASSIFICATION

Proposed by Dr. Milus M. House

General classification of patient’s mental attitude

They can be classified as:

Philosophic

Exacting

Indifferent

Critical

Skeptical

Hysterical

22

PHILOSOPHIC:

Willing to accept the dentist’s judgement without

question.

Best mental attitude for denture acceptance.

Motivation is generalized.

Ideal attitude for successful treatment, provided the

biomechanical factors are favourable.

23

EXACTING:

All good attributes of philosophic patient.

Require extreme care, effort and patience on the part of the dentist.

Immaculate appearance and dress.

Methodical, precise and accurate and at times make severe demands.

Want written guarantees or remakes at no additional cost.

Like each step of the procedure to be explained.

If intelligent and understanding they are the best

or else extra hours must be spent, prior to treatment, in patient education until an understanding is reached. 24

HYSTERICAL:

Submit to treatment as a last resort, have negative

attitude, often poor health, unfounded complaints.

Emotionally unstable, excitable, apprehensive and

hypertensive.

Unrealistic expectations.(demand equals to natural teeth)

Prognosis is often unfavorable.

Additional professional help (psychiatric) is required

prior to and during treatment.

25

INDIFFERENT:

Questionable or unfavorable prognosis.

Little concern for their teeth or oral health.

Without dentures or worn out dentures for years.

Seek treatment because of the insistence of family.

Pay no attention to instructions, are uncooperative &

give up easily if problems are encountered with their new

teeth.

Donot value the efforts or skills of the dentist.

Require more time for instruction on value and use of

their dentures.

26

CRITICAL:

Find fault with everything that is done for them.

Never happy with their previous dentist.

Failure to recognize this category of patients may cause

immense problems for the inexperienced dentist.

Exercise firm control over these patients

Dentist must direct all the treatment & decisions

Advise medical consultation.

27

SKEPTICAL:

Have had bad results with previous treatment.

Are doubtful if anyone can help them.

Often in poor health.

Unfavorable oral conditions.

Conduct a thorough examination taking more time than

usual, since care and attention to detail at this time will

help the patient to develop confidence in the dentist.

28

29

New M.M. HOUSE Classification

MM HOUSE MENTAL CLASSIFICATION REVISITED : INTERSECTION OF PARTICULAR PATIENT

TYPES & PARTICULAR DENTIST’S NEEDS(J Prosthet Dent 2003;89:297-302.) SIMON

GAMER,TUCH,GARCIA

30

O’Shea et al characterized the ideal dental patient as

compliant, sophisticated, and responsive.

Winkler described 4 traits that characterize the ideal

patient’s response: (1) realizes the need for the prosthetic

treatment, (2) wants the prosthesis, (3) accepts the prosthesis,

and (4) attempts to use the prosthesis.This patient corresponds to House’s philosophical- mind patient.

Koper characterized and typed patients who

have difficulty in adapting to complete dentures as problem

patients, difficult denture patients, or difficult denture birds.

Other classifications :

(J Prosthet Dent 2003;89:297-302.)

PATIENT MADE RECENTLY

EDENTULOUS:

Completely unaware of difficulties

Assume to continue same eating habits as with their

natural teeth

Patient education is of paramount importance and

must begin with the second examination appointment

and continue throughout the entire treatment sequence.

31

Expect their new teeth to last for a life time not

possible as changes occur in the basal seat causing

position of dentures to change i.r.t. their foundation & to

each other.

“Green Ridge”

Tooth sockets do not completely fill with new bone

Socket edges not rounded off as desired

Bony spicules remain from extraction site

Bony undercuts with a thin mucosal covering.

32

Alveolar ridges recently made edentulous subject

to large, rapid changes during the first year.

The dentist must inform the patient of these potential

changes before beginning, to avoid problems later on.

33

PATIENT EDENTULOUS FOR A LONG

TIME:

The problems they present are more difficult to treat

especially if they have been previous denture wearers.

These problems must be recognized before adequate

treatment procedures are planned

Most important among this group are the difficult

denture wearers Personality characteristics should be

assessed.

34

OBSERVATION OF THE PATIENT:

Begins when the patient enters the dental clinic.

Aspects to be observed

Motor skills

Facial features

Attitude and adaptive response.

35

Sheldon Winkler – Essentials of complete denture prosthodontics.

36

(I) MOTOR SKILLS:

CVA, Bell’s Palsy, nerve blocks for trigeminal neuralgia hemiplagia and dyskinesia.

Facial tremors/spasms indicate Parkinson’s disease, nervous habits or possibly drug induced tardive dyskinesia.

Psychotropic drug therapy may show

Uncontrollable chewing movements

Licking and smacking of lips

Uncoordinated tongue movements


Twitching of the nose

Puffing of cheek

These complications often result in prosthetic failure.

DIAGNOSIS:

Check fluency and quality of patient’s speech

Best judged during casual conversation

37


(II) FACIAL FEATURES:

Dentist must note

Length of face

Labial fullness

Apparent support of lips

38


Observe for hollowness/puffiness in

Philtrum

Nasolabial fold

Labiomental groove

39


Texture of skin determines the tone for anterior teeth

setup

Rough textured skin deserves a more rugged tooth

arrangement than smooth, light coloured skin.

40


Size of oral cavity, activity of lips and width of vermilion

border directly related to degree of tooth display.

Profile view indicates position of maxilla to mandible

first indication of patient’s occlusal classification.

41


(III) ATTITUDE & LEVEL OF EXPECTATION:

Factors producing adaptive response to complete

dentures:

Acceptance of & confidence in dentist

Previous favorable experience & capacity to cope

favorably with change

Favorable physical conditions

Realistic expectation of the patient

Good learning capacity

Desire to please the doctor

42


o Factors that produce a maladaptive response to complete

dentures

Lack of trust in the dentist

Poor dentist-patient communication

Negative previous experience

Unrealistic expectations on the part of the patient

Resistance to change

Inadequate tissue tolerance

43


MEDICAL HISTORY

44

MEDICAL HISTORY:

Patients today have a more complex health history than

ever before.

More likely to involve the dentist in medicolegal

challenge.

Therefore a complete medical history is an extremely

important part of the patient’s overall diagnosis and

treatment planning.

45

(I) SYSTEMIC STATUS OF THE PATIENT:

DEBILITATING DISEASES

They must be kept under medical control

Eg. Diabetes, Blood Dyscrasias and TB

Require

Extra instruction in oral hygiene, eating habits & tissue rest

Physician consultation

Frequent recall appointments to check the status of

underlying bone and thus occlusion

46

47

DIABETES

MELLITUS

Includes heterogenic group of disorders all having in common alteration

of glucose tolerance or impaired lipid & carbohydrate metabolism.

Type I – IDDM (autoimmune, destruction of b- cells of pancreas , 5- 10

% cases. In adoloscence)

Type II – NIDDM (insulin defeciency, 85-90% cases, genetic cause,

lifestyle disease, elderly people, obesity.)

Symptoms : Polyuria, Polydipsia, Polyphagia.

Oral manifestations : - Hyposalivation, Salivary Gland Dysfunction,

Parotid Enlargement, Taste Alterations, Burning Mouth Sensation &

Fungal Infections

Braz Dent J (1995) 6(2): 131-136 ISSN 0103-6440. Oral Manifestations of Diabetes Mellitus in

Controlled and Uncontrolled Patients.

DIAGNOSTIC CRITERIA & MANAGEMENT

Management -

Diet control

Regular exercise

Oral hypoglycaemic agents

- Sulfonylurea – Tolbutamide, Gliclazide

- Biguanides – Metformin

- Alphaglucoside inhibitors –Acrabose

Insulin therapy48

Diagnostic criteria –

Fasting Blood Sugar Level >/=140 mg/dL

Post Prandial - >/= 200 mg/dL

Glycosylated Hb – more than 6-8%

Dent Clin N Am 50 (2006) 591–606

PROSTHODONTIC CONSIDERATIONS

Blood Sugar Level

Shorter appointments preferably in mornings

Mucostatic impression technique

Avoid adrenaline in LA

Liquid supported dentures

Use of soft denture liners.

49

TUBERCULOSIS

50

TUBERCULOSIS


Spread by aerosolized droplets high risk to dentist

Past history of T.B. physician’s consultation if

culture positive only emergency treatment provided

Minimal use of high speed handpieces

Operating air should be vented out .

Oral lesions may make use of prosthesis difficult

51

DISEASES OF THE JOINTS

Primary osteoarthritis:

Familial disease

More common in females

“Heberdens nodes” involving terminal joints of fingers

difficult for patient to insert & clean dentures

52

Osteoarthritis of TMJ:

Painful mandibular movements difficulty in

construction of dentures

Special impression trays accommodate reduced

mouth opening

Difficulty in recording jaw relations

Occlusal corrections have to be made often

53

OSTEOPOROSIS

Osteoporosis is a systemic disease in the elderly.

Osteoporosis shows a decrease in the skeletal mass

without alteration in the chemical composition of bone.

Loss of the spongy spicules of bone that support the

weight bearing parts of the skeleton can be seen in

radiographs of regions of the skeleton that bear heavy

loads, such as the vertebral column, epiphysis of long

bones, the mandible and the fingers.

54

55

Osteoporosis is common in aging individuals, especially post menopausal women when the estrogenic blood level is low.

In elderly men and women, osteoporosis is caused by a variety of factors such as calcium loss, calcium deficiency, hormonal deficiency, change in protein nutrition and decreased physical activity.

Progressive loss of alveolar bone may be a manifestation of osteoporosis

CARDIOVASCULAR DISEASES

Includes ischemic heart disease(anginas), arterial

hypertension, arrhythmias, myocardial infarction &

chronic heart failure.

Consultation with patients cardiologist is indicated

Surgical procedure of any nature maybe contraindicated

Short appointments with pre- medication

56

57

Oral manifestation of cardiovascular disease.

Not specific.

Consequences of pharmacologic treatment, rather type of heart disease.

Most frequent cardiovascular drugs & their related manifestations are :

•ACE inhibitors : - Erythema Multiforme, Xerostomia, Loss Of Taste,

Pharyngitis, Burning Sensation & Ulcers.

•B- blockers : Xerostomia, Paresthesia.

•Calcium antagonists (nifedipine) : Gingival Hyperplasia, Sialorrhea

•Diuretics : Xerostomia, Parotid Gland Hypertrophy.

•Nitrates : Alterations Of The Denture Base Materials.

These all affects complete denture treatment .

For eg. Xerostomia - impairs prosthesis retention.

oral mucosa irritation

Adhesion of food to prosthetic materials

(Dent Clin N Am 50 (2006) 483–491 – ischemic heart diseases & their management. James R. Hupp)

58

Prosthetic Management

•Communicate with the patient’s physician.

•Prevent hemorrhage in pt. taking anti-coagulant therapy.

•Reduce patient’s stress and anxiety.

•Morning appointment.

•Short wait in waiting room.

•Reassurance & peaceful environment.

59

•Avoid surgical procedures if possible.

•If not, perform it under proper antibiotics coverage.

•Postpone procedures for at least 6 months if not very

necessary.

•Do not treat patient with coronary bypass until at least

2 weeks after operation.

•Always ready with emergency kit & services for an

immediate control.

60

HYPERTENSION

Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients

with Hypertension.Bruce Bavitz

Adult classification:

Classification Systolic BP Diastolic BP

Normal 120 80

Prehypertension 120–139 or 80–89

Stage I hypertension 140–159 or 90–99

Stage II hypertension 160 or 100

61

Oral side effects of antihypertensive medicines

Drug Oral adverse side effects

• Diuretics Dry mouth, lichenoid reaction

• Beta blockers Dry mouth, taste changes, lichenoid reaction

• ACE inhibitors Loss of taste, dry mouth, ulceration, angioedema

• Calcium channel blockers Gingival enlargement, dry mouth,

altered taste

• Alpha blockers Dry mouth

• Direct-acting vasodilators Facial flushing, possible increased risk

of gingival bleeding and infection

• Central-acting agents Dry mouth, taste changes, parotid pain

• Angiotensin 2 antagonists Dry mouth, angioedema, sinusitis, taste loss

Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension.Bruce Bavitz

ORAL MALIGNANCIES:

Most often detected by the dentist

Treatment of choice = eradication of lesion by surgery or

radiotherapy.

Prosthodontic treatment therein is best handled by a

maxillofacial prosthodontist.

62

Radiation therapist must be consulted if tissues lack

tonus & have a bronze colour denture construction

should be delayed.

Observe for signs of radiation necrosis

Dentures should be used on a limited basis

63

DISEASES OF SKIN

May have oral manifestations Eg.

Pemphigus & lichen planus

Oral mucosa is very painful

Medical treatment may or may not give

comfort

Constant use of dentures is

contraindicated their use is primarily

for mental comfort

64

65

White patch : - it may be :-

• Leukoplakia(non scrapable, habit associated)

• Frictional keratosis – seen only on ridges.

• Lichen planus – wickham striae.

• Candidiasis – scrapable

ORAL SUBMUCOUS FIBROSIS

An insidious chronic disease affecting any part of the

oral cavity & sometimes pharynx ,although occasionally

preceded by &/or associated with vesicle formation. It is

always associated with juxta epithelial inflamatory

reaction followed by fibro-elastic changes of lamina

propria, with epithelial atrophy leading to stiffness of

oral mucosa & causing trismus & inability to eat.

66

ETIOLOGY

Chronic irritation- chillies, tobacco, lime, arecanut

Nutritional deficiency

Defective iron metabolism

Bacterial infections

Collagen disorders

Immunological disorders

Genetic susceptibility

Altered salivary composition

67

MANAGEMENT

Restriction of habit

Medicinal therapy –

Supportive treatment

Steroids – local , systemic

Hyaluronidase

Vitamine E

Oral physiotherapy- Mouth opening, Ballooning of

mouth, Forceful mouth opening with mouth gag

68

Surgical treatment

Indications – marked trismus, neoplastic change

• Surgical treatments –conventional, laser, cryosurgery


Difficulty in impression making due to restricted

mouth opening

Solution – use of sectional impression trays

69

Journal of Prosthodontics 2010: 19; 299-302

Difficulty during border molding d/t restricted movement

of tongue

Difficulty in insertion & removal of dentures

Solution – use of sectional dentures

70

Journal of Prosthodontics 2010: 19; 299-302

VESCICULO-BULLOUS LESIONS

Vesciculo-bullous lesions which may have intra oral

manifestations are –

Pemphigus

Pemphigoid

Erythema multiformae

Management –

Topical / systemic steroids

Immuno-suppresive therapy

71

Prosthodontic consideration –

Difficulty in wearing removable prosthesis

Increased chances of trauma due to prosthesis

72

CANDIDA ASSOCIATED LESION

[DENTURE STOMATITIS]

[CHRONIC ATROPHIC CANDIDIASIS]

Site – usually under CD & RPD

Appearance patchy distribution often associated with

speckled curd like white lesion

Symptoms soreness & dryness of mouth

Signs palatal tissue bright red, edematous &

granular

73

Red patches erythematous or speckled sharply

outlined & restricted to the tissue actually in contact with

the denture

Multiple pinpoint foci of hyperemia involving maxilla

74

TREATMENT

Removal of the cause

Replacement of denture or relining or applying

mycostatin

Denture – cleaned thoroughly & regularly & should be

left out of the mouth at night in hypochlorite solution

Anti-fungal treatment

75

ANGULAR CHELITIS

[PERLECHE,ANGULAR CHEILOSIS]

Causes

Micro-organisms – mainly candida albicans

Mechanical factors – over closure of jaws

- edentulous patient

- prosthesis with decreased vertical dimension

Nutritional deficiency

Atopic/ seborrhoic dermatitis

Hypersalivation

76

CLINICAL FEATURES

Dry & burning sensation at corners of mouth

Rough triangular area of edema & erythema

Wrinkled & maserated epithelium,deep fissures appear

ulcerated do not bleed

77

MANAGEMENT

Removal of cause

Nutritional supplement

Antifungal treatment –Miconazole

Restore correct vertical dimension

78

HERPES

Recurrent intra oral herpes

Herpes zoster

Prosthodontic considerations

Use of prosthesis uncomfortable

Care taken to avoid herpetic whitlow

79

HIV AIDS

Acquired immuno deficiency syndrome

Epidemic disease

Associated with wide range of oral

lesions like

Oral candidiasis

Oral hairy luekoplakia

Kaposis sarcoma

NUG & NUP

Recurent aphthous ulcerations

80

Many of the dental treatments are contraindicated in HIV

patients

The treatment plan depends on the overall systemic

health of the patient

Precautions for prevention of transmission

81

NEUROLOGICAL

DISORDERS:

Eg. Bells palsy

Parkinson’s disease

Added Problems:

Denture retention

Maxillo-mandibular relation

records

Supporting musculature

82

83

BELL’S PALSY

JPD vol35, Issue 2, February 1976, Pages 192-201.Prosthetic support for unilateral

facial paralysis. Larsen & carter

Bell's palsy is a disorder of the nerve that controls movement of the muscles

in the face.

Damage to this nerve causes weakness or paralysis of these muscles.

Cause: Not clear. May be due to Herpes zoster infection

The face will feel stiff or pulled to one side, and may look different. Other

symptoms can include:

•Difficulty eating and drinking; food falls out of one side of the mouth

•Drooling due to lack of control over the muscles of the face

•Drooping of the face, such as the eyelid or corner of the mouth

•Hard to close one eye

84

Dr. Suresh s. & Dr. Vipul asopa : Prosthodontic management of complete edentulous

patients with neuromuscular disorders - Case reports. JADR Jan 2011 : 2(1); 67-72.

Symptoms:

•Problems smiling, grimacing, or making facial expressions

•Twitching or weakness of the muscles in the face

•Dry eye or mouth

•Loss of sense of taste

•Sound that is louder in one ear (hyperacusis)

85

•Prosthodontics considerations :

•Proper training on insertion & removal of dentures.

•Non- anatomic teeth.

•Heat strength metal reinforced denture bases

•Upright positions with head supported for making impressions.

•Repeated JR’s.

•Record neutral zone

•Denture hygiene instructions.

•Regular follow-up.

Dr. Suresh s. & Dr. Vipul asopa : Prosthodontic management of complete edentulous

patients with neuromuscular disorders - Case reports. JADR Jan 2011 : 2(1); 67-72.

86

Dr. James Parkinson in 1817.

Parkinson's disease is a disorder of the brain that leads to

shaking (tremors) and difficulty with walking, movement,

and coordination.

Occurs mostly above 50 yr. of age.

Cause – destruction of dopamine producing brain cells

which control muscular movement.

Parkinson’s disease (shaking palsy)

Symptoms

•Automatic movements (such as blinking) slow or stop

•Constipation

•Difficulty swallowing & Drooling

•Impaired balance and walking

•Lack of expression in the face (mask-like appearance)

•Muscle aches and pains

•Movement problems.

•Confusions, dementia, hallucinations, memory loss etc.

87

Gen Dent. 2008 May-Jun;56(4):e12-6.Complete denture prosthodontics for a patient with Parkinson's disease

using the neutral zone concept: a clinical report. Makzoume JE

Prosthodontic management :

•Neutral zone technique.

•If xerostomia is also present, then use of salivary substitutes

recommended.

MENOPAUSE:

Bone changes: generalized osteoporosis

Mental disturbances: mild irritability to complete

nervous breakdown

Oral symptoms: hot flushes, burning tongue, burning

palate and vague area pains.

Tranquilizers and psychotherapy may help.

Patient should be made aware of these conditions and

their possible effect during the period of denture

adjustment. 88

Seasonal attacks routine dental treatment – when

frequency of attacks is lowest

Patients on steroids additional dose may be required

to avoid serious reaction to dental stress

Avoid inhalation anaesthetics or analgesics

89

MANAGEMENT

Dietary calcium

Estrogen therapy

Regular exercise

90

ADDITIONAL TESTS &

MEDICAL CONSULTATION

Routine blood test.

Blood sugar.

Urine sugar.

Referral to family physician.

Specialist consultation.

PHYSICAL EXAMINATION

91

Clinical Evaluation

92

Square Square

tapering

Tapering Ovoid

Facial form according to House & Loop

Facial profile according to Angle

93

Class I

Normal

Class III

PrognathicClass II

Retrognathic

Muscle tone according to House

o Class I :Normal muscle tone(immediate denture pt.)

o Class II: Slightly impaired muscle tone(following loss of all natural teeth)

o Class III: Greatly impaired muscle tone & function

Muscle Development according to House

o Class I: Heavy

o Class II: Medium

o Class III: Light

Complexion (helps in shade selection)

o Hair

o Eye (pale anemic look)

o Skin( underlying disease)

o Nasolabial fold (normal 110 deg., wrinkles ) 94

Cracking, fissuring at corner & ulceration: indicative of

vitamin B-complex deficiency, candida infection,

overclosure of existing denture or neoplasm.

Lip contour - adequately supported or

unsupported(collapsed or wrinkled appearance)

Lip thickness

Lip length- long , medium and short.

Lip mobility – normal(classI)

reduced mobility(classII)

paralysis.(class III)

LIP EXAMINATION:

95

96

Lip thickness – thick or thin

•Thick – gives more freedom in teeth setting.

•Thin – any change in labiolingual position can alter fullness,

support or drape of thin lip.

Lip length – long or short. Measured from - base of the nose to vermillion border of lip

(ideal = 25 mm). or with index finger tip ,from incisive papilla

to upper lip.

•Long – will hide denture base & most of the tooh (maximum

facial expression is required for display of tooth).

•Short – any expression will expose most of the tooth or even

denture base.

LIPS CAN BE CLASSIFIED INTO 4 TYPES

1. Competent lips – lips are in slight contact

when the musculature is relaxed

2. Incompetent lips – morphologically short lips

which do not form a lip seal in a relaxed state

3. Potentially incompetent lips – normal lips , fail

to form lip seal

4. Everted lips – hypertrophied lips with weak

muscular tonocity 97

S.I. bhalajhi – orthodontics art &science, 3rd edition.

TEMPOROMANDIBULAR JOINT

Clicking(disc displacement), crepitations(osetoarthrosis)

Pain & tenderness on palpation

Temporomandibular arthralgia

Impaired mandibular mobility

Irregularity or deviation on opening & closing of

mandible

Deflection.

Locking of mandible.

98

99

Examination includes : Analysis Of Mandibular MovementsPalpationAuscultation

Two types of examination :- preauricular (8 – 13 mm ahead of tragus)

intraauricular

Preauricular is performed at 7o’ clock & 12 o’ clock positionIntraauricular is performed only at 12 o‘clock position.

Neuromuscular Evaluation

Speech- normal or affected.

Coordination :-

Class I: Excellent

Class II: fair

Class III: poor

Arch Size

Class I: Large (best for retention & stability)

Class II: Medium (good retention & stability but not ideal)

Class III: Small (difficult to achieve good retention and stability)

100

Determines the amount of basal seat available for

denture foundation.

Greater the size, more the support

Greater the contact surface, greater the retention.

Discrepancy in size of the maxilla and mandible can

present a problem of stability in the smaller arch.

101

ARCH FORM

102

Class I

SquareClass II

Tapering

Class III

Ovoid

103

BORDER ATTACHMENTS (HOUSE) :-

Class I – Attachements are high in maxilla or low in mandible with relation to

ridge crest (0.5 inches or more between level of attachment and crest of

ridge)

Class II – Attachements height is 0.25 to 0.50 inches.

Class III - < 0.25 inches from ridge crest.

FRENUM ATTACHMENTS (HOUSE):-same as border attachements

Class I – high in maxilla or low in mandible i.r.t. ridge crest.

Class II – medium

Class III – freni encroach on the crest of the ridge and may interfere with

denture seal. Surgical correction may be required (frenotomy or frenectomy)

RIDGE FORM:

104

Class I

Class II

ClassIII

Square

V-shaped

FlatShort

Inverted

Flat

Inverted U-shaped

Inverted

W

Tall

Inverted

Maxillary Mandibular

RIDGE CONTOUR:

Type I: High, well rounded bone profile

+ve resistance

Type II: Narrow, knife edge ridge

-ve resistance

Type III: Rounded but lowered residual ridge

-ve resistance

Type IV: Terminal stage

-ve resistance105

RIDGE RELATIONSHIP ACCORDING TO ANGLE

GPT8 - The positional relation of the mandibular ridge &

maxillary ridge.

106

Class – I Parallel Class – II Divergent Mandibular

Class – III Divergent Maxillary & Mandibular

RIDGE RELATIONSHIP ACCORDING TO SMITH

It can be described as the Anteroposterior position of the mandibular residual

ridge relative to the maxillary residual ridge when the jaws are in centric

relation.

107

HARD PALATE:

U-shaped palatal vault; most favourable for retention &

lateral stability.

V-shaped vault: less favourable for retention.

Flat palatal vault: also unfavourable.

108

SOFT PALATE:

Classified according to configurations based on the degree of flexure the soft palate makes with the hard palate and the width of the seal area.

Class I: Horizontal & demonstrating little muscular movement. Most favourable condition as it allows for more tissue coverage for posterior palatal seal. Forms a 10o angle.

Class II: Turns downward forming a 45o angle to hard palate. Potential tissue coverage is less than for class I.

Class III: Turns downward sharply at 70o angle just posterior to hard palate. Least favourable soft tissue form. 109


V- shaped vault: associated with Class III soft palate

Flat palatal vault: usually associated with Class I or Class

II soft palate.

110


Most ideal is a high ridge with a flat crest and parallel or

nearly parallel sides maximum support & stability.

Knife edge ridges or ridges with multiple bony spicules

offer the poorest prognosis incapable of with standing

much occlusal force.

Best determined by careful palpation.

111

PALATAL THROAT FORM: HOUSE

CLASS – I

Large and normal in form

Immovable band of resilient tissue 5-12 mm distal to a distal edge of the tuberosities

CLASS – II

Medium size and normal in form

Relatively immovable resilient band of tissue 3-5 mm distal to distal edge of the tuberosities

CLASS – III

Usually accompanies a small maxilla

Curtain of soft tissue turns down abruptly 3-5 mm anterior to distal edge of the tuberosities

112

GAG REFLEX:

Normal defense mechanism developed by the body

to prevent foreign bodies from entering the trachea.

Can be caused by:

Systemic disorders,

Psychological factors,

Extraoral & intraoral physiological factors

Iatrogenic factors.

Controlled by glossopharyngeal nerve.113


MANAGEMENT OF GAG REFLEX:

Clinical techniques, pharmacological measures,

psychological intervention.

Identify the existence of gag reflex with a thorough

conversation with the patient.

Careful handling of impression procedure and constant

reassurance of the patient will suffice.

In severe cases, a specialist maybe needed to treat the

problem at a psychological level.

114


PALATAL SENSITIVITY : HOUSE

Class I: Normal

Class II: Subnormal (Hyposensitive)

Class III: Supernormal (Hypersensitive)

Mucosal Thickness according to House

Class I: Normal uniform density (1 mm)

Class II: Thin investing membrane

Soft tissues have mucous membranes twice the normal thickness.

Class III: Thick investing membrane(redundant tissue,

tissue treatment)115

Mucosa condition according to House

Class I: Healthy

Class II: Irritated

Class III: Pathologic

116

Class I

Class II

Class III

LATERAL THROAT FORM [MANDIBULAR] : NEIL

117

Lateral throat form is classified according to the extent of anterior movement

of the retromylohyoid curtain as the tongue is extended anteriorly beyond the

vermilion border of the lip.

SALIVA :

Class I: Normal(cohesive & adhesive)

Class II: Excessive(mucus)

Class III: Xerostomia(remaining mucinous.)

Flow – regular or irregular.

Quality – thin serous, mucinous, mixed.

Quantity – normal, excessive, scanty.

Contact – competent & incompetent.

Deficient saliva: retention of denture will be affected.

Excess of saliva: complicates impression making.118

Thick mucous saliva makes dentures more difficult to

wear. It will push out denture by accumulating beneath

the denture.

Mixture of both Thin serous & Thick mucous saliva is

the best to work with.

119

COLOUR OF MUCOSA:

Ranges healthy pink to angry red.

Redness indicative of inflammation: related to ill fitting

denture, underlying infection, systemic disease or

chronic smoking.

Pigmented spots or lesions.

White patches keratotic areas caused by denture

irritation.

120

TONGUE:

If patient has been without teeth for a long time: tongue

becomes enlarged & powerful. This will create a

problem in impression making & may contribute to

denture instability.

A small tongue: may jeopardize lingual seal.

Tongue position is very important to the prognosis of the

mandibular denture.121

122

According to House : -

Class I – normal in size, development, & function.

Class II – teeth have been absent for long time

.permits change in form & function.

Class III – excessively large tongue.all teeth have

been absent for a long time, allowing for abnormal

development of the size of the tongue.

WRIGHT CLASSIFIED TONGUE POSITIONS AS

FOLLOWS:

Class I: Tongue lies in the floor of the mouth with the tip

forward & slightly below the incisal edges of mandibular

anterior teeth. Most favourable prognosis.

Class II: Tongue is flattened and broadened but the tip is in the

normal position.

Class III: Tongue is tensed, retracted & depressed into the

floor of the mouth with the tip curled upward, downward or

assimilated into the body of the tongue. Least favourable

prognosis.

123

EXAMINATION OF EXISTING DENTURES

Mucosa examined for pathological changes

As per the study conducted by ostlund in 1953 it was reported that in 77 % of the denture wearing patients there will be presence histological changes even though mucosa appears clinically normal.

Evaluation of

Denture cleanliness

CR & CO premature contacts, sliding

Vertical dimension

Denture extensions

Type of teeth

Retention , stability

Esthetics

phonetics 124

RADIOGRAPHIC EXAMINATION

125

RADIOGRAPHIC EXAMINATION

The interpretation of the panoramic radiograph should

follow a five step analysis:

1. Screen jaws for defect in structure and bony enlargement,

2. displacement of jaw parts,

3. unerupted teeth or retained root fragments,

4. foreign bodies,

5. radiolucencies as well as radio opacities.

TMJ can be screened and findings correlated with history

and clinical examination.

126

Describe the appearance of the lesion as well as any

bony changes adjoining the lesion

Correlate the radiographic findings with the clinical,

historical and laboratory findings.

Perform a differential diagnosis which includes all the

diseases that could explain the findings.

Estimate the growth of the lesion by the appearance of

the jaw structures adjoining the lesion.

127

Panoramic radiographs also aid in determining the

amount of ridge resorption.

Wical & Swoope advocated measuring the distance from

the inferior border of the mandible to the inferior margin

of the mental foramen and then multiplying it by 3, the

resultant product is a reliable estimate of the original

alveolar ridge crest height.

128.

Studies of residual ridge resorption. I. Use of panoramic radiographs for evaluation and

classification of mandibular resorption. J Prosthet Dent. 1974 Jul;32(1):7-12

Wical KE, Swoope CC

Class I: Mild resorption, is a loss of upto one third of the

orignal vertical height.

Class II: Moderate resorption, is a loss from one third to

two thirds of vertical height.

Class III: Severe resorption, is a loss of two thirds or

more of vertical height.

129

130

Radiographs is useful in the following instances : -

1. Bone pathosis, cysts, tumors.

2. Retained roots or teeth.

3. Bony fractures.

4. Soft tissue thickness.

5. Extent of bone resorption.

6. Thickness of body of mandible.

7. To locate mandibular canal & it’s proximity to ridge crest.

8. To locate maxillary sinuses.

9. To plan surgeries.

10. Remaining bone density and quality.

11. As treatment records.

12. For patient education.

TMJ DISORDER

131

Temporomandibular Disorders (TMD)

It represents a constellation of painful symptoms in the

jaw muscles and TMJs.

Patient with TMDs commonly complain of pain in the

muscles of mastication, most frequently the masseter and

temporal muscles).

132

CLASSIFICATION

Group Disorder

Group I Muscle disorders

Ia Myofacial pain

Ib Myofacial pain with limited opening

Group II Disc displacement

IIa Disc displacement with reduction

IIb Disc displacement with reduction, with limited opening

IIc Disc displacement with reduction, without limited opening

Group III Arthralgia, arthritis, arthrosis

III a Arthralgia

III b Osteoarthritis of the TMJ

III c Osteoarthrosis of the TMJ133

JAW DISABILITY CHECKLIST

What activities does your present jaw problem prevent or limit you from doing:

Chewing

Drinking

Exercising

Eating hard foods

Eating soft foods

Smiling/laughining

Cleaning teeth or face

Yawning

Swallowing

Talking

Keeping your usual facial appearance

134

CLINICAL CONSIDERATIONS FOR DETERMINING

THE PROBABILITY OF A TMD

Consider

ations

High Low

Pain •Constant ache / tightness

•Sharp pain with jaw use

•Sharp, electric, burning, paroxysmal,

intermittent, spontaneous pain.

•Sharp pain with jaw use

Muscles Masticatory muscles or TMJ Site not necessarily in muscles or TMJs

Jaw use Aggravated by jaw use No definitive change with jaw use

Clinical •Pain reproduced with palpation

•Reduced range of mandibular motion

•Painful clicks or grinding in TMJs

•Jaw catches or locks

•Associated ear, neck, tension – type

headaches

May be associated with paresthesia,

dysesthesia or other neurologic signs

135

PROSTHODONTICS AND TMDS

Alteration of TMJ anatomy, including disc displacements

and bony degeneration, may influence occlusal stability.

Thus, prior to prosthodontic treatment, it is prudent to

provide clinical and radiographic evaluation of the TMJs.

If clinical examination reveals crepitus and radiographic

evidence of bony alterations of the condyle or articular

eminence, the following steps may be considered prior to

prosthetic treatment:

1. CT scan of temporomandibular joints – it allows accurate

assess of the degree of degeneration of affected joints but

clinician can not predict whether the degeneration is active.136

2. Scintigraphy . To assess the extent of active

metabolic degeneration, aTc 99m bone scan may be

requested.

If uptake is identified in TMJs, postpone prosthetic

treatment.

If treatment proceeds in actively degenerating joints,

occlusal stability certainly cannot be predicted and

treatment failure may occur.

3. Diagnostic stabilization appliance

137

PRE TREATMENT RECORDS

138

PRETREATMENT

RECORDS:

Diagnostic casts:

Helps dentists avoid a potential problem

Time consuming

Aid in determining the inter ridge space, ridge relationships,

ridge shape and form that cannot be adequately determined

by clinical examination alone.

139

Pre extraction records:

Old diagnostic casts: determining both size, position &

arrangement of teeth.

Old radiographs: determining tooth size & bony change.

Photographs: relay information regarding tooth size,

position & display during facial expressions. Forms an

effective tool in achieving proper esthetics & patient

satisfaction.

140

PREPROSTHETIC SURGERY

141

REDUNDANT TISSUE:

Excess amount of flabby tissue: cause denture base to

shift & move as force is applied, due to instability of

denture foundation.

Surgical excision may improve the condition before

impression making.

142

HYPERPLASTIC TISSUE:

When present under ill fitting dentures it may present as

an epulis fissuratum, papillary hyperplasia or

hyperplastic folds.

Patient should be instructed to rest the tissues by not

wearing the existing denture.

Proper oral hygiene and tissue massage.

Existing denture should be refitted with a tissue

conditioning or temporary relining material. Occlusion

should be improved if possible.

Last resort is surgical correction.

143

BONY UNDERCUT:

Frequently found on both maxillary & mandibular

ridges.

Usually pose no problem in denture insertion.

Rule should be selective relief of denture rather than

surgical reduction.

On mandibular ridge, the only undercut that can pose a

real problem is a prominent sharp mylohyoid ridge.

144

145

. DEFECTS

Exostose or divots.

Preprosthetic surgeries may be

required

TORI:

Torus palatinus & lingual tori frequently present.

Torus palatinus: range from a small prominence in the

midline to one that covers the entire hard palate.

Adequate relief must be planned.

Lingual tori: interfere with denture construction & unless

very small should be surgically removed.

146

147

Classification : -

Class I - Tori absent or minimal in size. Donot interfere with denture

construction.

Class II – Moderate size. Mild difficulties in denture construction

and use. Surgery not required.

Class III – Large in size. Compromise fabrication & function of

dentures. Requires surgical recontouring or removal.

FLOOR OF THE MOUTH:

Near the ridge crest or when magnitude of movement is

great, retention and stability of the denture

Sublingual gland & mylohyoid areas are concern where

floor of the mouth is high cannot be selectively

displaced by the denture flange, the prognosis of the

mandibular denture will be poor.

Retromylohyoid space maybe partially or totally

obliterated by tongue movement.

148

TREATMENT PLANNING:

Process of matching possible treatment options with

patient needs and systematically arranging the treatment

in order of priority but in keeping with a logical or

technically necessary sequence.

Must have a parallel process of developing a prognosis.

Driven by the diagnosis but must take other factors such

as prognosis, patient health and attitudes into account.

149

WHY TREATMENT PLAN?

150

Treatment Plans

Addresses patient needs

Lists specific treatment

Specific logical sequence

Informed consent

Treatment

Time

Fees

Enables dentist to

Estimate

•Operating time

•Laboratory time

•Calender time

•Fees

Enables patient to

Delivered care

•Patient specific

Patient

receive

Dentist delivers

Enables

dentist

to

Treatment planning determines the patients problems by

way of a thorough case history as previously described

Thus making selection of the treatment option that is

most ideally indicated for the particular case at hand.

By placing a primer on determining patient problems, it

also places a primer on the various treatment options that

are best suited for those particular conditions.

151

152

Steps in t/t planning :-

•Tissue conditioning (finger massage, soft reline)

•Pre-prosthetic surgery (if any)

•Articulator (no, manufacturer, control settings)

•Tooth selection.

•Denture base materials.

•Denture base shade.

•Characterization.

PATIENT EDUCATION

Use the treatment plan as an educational tool to raise the

patient’s level of understanding.

Essential element in patient care and should start with the

initial contact with the patient.

It is defined as an initial and continuing activity integral

to, and supportive of the treatment plan.

153

PURPOSES:

Appraise the patient of their dental health & it’s

significance.

Give the patient understanding of the significance of

edentulism.

Harmonize the patient’s expectations with reality of

treatment potential.

Explain the nature and use of prosthesis.

Identify alternative treatment & their consequences.

154

155

Occasionally, a patient might not agree to suggested treatment

plan, due to various reasons.

1. Surgery.

2. Time.

3. Expense.

4. Demand or requests.(within limits)

The alternate treatment plan may be less than ideal, but is

often necessary for various reasons. However, we must still

try to achieve the best possible result.

ALTERNATE TREATMENT PLAN

156

REFUSAL OF TREATMENT

It is the duty of the Prosthodontist to respect the patients

wishes and include it in treatment plan whenever possible.

Sometimes, however, a patient’s demand may be unreasonable

or against professional judgement or ethics.

In such case, the dentist may refuse treatment or refer him

to another dentist for a second opinion

157

Definition- A forecast as to the probable result of a

disease or a course of therapy.(GPT 8)

•After considering all the factors of the case, an

experienced dentist should be able to predict the degree of

success that can be expected.

•It includes realization by the patient of what can & cannot

be achieved.

•Ultimately leads to more realistic expectations & less

frustration & disappointment

Prognosis

158

FEES AND INFORMED

CONSENT

•Diagnosis and treatment planning also helps the dentist decide the

fees that is fair to both the dentist and the patient.

•Once the patient has fully understood and agreed on the treatment

(including the fees), he/ she must sign a written consent.

•A signed consent is essential to prevent later misunderstanding.

A PRIMER ON TREATMENT OPTIONS

159

ADJUNCTIVE CARE

Elimination of infection

Elimination of pathoses

Surgical improvement of denture support & space

Tissue conditioning

Nutritional counselling

160

PROSTHODONTIC CARE

Edentulous Patient

Complete denture

Immediate or conventional

Definite or interim

Tooth, implant or tissue supported.

161

Thus it is seen that diagnosis and treatment planning help

both the dentist as well as the patient understand the:

Diagnostic procedures

Diagnostic results

Treatment plan

Use of prosthesis

Continuing care

Fees

162

CONCLUSION:

All the facts must be known before they can be

correlated in such a way that decision can be made. Only

then can treatment plans be developed to best serve the

needs of each individual patient.

For the patient to be happier the dentist should not only

require the skills of complete denture construction but

also the skills to treat a patient’s aspirations &

expectations.

163

REFERENCES :

William R. Laney: Diagnosis and treatment in prosthodontics,

2nd edition

Boucher’s: Prosthodontic treatment for edentulous patients,

10th &12th edn.

Winkler: Essentials of complete denture prosthdontics, 2nd

edn.

J.J. Sharry: Complete denture prosthodontics, 3rd edn.

Rahn & Heartwell: Textbook of complete denture, 5th edn.164

Sheldon Winkler – Essentials of complete denture

prosthodontics.

Bernard levin – impressions for complete denture.

Fenn- Clinical denture prosthetics, 3rd edn.

S.I. bhalajhi – orthodontics art &science, 3rd edition.

JADR Vol II:Issue I: Jan, 2011.Prosthodontic

management of complete edentulous patients with

neuromuscular disorders - Case reports. Dr. Suresh s. &

Dr. Vipul asopa165

166

•The dental clinics of North America, Jan 1996;40(1)

•The Dental Clinics of North America, Apr 1977;21(2)

•Radiographic examination of edentulous mouths, JPD 1990;64:180-182.

•Arthur Grieder : Psychological aspects of prosthodontics, JPD 1973;30:736-744

•Wical K.E. & Swoope C.C. : Studies of residual ridge resorption. Part I Use of panoramic radiographs for evaluation and classification of mandibular resorption. JPD 1974;32:7-12

•James R. Hupp : Ischemic Heart Diseases & Their Management. Dent Clin N Am 2006 :50 (4); 483–491

•Bruce Bavitz : Dental Management Of Patients With

Hypertension. Dent Clin N Am 2006 : 50 (4); 547–562

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