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Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients Rola M. Shadid, BDS, MSc.

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Presentation on theme: "Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients Rola M. Shadid, BDS, MSc."— Presentation transcript:

1 Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients
Rola M. Shadid, BDS, MSc

2 Procedures Carried Before Denture Treatment
General information Chief complaint & patient expectations Medical history & current medication Dental history Visual & manual examination of the mouth and head and neck Radiographic examination

3 Continue Referring for additional tests or medical consultation
Referring for second opinion Making alginate impressions & preparing mounted study models Discussion of diagnosis, treatment planning & prognosis with patient Finalizing the fees & obtaining a signed consent

4 The First Meeting Most important
Prior to meeting, you should review general information Your confidence is as important as the treatment itself You should be a good listener Your communication should be in a simple & truthful manner

5 Recording General Information
Name Race Occupation Address and telephone no. Previous dentist

6 Age With advancing age*:
Decrease capacity of tissue to tolerate stress Tissue takes longer time to heal Many diseases are prevalent in older age Women at postmenopause may have psychological disturbances (exacting or hysterical) Men at this age may be concerned with only comfort & function (indifferent) * It is not necessary that chronological age match with physical age of the patient. Maybe an 85 ys old individual having the health, energy, and appearance of a 50 ys old one.

7 Psychological Evaluation (House Classification of Denture Patients)
Philosophical patient: well motivated, cooperative, calm & composed even in difficult cases. Exacting (critical): likes each step in detail, makes alternative treatment for dentist, makes severe demands.* * Extra care and patience are required on the part of the dentist. This pt can be a good pt if he is intelligent and understanding. With less intelligent exacting pts, the dentist should listen to their demands but must not respond to them especially if they are unreasonable.

8 Continue Indifferent: not very interested in treatment, blames the dentist for any mishap, not follow instructions, been coerced to come by friend, relative….* *Management: difficult to manage, the trick is to identify such a patient before treatment is started. An attempt is made to educate the pt and improve his interest, but if this fails, it is best to postpone or refuse treatment until improvement is observed.

9 Continue Hysterical: easily excited, highly apprehensive, unrealistic expectations* Skeptical: bad results from previous treatment, doubtful, often have severely resorbed ridges and poor health, might have psychological disturbances from recent personal trajedy # *Management: a lot of time and effort is needed, often medical consultation is required, these pts must be made aware that many of their problems are primarily systemic and not the result of dentures. Avoid making immediate dentures with them. #Management: psycholohical management is as important as the denture treatment. This pt can be made into excellent pt if handled with care and sympathy.

10 Chief Complaint & Patient Expectations
Patient’s own words Why he is seeking prosthodontic treatment You should assess if patient expectations are realistic or not If not realistic, you should educate pt and scale them down

11 Medical History* Diabetes Mellitus Cardiovascular diseases
Diseases of joints: osteoarthritis Diseases of skin: pemphigus ? Neurological disorders (Bells balsy and Parkinson) Sjogren’s syndrome Transmissible diseases *The dentist should determine the vital signs so if he finds deviations from the norm, he will advise pt to seek the services of a physician. Diabetes is not a contraindication for denture treatment. However, it may affect wound healing especially if preprosthetic surgery is planned. Osteoarthritis: special impression trays are needed if pt is not able to open his mouth wide, and jaw relations may be difficult to record. Pemphigus: constant wearing of dentures is contraindicated. Neurological disorders (Bells balsy and Parkinson): denture procedures are more difficult because of the patients’ inability to cooperate completely, also they have difficulty in maintaining denture hygiene so they need assistance in cleaning their dentures. Sjogren’s syndrome causes xerostomia.

12 Radiation Therapy Vs. Dentures
Consequences of Radiation therapy Preprosthetic surgery Wearing of previous denture * Denture Fabrication # *It is recommended that edentulous pts with preexisting dentures who have undergone radiation therapy with the mandible in the field, start using their dentures again in 3-12 months. # Dentures can be a source of trauma to thin friable dry soft tissue, so it is recommended to postpone construction of complete denture for pt who has received radiation therapy in head and neck region 6-12 months from radiation therapy.

13 Denture Fabrication in Radiation Therapy Patient
Avoid impression material that dry tissue (impression plaster) or heavily flavored materials (ZOE) Consider non-anatomic teeth Teeth set in neutral zone Slight reduction in vertical dimension Soft liners are controversial due to porosity and possibility of candida

14 Current Medication Insulin * Anticoagulants
Antihypertensive: dryness & postural hypotension Corticosteroids: dryness, confusion & behavioral changes Antiparkinson agents like Norflex and Akineton: dryness, confusion & behavioral changes *hypoglycemic shock may be induced by local anasthetic injection so the dentist must enquire if pt has eaten a meal after his insulin injection

15 Dental History History of tooth loss: cause, time* Edentulous period
Cause: poor ridges can be expected if teeth were lost due to periodontal diseases Time: teeth lost at different time intervals would result in different ridge levels. The most rapid rate of resorption occurs in the first 6 months after extraction, so rapid loosening can be expected if dentures are constructed soon after total extraction and relining or remaking may be necessary within a short period of time.

16 Beware of Patients Who Have A “Bag of Dentures” *
*The dentist should refrain from treating such a pt unless it is possible to determine ways in which new prostheses can be made significantly better than previous attempts.

17 Extraoral Examination
General appearance (healthy, signs of proper nourishment?) Facial symmetry Skin: color, deep wrinkles Palpation of the head & neck (lymph nodes & muscles)

18 Extraoral Examination
Muscle tonus Neuromuscular coordination* TMJ examination * Pts with poor neuromuscular coordination (CVA, pakinson, paralysis) may find it difficult to adapt to new dentures. The pt is asked to perform various mandibular movements to determine neuromuscular coordination.

19 Classification of Frontal Face Forms (House, Frush & Fisher) *
This is important for selection of tooth shape.

20 Classification of Lateral Face Forms
Normal Retrognathic prognathic

21 Lips Length* Thickness Mobility Smile line
Short lips show more of the denture base when pt smiles or talks, longer teeth may have to be selected. Long lips would hide the denture base and most of the teeth during facial expressions. Tooth visibility as a guide to anterior teeth positioning would be impractical Thin lips are very sensitive to small changes in anterior teeth position.

22 Lip (smile) line * High smile line Normal smile line
*the greatest height to which the inferior border of the upper lip is capable of being raised by muscle function. High smile line Normal smile line

23 Intraoral Examination
Cheeks, tongue, floor of the mouth (FOM), maxillary tuberosity, hard palate, soft palate, arch relationship, residual ridge form, saliva, undercuts

24 Cheeks Draping of the cheeks over the buccal flanges essential for peripheral seal Opening of Stenson’s duct Location for many lesions (lichen planus, submucosal fibrosis, leukoplakai, malignancies as sqauamous cell carcinoma (SCC))

25 Leukoplakia Oral malignancies are most common in people who are old enough to need complete dentures

26 The Tongue Favorable tongue is average sized, moves freely, covered by healthy mucosa Normally, it should rest in a relaxed position on lingual flanges, this will retain denture & contributes to denture stability by controlling it during speech, mastication & swallowing.

27 Tongue Size Normal Large *
*An edentulous pt who has not been wearing a mandibular denture often will use the tongue as an antagonist for the maxillary arch in mastication.. It may slowly regain its normal size after a period of wearing complete dentures.

28 How to Manage Large Tongue?
Lower the occlusal plane Use narrower teeth Increase the intermolar distance Grind off the lingual cusps Avoid setting a second molar

29 Tongue Position Normal: normal size and function. Lateral borders rest at level of mandibular occlusal plane while dorsum is raised above it. Apex rests at or slightly below the incisal edges of mandibular anteriors

30 Tongue Position Retruded tongue position deprives pt of border seal of lingual flange in sublingual crescent and also may produce dislodging forces on distal regions of lingual flange

31 Tongue Mucosa The specialized mucosa covering the tongue is said to be a “window” on systemic diseases. * Aided by a gauze, the dentist can hold the tongue while using a mirror to examine it. The sides and ventral surface of tongue are common locations for carcinogenic lesions. An ulcer like lesion should be viewed with suspicion.

32 Frenal Attachments Fold of mucosa found at different locations in the sulcus region of upper & lower ridge Classification Class I: sulcal or low attachment Class II: midway betw. sulcus & crest of ridge Class III: crestal attachment (frenectomy)

33 Floor of the Mouth If FOM is near the level of the ridge crest, retention & stability of denture is less. Hyperactive FOM reduces retention & stability If great ridge resorption, FOM in sublingual and mylohyoid regions spills on the ridge Patency of submandibular ducts * * The patency of Wharton’s duct & the production of saliva by submandibular gland should be demonstrated by watching for the expression of saliva from the duct orifice as the gland and duct are gently squeezed by bidigital palpation.

34 Maxillary Tuberosity*
If enlarged: the posterior occlusal plane may be placed too low no enough space to set all molars Maxillary tuberosity can present problems if it is enlarged and undercut. An undercut maxillary tuberosity can make denture removal and insertion difficult and painful. Management: from radiograph, it is determined if the enlarged tuberosity is bony or fibrous or a combintion, then removed surgically.

35 Maxillary Tuberosity Palpate for undercuts - if extreme, denture might not seat

36 The Hard Palate Class I: U shaped, most favorable for retention & stability Class II : V shaped: Not very favorable* Class III: Flat or shallow vault: Not very favorable, accompanied by resorbed ridges, poor resistance to lateral forces *slight movement of denture will break seal and cause loss of retention, may be associated with tapered arch

37 V-shaped hard palate

38 Tori * Palatal torus Mandibular tori
* Tori are benign bony enlargements found in some pts at the midline of the hard palate or on the lingual aspect of the mandible in the premolar region. Small ones may be accommodated by relief of denture base. Others are so large and their interference with denture design warrants their surgical removal. Tori are covered by thin mucoperiosteum so they are sensitive to pressure. Generally surgical removal of palatal torus should be avoided except if it is so large or extends very far back (interferes with posterior palatal seal). Mandibular tori generally need surgical removal because it is often difficult to provide adequate denture relief for them withour breaking the peripheral seal. After surgery, the formation of new cortical plate takes 2-6 months.

39 Bony Prominences Midpalatal raphe Sharp ridge crest
Sharp mylohyoid ridge Prominent genial tubercles Bony fragments & fractured root pieces Tori

40

41 The Soft Palate (Palatal Throat Form)
House’s classification * Class I: the soft palate is almost horizontal curving gently downwards Class II: the soft palate turns downward at about 45 angle from the hard palte Class III: the palate turns downward sharply at about 70 angle to the hard palate. Class I: most favorable as more surface area for retention, as well as allowing for a wider seal area. The muscular activity is minimal. Class III: usually seen along with deep V shaped palate. Because of the greater movement of soft palate during function and the narrower seal area, the class III is the least favorable.

42 Palatal Throat Form Maxilla I II III

43 Undercuts The contour of a cross section of a residual ridge that would prevent the placement of a denture or other prosthesis

44 Undercuts Unilateral or bilateral; labial or lingual; mild, moderate or severe Common locations: Labial portion of maxillary anterior ridge Buccal to maxillary tuberosity Retromylohyoid area of residual ridge Labial or lingual slopes of mandibular anterior ridge

45 Undercuts Management Isolated anterior undercut- not present any problem Unilateral posterior undercut- may not present much of a problem as path of insertion is varied Bilateral undercut-surgical removal of the more severe one is indicated

46 Residual Alveolar Ridge
Arch form (House’s classification) Class I: square Class II: tapered (V-shaped), associated with high arched palate, less retention & stability Class III: ovoid (less common)

47 Residual Alveolar Ridge (Cross Sectional Contour) *
U shaped V shaped Knife edged Flat Inverted Undercut U shaped: Good prognosis, large U shaped ridges supported by firm keratinized mucosa are favorable for good retention and support V shaped or tapered: favorable prognosis, common in mandible Knife edged: poor prognosis, common in mandible, the crest of ridge has to be relieved to avoid soreness. Flat: poor prognosis Inverted: poor prognosis

48 Soft Tissue Support of the Ridge
Firm & resilient Flappy and hypermobile: poor support because denture base shifts during masticatory function Management of flappy ridge ranges from modified impression techniques to surgery

49 Anterior Arch Relationships *
*Class I: normal overjet of around 2-8 mm Class II: increased overjet of > 8mm Class III: lower incisors may be in edge to edge incisal relationship or may be anterior to maxillary incisors. You should distinguish betw. Pseudo class III and skeletal class III: Habitual or pseudo class III: the pt assumes a protruded mandibular position that is habitual. This is often seen in many edentulous individuals who have been without teeth for a period of time, so they tend to use the anterior part of ridge for chewing.

50 Intraoral Examination
Posterior arch relationships Interridge space Residual ridge size

51 Saliva * Consistency: Amount:
Thin serous: provides an insufficient film for denture retention. Thick mucus: thick ropy saliva tends to displace denture. Mixed Amount: Normal: ideal for denture retention Excessive: make denture const. messy Reduced: reduced retention and increased soreness; salivary substitutes may be prescribed Saliva is an important factor in denture retention as well as the health of tissues. You should note the amount and consistency of saliva.

52 Drugs Causing Xerostomia *
Diuretics Antihistamines Atropine Anticholinergic Antihypertensive Antiparkinson (Norflex) Corticosteroids Xerostomia is also caused by radiation therapy in head and neck region and by Sjogren’s syndrome. Aging is no longer considered to be a primary factor in diminished salivary flow.

53 Examination of an Old Denture Wearer
Esthetics, lip fullness, symmetry, amount of display during smiling, phonetics, teeth position, size, excessive wear Fracture, cracks, porosity, denture hygiene Occlusal vertical dimension (due to excessive occlusal wear, OVD may have reduced)

54 Reduced vertical dimension

55 Examination of an Old Denture Wearer
Epulis fissuratum Angular cheilitis Papillary hyperplasia Flappy hyperplastic ridge* Combination syndrome Hyperplastic tissue will be found in relation to edentulous ridges and border tissues, as a reaction either to trauma or to the resorption of supporting bone. *When bone resorbs, it leaves a void in the denture foundation as defined by the existing denture. This space often will remain at least partially filled with hyperplastic tissue. This condition is seen most frequently in maxillary arch. On the mandible, it is seen more frequently in the anterior region. This hyperplastic tissue doesnot provide sound denture support.

56 Epulis Fissuratum Epulis fissuratum: border tissues chronically traumatized by overextended flanges, or by flanges of dentures that have settled as a result of loss ridge support, often will produce a reactive hyperplasia referred to as Epulis fissuratum. Common site is maxillary labial sulcus region. Usually not painful.

57 Inflammatory Papillary Hyperplasia
Papillary hyperplasia: papillary type or hyperplastic tissue is formed due to excessive relief on the palatal portion of maxillary denture or occurs with long-term denture wearers. Often this tissue is inflammed and it is referred to as inflammatory papillary hyperplasia. These tissues are prone to candida albicans infection. The best treatment is surgical removal after management of infection.

58 Angular Cheilitis (Perleche)
Angular cheilitis: the corners of the mouth may be moist and drooping, fungal infection is often seen in the fold. This condition is often seen when the vertical dimension is reduced, it may also be seen when there is vitamin B12 deficiency or secondary to fungal infection in the mouth. It may be caused by staphlococcal infection.

59 Combination (Kelly’s) Syndrome *
*This occurs when a maxillary denture is worn opposing natural mandibular anterior teeth and a distal extension partial denture. The mandibular anterior teeth exerts a lot of force on the maxillary anterior ridge and causes it to resorb. The maxillary anterior ridge becomes hyperplastic and flappy Epulis fissuratum may form in maxillary labial sulcus Resorption under mandibular partial denture Supraeruption of mandibualr anterior teeth Enlargement of maxillary tuberosities The maxillary occlusal plane drops posteriorly and rises anteriorly Papillary hyperplasia may develop in palate

60 Radiographic Examination
A routine radiographic exam. must be ordered to rule out any bony conditions that could affect the treatment Panomaric radiograph is usually ordered for denture cases The radiograph is useful in the following instances: bone pathosis, cysts, tumors, retained roots or teeth, bone fractures, to study soft tissue thickness and extent of bone resorption, to locate mandibular canal and its proximity to ridge crest, to locate maxillary sinuses, to determine thickness of body of mandible, to plan surgeries, as treatment records, and for pt education.

61 Radiographic Examination
Fractured roots or roots lying close to the surface should be removed if pt is fit for surgery; deep seated retained teeth or root fragments may be left if they are asymptomatic Supplemental radiographs may be prescribed if required such as periapical, occlusal, and lateral cephalometric

62 Panoramic Radiograph

63 Additional Tests & Medical Consultation
Routine blood test, blood & urine sugar levels Medical consultation Dental consultation

64 Diagnosis A specific evaluation of existing conditions
Involves thorough examination of all factors which are bound to affect the success of treatment This includes both systemic & local factors & the mental condition of the patient

65 Treatment Plan The sequence of procedures planned for the treatment of a patient following diagnosis Explained to the patient in a simple and straightforward manner including all of the factors that might complicate the treatment

66 Alternate Treatment Plan
May be less than ideal but is often necessary for various reasons

67 Refusal of Treatment The patient’s demand may be unreasonable or against professional judgment or ethics; so may refuse treatment or refer him (“bag of dentures”)

68 Prognosis A forecast to the probable result of a disease or a course of therapy After considering all the factors, you should be able to predict the degree of success that can be expected & the patient should know of what can and cannot be achieved.

69 Fees & Signed Consent When patient agreed on treatment including fees , he must sign a written consent to prevent later misunderstanding

70 Prescription, Nutritional Supplements, & Tissue Conditioning
Assess if nutritional deficiency Recommend finger massage of oral tissues If old denture wearer, tissue conditioner placed to condition abused soft tissue Instruct patient to discontinue wearing denture 48 hrs prior making final impression

71 A good clinician is one who is able to diagnose potential problems during the initial examination & suggest the best possible treatment plan compatible with the age, physical, mental & financial status of the patient

72 Any Question

73 References Complete Denture Prosthodontics, 1st Edition, 2006 by John Joy Manappallil, Chapter 2. Zarb. Prosthodontic Treatment for Edentulous Patients, 12th edition. Chapter 7.


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