Complete Denture Overview - Dr

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Complete Denture Overview - Dr Powered By Docstoc
					Examination, Diagnosis and
  Treatment Planning for
  Edentulous or Partially
   Edentulous Patients

         Rola M. Shadid, BDS, MSc
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

 Referring for additional tests or medical
 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
The First Meeting
Ÿ Most important
Ÿ Prior to meeting, you should review
  general information
Ÿ Your confidence is as important as the
  treatment itself
Ÿ You should be a good listener
Ÿ Your communication should be in a
  simple & truthful manner
Recording General Information
1. Name

2. Race

3. Occupation

4. Address and telephone no.

5. Previous dentist
With advancing age*:
1. Decrease capacity of tissue to tolerate stress
2. Tissue takes longer time to heal
3. Many diseases are prevalent in older age
4. Women at postmenopause may have psychological
   disturbances (exacting or hysterical)
5. Men at this age may be concerned with only comfort
   & function (indifferent)
 Psychological Evaluation
 (House Classification of Denture

q Philosophical patient: well motivated, cooperative,
  calm & composed even in difficult cases.

q Exacting (critical): likes each step in detail, makes
  alternative treatment for dentist, makes severe
qIndifferent: not very interested in
 treatment, blames the dentist for any
 mishap, not follow instructions, been
 coerced to come by friend, relative….*
q Hysterical: easily excited, highly
  apprehensive, unrealistic expectations*
q Skeptical: bad results from previous
  treatment, doubtful, often have severely
  resorbed ridges and poor health, might
  have psychological disturbances from
  recent personal trajedy #
Chief Complaint & Patient
Ÿ Patient’s own words
Ÿ Why he is seeking prosthodontic
Ÿ You should assess if patient
  expectations are realistic or not
Ÿ If not realistic, you should educate
  pt and scale them down
    Medical History*
 Diabetes Mellitus
 Cardiovascular diseases
 Diseases of joints: osteoarthritis
 Diseases of skin: pemphigus ?
 Neurological disorders (Bells balsy and
 Sjogren’s syndrome
 Transmissible diseases
Radiation Therapy Vs. Dentures

  Ÿ Consequences of Radiation
  Ÿ Preprosthetic surgery
  Ÿ Wearing of previous denture *
  Ÿ Denture Fabrication #
Denture Fabrication in Radiation
Therapy Patient

Ÿ Avoid impression material that dry tissue
  (impression plaster) or heavily flavored
  materials (ZOE)
Ÿ Consider non-anatomic teeth
Ÿ Teeth set in neutral zone
Ÿ Slight reduction in vertical dimension
Ÿ Soft liners are controversial due to porosity and
  possibility of candida
Current Medication
Ÿ Insulin *
Ÿ Anticoagulants
Ÿ Antihypertensive: dryness & postural
Ÿ Corticosteroids: dryness, confusion &
  behavioral changes
Ÿ Antiparkinson agents like Norflex and
  Akineton: dryness, confusion & behavioral
Dental History

 History of tooth loss: cause, time*

 Edentulous period
Beware of Patients Who Have
   A “Bag of Dentures” *
  Extraoral Examination

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

  Ÿ Muscle tonus
  Ÿ Neuromuscular
  Ÿ TMJ examination
Classification of Frontal Face
Forms (House, Frush & Fisher) *
Classification of Lateral Face
  Ÿ Normal

  Ÿ Retrognathic

  Ÿ prognathic

Ÿ   Length*
Ÿ   Thickness
Ÿ   Mobility
Ÿ   Smile line
     Lip (smile) line *

High smile line    Normal smile line
Intraoral Examination

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

 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))
 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.
Tongue Size

    Ÿ Normal
    Ÿ Large *
How to Manage Large Tongue?

   1.   Lower the occlusal plane
   2.   Use narrower teeth
   3.   Increase the intermolar distance
   4.   Grind off the lingual cusps
   5.   Avoid setting a second molar
Tongue Position

  Ÿ 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
Tongue Position

    Ÿ 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
Tongue Mucosa

 The specialized mucosa
  covering the tongue is said to
  be a “window” on systemic
  diseases. *
   Frenal Attachments

 Fold of mucosa found
  at different locations in
  the sulcus region of
  upper & lower ridge
 Classification
  Class I: sulcal or low
  Class II: midway betw.
  sulcus & crest of ridge
  Class III: crestal
  Floor of the Mouth
Ÿ If FOM is near the level of the ridge crest,
  retention & stability of denture is less.
Ÿ Hyperactive FOM reduces retention & stability
Ÿ If great ridge resorption, FOM in sublingual
  and mylohyoid regions spills on the ridge
Ÿ Patency of submandibular ducts *
  Maxillary Tuberosity*

If enlarged:
 the posterior
  occlusal plane may
  be placed too low
 no enough space to
  set all molars
Maxillary Tuberosity

Palpate for
 undercuts - if
 extreme, denture
 might not seat
   The Hard Palate
Ÿ Class I: U shaped, most favorable for
  retention & stability
Ÿ Class II : V shaped: Not very favorable*
Ÿ Class III: Flat or shallow vault: Not
  very favorable, accompanied by
  resorbed ridges, poor resistance to
  lateral forces
V-shaped hard palate
   Tori *

 Palatal torus

 Mandibular tori
Bony Prominences

   Midpalatal raphe
   Sharp ridge crest
   Sharp mylohyoid ridge
   Prominent genial tubercles
   Bony fragments & fractured root pieces
   Tori
The Soft Palate (Palatal Throat Form)

House’s classification
 Class I: the soft palate is
  almost horizontal
  curving gently
 Class II: the soft palate
  turns downward at about
  45 angle from the hard
 Class III: the palate turns
  downward sharply at
  about 70 angle to the
Palatal Throat Form



Ÿ The contour of a cross
  section of a residual
  ridge that would
  prevent the placement
  of a denture or other
Unilateral or bilateral; labial or
 lingual; mild, moderate or severe
Common locations:
a) Labial portion of maxillary anterior ridge
b) Buccal to maxillary tuberosity
c) Retromylohyoid area of residual ridge
d) Labial or lingual slopes of mandibular anterior
Undercuts Management

1. Isolated anterior undercut- not
  present any problem
2. Unilateral posterior undercut-
   may not present much of a
   problem as path of insertion is
3. Bilateral undercut-surgical
   removal of the more severe one is
  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
Residual Alveolar Ridge (Cross
Sectional Contour) *

 a. U shaped
 b. V shaped
 c. Knife edged
 d. Flat
 e. Inverted
 f. Undercut
Soft Tissue Support of the
Ÿ Firm & resilient
Ÿ Flappy and hypermobile: poor
  support because denture base
  shifts during masticatory function
Ÿ Management of flappy ridge ranges
  from modified impression
  techniques to surgery
Anterior Arch Relationships *
Intraoral Examination

   Ÿ Posterior arch
   Ÿ Interridge space
   Ÿ Residual ridge size
Saliva *
Thin serous: provides an insufficient film for
denture retention.
Thick mucus: thick ropy saliva tends to displace

Normal: ideal for denture retention
Excessive: make denture const. messy
Reduced: reduced retention and increased
soreness; salivary substitutes may be prescribed
Drugs Causing Xerostomia *
  Ÿ   Diuretics
  Ÿ   Antihistamines
  Ÿ   Atropine
  Ÿ   Anticholinergic
  Ÿ   Antihypertensive
  Ÿ   Antiparkinson (Norflex)
  Ÿ   Corticosteroids
Examination of an Old Denture
 o Esthetics, lip fullness, symmetry,
   amount of display during smiling,
   phonetics, teeth position, size,
   excessive wear

 o Fracture, cracks, porosity, denture

 o Occlusal vertical dimension (due to
   excessive occlusal wear, OVD may
   have reduced)
Reduced vertical dimension
Examination of an Old Denture
   Epulis fissuratum

   Angular cheilitis

   Papillary hyperplasia

   Flappy hyperplastic ridge*

   Combination syndrome
Epulis Fissuratum
Inflammatory Papillary
Angular Cheilitis (Perleche)
Combination (Kelly’s) Syndrome *
Radiographic Examination

  Ÿ A routine radiographic exam.
    must be ordered to rule out
    any bony conditions that
    could affect the treatment
  Ÿ Panomaric radiograph is
    usually ordered for denture
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
Panoramic Radiograph
Additional Tests & Medical
Ÿ Routine blood test, blood & urine sugar
Ÿ Medical consultation
Ÿ Dental consultation
Ÿ A specific evaluation of existing
Ÿ Involves thorough examination of all
  factors which are bound to affect the
  success of treatment
Ÿ This includes both systemic & local
  factors & the mental condition of the
Treatment Plan
  Ÿ The sequence of
    procedures planned for the
    treatment of a patient
    following diagnosis
  Ÿ Explained to the patient in a
    simple and straightforward
    manner including all of the
    factors that might
    complicate the treatment
Alternate Treatment Plan

Ÿ May be less than ideal but is
  often necessary for various
Refusal of Treatment

  Ÿ The patient’s demand may be
    unreasonable or against
    professional judgment or
    ethics; so may refuse
    treatment or refer him (“bag of
 Ÿ A forecast to the probable
   result of a disease or a course
   of therapy
 Ÿ 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.
Fees & Signed Consent

  Ÿ When patient agreed on
    treatment including fees , he
    must sign a written consent to
    prevent later
Prescription, Nutritional
Supplements, & Tissue
Ÿ Assess if nutritional deficiency
Ÿ Recommend finger massage of oral tissues
Ÿ If old denture wearer, tissue conditioner
  placed to condition abused soft tissue
Ÿ Instruct patient to discontinue wearing
  denture 48 hrs prior making final
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

I. Complete Denture Prosthodontics, 1st
   Edition, 2006 by John Joy Manappallil,
   Chapter 2.

II. Zarb. Prosthodontic Treatment for
    Edentulous Patients, 12th edition.
    Chapter 7.

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