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Examination, Diagnosis, Treatment Planing I


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Clinical Removable Prosthodontics
Forth Year

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Examination, Diagnosis, Treatment Planing I

  1. 1. Clinical Removable Prosthodontics (Complete Denture) /4th year Examination, Diagnosis and Treatment planning References: 1. Clinical Complete Denture Prosthodontics. by Dr Mustafa A. Hassaballa. 2. Boucher’s Prosthodontics Treatment for Edentulous Patients, by George Zarb. Dr Ali Hmud BDS, MSc, ADCC College of Dentistry, KFU, Dammam Sunday 1/3/2009 G, 4/3/1430 H
  2. 2. History taking: It consists of talking with the patient in order to obtain essential personal details including health information.
  3. 3. A logical approach to diagnosis begins with: 1. History taking (medical & dental history). 2. Extraoral & intraoral examination . 3. Radiographic examination.
  4. 4. Patient data: These data are important records from a medicolegal point of view and provide information that will be useful in the treatment plan. A. Name, address and telephone number: These must be recorded so that correct naming can be made and the patient can be contacted as required.
  5. 5. B. Age: The age of the patient gives an indication of his/her ability to use dentures. Young patients are adaptable to change, i.e. their tissues heal rapidly & have good resistance.
  6. 6. Old patients found to be difficult to adapt to new situations. Also: Tissue repair is often slow,& in many cases they show more bone resorption in their alveolar ridges.
  7. 7. C. Sex/Gender: Esthetic is first priority for women than men, however, younger men are also concerned about esthetics.
  8. 8. D. Occupation Teeth are more important to some people than to other. The higher the social position, the more demanding the patient is about the esthetics.
  9. 9. Chief complaint: The patient’s reason for seeking dentures should be determined. The patient should describe the complaints as they see them, this will enable the dentist to know what concerns the patient. Also it gives an idea about the patient personality.
  10. 10. Medical and Dental History: Notes should be made of a patient past &present medical history related to future dental treatment. During diagnostic phase a thorough & accurate medical history must be obtained.
  11. 11. The patient past medical history& current medical states must be reviewed with particular attention to allergies, drug reaction, medications, and hemorrhagic tendencies.
  12. 12. Some systemic diseases have local oral manifestations, others have both local & systemic manifestations which bear a direct relationship to the successful wearing of complete dentures.
  13. 13. These systemic diseases can be broadly divided into (3) types: 1. Diseases which affect the shape of the ridges: e.g. Fibro-osseous dysplasia, such as Paget’s disease, Acromegally or hyperparathyroidism.
  14. 14. 2. Diseases which affect the shape of the oral mucosa: They include blood dyscrasias such as anaemias, skin diseases such as Pemphigoid lesions, Lichen Planus, Erythema Mutilforme, and Aphthous Stomatitis.
  15. 15. 3. Diseases which affect the shape of the patient’s physical capacity to control dentures. These include Parkinson’s disease, facial paralysis, epilepsy and so on.
  16. 16. Questions under medical history help to alert the dentist to possible medical problems.
  17. 17. The medical history examination chart must be filled by the patients themselves and then reviewed by the dentist.
  18. 18. Extra Oral examination: Head & neck region should first be examined for the presence of any pathologic conditions. The face & neck are palpated for any mass or enlarged nodes.
  19. 19. Lymph nodes: Any palpable or tender lymph nodes about the face, joints or neck should be noted and their cause determined.
  20. 20. Neuromuscular ability or coordination: This can be seen in how a patient walks, moves & handles him/herself.
  21. 21. Patient with good neuromuscular coordination can be expected to learn to manipulate dentures quickly & adapt easily to new dentures.
  22. 22. Parafunctional & uncontrolled jaw movements complicate the recording of the maxillomandibular relations.
  23. 23. Muscle tone: If the facial muscles are too tense, manipulation will be difficult, if too loose, the lips & cheeks may be easily displaced by dentures.
  24. 24. A face that has poor tissue tone, with loose or wrinkled tissues can not be made to appear youngful by new dentures.
  25. 25. Excessive facial muscle droopiness (flabbiness or slackness) affects on both esthetics & the patient’s ability to control dentures.
  26. 26. TMJ: They should be observed & examined. Any asymmetry during opening & lateral movements of jaws should be noticed.
  27. 27. Check if the pain & tenderness during opening & closing is present. Any sounds during condylar movements, any limitations of movements.
  28. 28. Digital examination (manual) of the area over TMJ should me made. Place your finger over each joint& ask patient to open & close. Any sign present must be treated before new dentures are made.
  29. 29. Any clicking in the joints or crepitus (cracking sound caused by the rubbing together of dry synovial surfaces of the joint) must be checked & treated.
  30. 30. Gagging: (retching, sick, vomit ,throw-up) The involuntary contraction of the muscles of the soft palate that result in retching. If it is an active one, it can compromise the dental treatment plane.
  31. 31. •It can upset & annoy both the dentist & patient. •A thorough history & oral examination will reveal the presence of such reflex early in the patient-dentist relationship phase.
  32. 32. 1. 2. 3. 4. 5. It Could be due to: Iatrogenic factors (caused by ill-fit old denture). Organic disturbances (e.g. visual, auditory, olfactory stimuli). Anatomic anomalies (narrow vaults, retracted tongue) . Biomechanical inadequacies of existing prosthesis. Psychological factors.
  33. 33. Reassurance & kind handling of the patient proved to be useful. Patients who show severe gagging should be seen by a specialist.
  34. 34. Intraoral examination Color of the mucosa: The color varies from pink in healthy mucosa to red in inflamed tissues. Some tissues will recover with simple rest (by keeping the denture out) others require tissue conditioning resins, while others require surgery.
  35. 35. Arch size: It might be: 1. Large. 2. Average. 3. Small. The larger the arch, the greater the advantage for retention, stability and support.
  36. 36. Arch form: Generally, they are classified into: 1. Square 2. Tapering 3. Ovoid. Square arch is the best form to prevent rotational movements.
  37. 37. Residual ridge contour: It varies between upper & lower arches & from one area of the arch to another arch. It can be divided into: 1. Normal ridge. 2. Flat ridge (resorbed ridge) 3. Knife-edge ridge (narrow V-shaped) 4. Irregular or undercut ridge (bulbous).
  38. 38. Mucosa condition: Membranes covering lips, cheeks, floor of the mouth, tongue, hard and soft palates, tonsillar areas, the jaws and residual alveolar ridges should carefully examination. It is classified into: 1. Healthy 2. Irritated 3. Pathologic.
  39. 39. End of 1 lecture st
  40. 40. Tongue: It plays a major role in the retention of the mandibular denture. Tongue position: Might be normal, subnormal and abnormal. Normal tongue is in a correct position. The tip is relaxed where it rests in the area of the lingual surfaces of the lower anterior teeth.
  41. 41. Tongue size: Large tongue occurs when all teeth lost for a long period of time. Impression making is difficult with this type of tongue and denture stability is difficult too.
  42. 42. Class I: Tongue is of adequate size & does not over fill the floor of the mouth so there is enough room for the denture. Class II: Tongue slightly overfills the floor of the mouth. Class III: Tongue completely fills the floor of the mouth & covers the alveolar ridge.
  43. 43. Residual Ridge Relationship: It could be: 1. Normal. 2. Retrognathic. 3. Prognathic.
  44. 44. 1. Normal:  when upper ridge is directly above the lower ridge crest. Arrangement of teeth will be conventional. As in fig. (A)
  45. 45. 2. Retrognathic: Lower jaw is smaller than upper jaw. Arrangement requires that the vertical & horizontal overlap will be increased with the reduction or elimination of lower first premolar. As in Fig. B
  46. 46. 3. Prognathic: The lower jaw is larger than upper jaw & lies outside the crest of the upper ridge. As in Fig. C
  47. 47. Residual Ridge Parallelism: 1. Parallel Residual Ridge: when upper& lower ridges are parallel to each other while patient is in rest position. 2. Divergent Residual Ridge: upper & lower jaws diverge forward with inter-ridge distance greater in anterior than in posterior.
  48. 48. Palatal throat form: Is the width of area between the distal border of the hard palate & the anterior border of the movable tissues of the soft palate.
  49. 49. A wide posterior palatal seal is most favorable because a large seal can be placed. There are 3 classes: 1. Class I Soft palate. 2. Class II soft palate. 3. Class III soft palate.
  50. 50. Inter-arch Space (Inter-ridge distance): The vertical distance between ridge crests may be: 1. Favorable inter-ridge space. 2. Limited inter-ridge space. 3. Excessive inter-ridge space.
  51. 51. Saliva: Class I: Normal in amount & consistency, where cohesive and adhesive properties of saliva are ideal. Class II: Excessive saliva. It complicates impression procedure & minimizes retention. Class III: Insufficient saliva, which reduces retentive qualities of the dentures.
  52. 52. Consistency of saliva: 1.Thin- watery saliva. 2.Thick-ropy saliva (causes less retention)& difficulty in impression taking.
  53. 53. Tori: Bony protuberance, found along the median palatal suture (Torus Palatinus) or on the lingual side of the mandible at premolar area (Torus Mandibularis).
  54. 54. Tori are classified as: 1. None. 2. Small (does not interfere with denture construction). 3. Large (demands surgical removal).
  55. 55. Lips: Lip length might be: 1.Short lips, will expose all upper anterior teeth & much of labial flange of the denture base. 2.Long lips, make it difficult to show sufficient tooth and usually they hide upper anterior teeth& denture base.
  56. 56. Form of lip, might be: 1. Thick lip, they give the appearance of adequate support when no teeth are present. 2. Thin lip.
  57. 57. Radiographic examination Radiographs are valuable aids as they reveal embedded teeth, retained roots, residual cysts, foreign bodies, developmental abnormalities, inflammatory and neoplastic pathologies.
  58. 58. Radiographic landmarks  Edentulous patients 1. Nasal Cavity 2. Maxillary Sinus 3. Zygomatic Arch 4. Head of the Condyle 5. Cornoid Process 6. Soft Palate 7. Maxillary Tuberosity 8. Hard Palate 9. Tongue Shadow 10.Mandible 11.Mental Foramen 12.Submandibular Fossa 13.Inferior Alveolar Canal
  59. 59. Radiograph can show the relative thickness of submucosa covering bone, location of mandibular canal & mental foramen in relation to basal seat for mandibular denture. Sharp spicules of bone on ridge crest can also be seen.
  60. 60. Mental attitude Dr House classified patient’s mental attitudes into 4 classes: Class I, Philosophic patients: Those patients are willing to accept the adjustment of their dentists without question. They accept their oral situation & know that their dentist will do the best that can be done. They are easy going, mentally well-adjusted & cooperative. Prognosis is excellent.
  61. 61. Class II, Exacting (demanding) patients: They are precise, not satisfied with past treatment, doubt the ability of the dentist to satisfy him, and asks for written guarantee or remake at no additional charge.
  62. 62. Class III, Hysterical patients: Unstable personality, excitable, apprehensive & hypersensitive. Have negative attitude, often have poor health, have failed in the past to wear dentures, ask for esthetic & function equal to natural teeth A medical consultation is always advisable for them before starting. Prognosis is unfavorable.
  63. 63. Class IV, Indifferent:      Not concerned with appearance. They go without dentures for years. Have little appreciation for the efforts of their dentists & often seek treatment because of the insistence of their families. They discontinue easily if problems are encountered with their new teeth. Prognosis is uncertain or unfavorable.
  64. 64. Assessment of the existing denture After examination oral anatomy, a detailed & systemic intra & extra oral examination of the patient’s existing denture should be made by the dentist.
  65. 65. This examination should include examination of the tissue surface, occlusal and polished surfaces of the existing denture. All patients should mention in their records if they own old dentures: Length of time dentures have been worn.
  66. 66. How many sets have been made since the teeth were extracted. The success of the existing old dentures. The attitude of the patient to their appearance.
  67. 67. Pre-extraction records Include: 1. Diagnostic casts ( from old treatment). 2. Close-up photograph.  It must be explained to the patient that the information is to be used as a guide and that it is rarely possible to return to the exact appearance shown in the photograph.
  68. 68. Treatment planning The dentist can usually direct his patients to the most favorable treatment plan by proper education since they know very little about the treatment options.
  69. 69. Patient education should begin during diagnosis & continues throughout the treatment. The more information a patient is given the more he or she will accept that treatment. Usually a more highly motivated patient has a significant positive effect on a successful prognosis.
  70. 70. Prognosis The degree of success the proposed line of treatment is likely to achieve. The overall picture including the patient’s expectations, understanding and mental attitude. If problems are expected, they should be explained to the patient before treatment proceeds. The patient is then more likely to cope with the unavoidable limitations of the new dentures.