Diagnosis and Treatment Planning (PDF)

 CLINICAL COMPLETE DENTURES Prof.Dr. Amal Fathy Kaddah Professor of Prosthodontic, Faculty of Oral &Dental Medicine, Cairo University Dr. Ali Abdulghani AlSourori lecturer of Prosthodontic, Faculty of dentistry IBB University Faculty of Oral &Dental Me...

 CLINICAL COMPLETE DENTURES Prof.Dr. Amal Fathy Kaddah Professor of Prosthodontic, Faculty of Oral &Dental Medicine, Cairo University Dr. Ali Abdulghani AlSourori lecturer of Prosthodontic, Faculty of dentistry IBB University Faculty of Oral &Dental Medicine, Nahda University  Topic Week No. Interactive Lecture Practical Diagnosis, examination and treatment planning of W1 Diagnosis, clinical examinations and data collections. Completely edentulous patient. Complete denture impressions. The primary W2 Primary impression impression Complete denture impressions. The final W3 Primary impression impression Jaw relation records W4 -Occlusal Plane orientation Secondary impression -Vertical Jaw Relation Records Jaw relation records W5 Secondary impression -Horizontal Jaw Relation Records W6 Complete denture Occlusion Jaw relation registration. W7 Evaluation of Trial dentures Jaw relation registration. W8 Complete Denture Try-in Mid-term Exams W9 Complete Denture Insertion. W10 Denture Insertion Complete Denture Insertion. Follow-up Clinical remount, occlusal adjustment and Post W11 Complete Denture Insertion. Follow-up Insertion Maintenance Complete Denture Insertion. W12 Complete denture complains Follow-up W13- W15 Revision for final written exams & interactive oral discussion & case studies W16 Final practical exam W17 &W18 Final written & oral exams  DIAGNOSIS, EXAMINATION AND TREATMENT PLANNING OF COMPLETELY EDENTULOUS PATIENT. Dr. Ali Abdulghani AlSourori Lecturer of Prosthodontic, Faculty of Oral &Dental Medicine, Nahda University  Faculty of Oral &Dental Medicine Department Name: Prosthetic Dentistry Removable Prosthodontics Division Course Director: Dr. Ali Al Sourori Course Title: Removable Prosthodontics Clinics 3 Course Code: RPC 401 Lecture NO.:1 Intended Learning Outcomes (ILOs) List diagnostic forms and methods of diagnosis. Explain and relate between proper diagnosis and the success of complete denture. Apply different methods of diagnosis and predict the prognosis.  INTRODUCTION TO COMPLETE DENTURE CONSTRUCTION Definitions: 1. Prosthetics The art and science of supplying , fitting and servicing artificial replacement of missing parts of the human body. 2. Prosthesis The artificial replacement of an absent part of the human body. e.g. eye prosthesis , Leg prosthesis. 3. Prosthodontics or Prosthetic Dentistry 3. Prosthodontics or Prosthetic Dentistry 4. Dentulous 5. Edentulous 6. Partially Edentulous  Complete Denture Definitions : “A prosthesis that replaces the lost natural dentition and associated structures of the mandible and / or the maxilla “. Component Parts : Denture Base Denture Flange Denture Border (Edge) Denture Surfaces : Fitting Surface Polished Surface Occlusal Surface Principle of Denture Retention Support Stability  CLINICAL AND LABORATORY STEPS FOR C.D. CONSTRUCTION CLINICAL LABORATORY 1. Examination and Diagnosis. 3. Pouring the Impression (Study Cast). 2. Preliminary Impression. 4. Special Tray Construction. 5. Final Impression. 6. Boxing the impression 7. Pouring the Impression. 8. Occlusion Blocks Construction. 9. Jaw Relation Records. 10.Mounting U/L casts. 11. Arrangement of Artif. Teeth. 12.Waxing Up. 13.Try In Stage. 14.Denture Processing. 15.Denture Insertion. 16. Follow Up. CLINICAL 1. Examination and Diagnosis. 2. Preliminary Impression. Stock Trays Alginate Impression Upper Lower Impression Compound LABORATORY 3. Pouring the Impression. LABORATORY 4. Special Tray Construction. Lower Special Tray Upper Special Tray CLINICAL 5. Final Impression. Upper Impression Lower Impression LABORATORY 6. Boxing the impression 7. Pouring the Impression. LABORATORY 8. Occlusion Blocks Construction. Upper Occlusion Blocks Lower Occlusion Blocks CLINICAL 9. Jaw Relation Records. LABORATORY 10.Mounting U/L casts. LABORATORY 11. Arrangement of Artificial Teeth. CLINICAL Try In Stage. LABORATORY 14.Denture Processing. CLINICAL 15.Denture Insertion. 16. Follow Up. Objectives of Complete Denture Prosthesis 1. Preservation of the tissues in good health 2. Restoration of functions Mastication. Speech. 3. Restoration of esthetics. 4. Psychological comfort of the patient. Diagnosis, Examination and Treatment Planning of Completely Edentulous Patient.  Diagnosis Is Determination of the nature, location, and causes of diseases  Diagnosis Process of deciding the nature of underlying condition by: History Examination Observation taking OBJECTIVES OF DIAGNOSIS Assessment of patient’s general health. Psychological and mental evaluation of patient under treatment. Evaluation of the condition of oral tissues before prosthesis fabrication. Determination of possible difficulties expected for the case. Reaching the highest level of patient satisfaction.  DIAGNOSTIC PROCEDURES Patient’s history History taking Past medical history Past dental history Extra-oral examination Intra-oral examination Clinical Pre-extraction records examination Xrays Study models Photographs Diagnostic Procedures Patient’s History Clinical Examination Investigations: Radiographic Evaluations Diagnostic Cast Treatment Plane I-Patient’s History Personal Details. Social details. Reason for attendance Dental History. Medical and surgical History.  Patient’s history Personal and Reason for social details attendance Name, address Age Appearance Young: better coordination Faster adaptation Lighter teeth shade Function Sex Esthetics Replace teeth menopause Occupation Public speakers: complain Retention,esthetics,phonetics Personal &Social Details Name - Address - Tel. N0 Age - Sex Occupation & Socio-economic Class Public speakers and singers Wind instrument players Psychological conditions  Social Details Occupation: Socio-economic Class Attendance Special treatment needs Social conditions: Clenching (Loneliness, problems) Severe reaction Inability to use denture  Mental Attitude (House Classification) Philosophical patients Exacting patients Hysterical patients Indifferent patients Philosophical Patients (Truth-seeking) Best mental attitude-Definite- incentive- thoughtful - Learns to adjust rapidly- Clear- cut -kind-caring Good prognosis Exacting Patients (Demanding ) Good as philosophical- needs great care, effort &explanations- tough Good prognosis. (Might doubt ability of dentist to provide a good prosthesis) Hysterical Patients (Panic-stricken) Unstable- Excitable, Apprehensive, hypertensive, needs medical consultation (neurosis or psychosis), needs additional help during and after tr. Poor prognosis Indifferent Patients (Uncaring ,cool) Uninterested- depressed-lack of motivation- no cooperation- unfavorable prognosis In 2003, Gamer, S et al stated that, “House provided little attention to how the patient’s reaction and behavior are codetermined by the treatment and behavior of the dentist” So the idea of evaluating the patient in isolation from the effect of the dentist personality is a mistaken idea. “The myth of the isolated mind”  The proposed classification is based on 2 factors: 1. The level and quality of the engagement of the patient towards the dentist. 2. The level of willingness to trust the dentist  Ideal patient‫مثالى‬ Reasonably engaged and reasonably willing to trust the dentist.  Submitter‫ خاضع‬. ⚫ lack discrimination and tend to idealize the dentist which result in high degree of engagement.  Reluctant patient ‫رافض‬ The patient is always leery of the dentist and skeptical of the treatment plan  Indifferent patient ‫غير مهتم‬ Patient is minimally engaged and the patient’s willingness to trust the dentist is not an issue to him  Resistant patient ‫مقاوم‬ These patients are skeptical of the dentist as a person and of being helped by any one under any circumstances.  The interaction between the patient type and the dentist needs will definitely affect the treatment outcome eg: A dominating dentist will enter into a battle with a resistant patient  (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 Sheldon Winkler – Essentials of complete denture prosthodontics. 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 Sheldon Winkler – Essentials of complete denture prosthodontics.  Reason For Attendance - Restore - Restore - Maintain - Replace - Replace teeth - Old restorations: Appearance Function Health restorations number, quality, experience  Medical History Some chronic diseases facing difficulties in wearing of dentures because of a low tissue tonus and tolerance to mechanical irritation. e.g. - Diabetes - Tuberculosis -Anemia. -Hepatic diseases  Medical history Systemic diseases Drugs Diabetes Reduced salivary flow Antihypertensive drugs Increased rate of bone resorption Hormonal disorders Acromegaly Diuretics Hyperparathyroidism Parkinsonism Arthritis  Dental History Reasons & Sequence of loss of natural teeth Earlier Prosthesis Success or Failure & Reason of Failure Gagging Reflex during previous dental treatment  Dental history Reason for tooth loss: Periodontal cause gives indication for rapid bone resorption Old versus new denture wearer Complains with previous denture II-Clinical Examination Extra oral Intra-oral Facial Examination Visual Examination Digital Examination TMJ Examination Radiographic Examination  Extra-oral examination General look TMJ examination Facial appearance Tremors Range of motion Facial wrinkles Walking cane TMJ sounds Decrease or increase Short breath Mouth opening of vertical dimension Deviated mouth in old dentures. opening Class II, III angle classification Lip length/thickness/tone Skin folds/colour Distorted philtrum  Extra oral Examination A- Facial Examination Front View Profile View Angle of the Size - Form – Shape mentolabial Sulcus of the face Vertical dimension Juvenile Appearance of old denture of the patient wearers  Facial Visual Examination An edentulous patient should be examined facially in front and profile views. It may be noted that 1-The fullness and normal contour of the upper lip is lost due to the lack of support by the loss of teeth 2.The normal lip line and natural vermilion border of the upper lip is changed due to this falling in and the philtrum looks unsupported. 3.The nasal folds are deepened, the mental tip is exaggerated and facial wrinkles may result if the person has been without teeth for sometime. B- TMJ Examination  Extra oral Examination B- TMJ Examination Clinical Interpretation Radiographic Interpre. DigitalExam. Panoramic Corrected Cephalometric Clicking or Pop Tomography sounds on jaw Transcranial Radiography Opening Computerized Tomography MRI  Examination of the TMJs Mandibular Range of Motion Identification of TMJ Sounds Palpation of the TMJs Loading of the TMJs Lateral and distal palpation of the TMJ Identification of the TMJ Sound Using a medical stethoscope or the Electrosonograph (ESG) TMJ Sounds 1- Clicking, Popping or Thud 2- Crepitating or Grating Sound  TMJ Sound Clicking, Popping or Thud Due to: Deviation in Form hypermobility Incoordination Disc Displacement With Reduction Crepitating or Grating Sound Normal opening and closing ‫َهلْ َج َزاء اإلح َسْانْ‬ ‫إ ْلا اإلح َسانْ‬  Intra Oral Examination A- Visual Examination Completely Edent. pt Partially Edent. pt Edentulous Area Remainimg Natural Teeth Colour- Contour-Ridge N0 - Form-Location-Caries- Existing Restoration- Relationship -Tongue Periodontium-Positions- Tori-Undercut–Throat Occlusion. form- Saliva- Frena Att. Edentulous Area The Same for Comp. Edent. pt Intra oral Examination Intra-oral examination Arch size and form Denture bearing mucosa Border tissues Frenula Ridge form Inter-ridge space Maxillo-mandibular relationship Hard palate/soft palate Maxillary tuberosity Tori Undercuts Tongue size and type Muscle tonicity Floor of the mouth Saliva Bony spicules Arch size and form  Arch size and form Large arch size improved support , retention and stability.  Denture bearing mucosa Firm Non edematous Even thickness Pink colour 1-2 mm resiliency Non-resilient tissues: not favourable for retention, requires relief. More than 2mm resiliency: unstable denture foundation. Flabby tissues/inflammation/sore spots/abrasion.  Border tissues should be slightly displaceable to provide adequate peripheral seal. Broad labial frenum Frenectomy Excessive relief deep, wide v-shaped notch Loss of peripheral seal Midline fracture Ridge form Flabby ridge  U- shaped ridge: resists lateral and vertical displacement. Flat ridge: lacks resistance to lateral displacement Mental foramen needs relief Special impression techniques Knife edged ridge: poor denture supporting area Selective pressure impression  Inter ridge space Too low Too high Better retention Less retention &stability &stability Problem in teeth No problem in setup teeth set up No leverage Strong leverage  Maxillo-mandibular relation Angle class I: favorable prognosis Angle class II: decreased mandibular denture bearing area. Angle class III: trauma to anterior maxillary ridge  Hard palate High vault: unfavourable for denture retention. Flat vault: unfavourable for denture stability Soft palate  Maxillary tuberosity Important for support and retention. Unilateral undercut: path of insertion Bilateral undercut: Resilient liner Surgical removal augmentation  Tori Relief Surgical removal  Tongue Class I: Normal size and function, apex at or slightly below incisal edge of mandibular anteriors. Class II: tongue is retracted and the apex is pulled down Class III: tongue is tense and more retracted and the tip is pulled into the tongue body  Saliva Quantity and quality. Important for: retention tissue lubrication accuracy of impression  Pre-extraction records Radiographs Photographs Diagnostic cast Shade record  Roentgenographic examination Retained roots Impacted teeth Residual cyst Bone quality index Rough , irregular residual ridge You must NEVER give a treatment recommendation to any patient before creating and analyzing the entire patient data base Proper Diagnosis is the Key of Best Prognosis Adjunctive Care - Elimination of infection and pathoses -Surgical improvement of denture support -Tissue Conditioning -Nutritional Counselling Prosthodontic Care  Information gathering 1.Medical, Dental , Psycosocial Histories. 2.Clinical Examination. 3. Radiographic Examination. 4. Diagnostic Aids. Evaluation of Findings Significant Finding Problem Diagnosis List Treatment Objectives Patient Modifier Dentist Modifier Treatment Plan 1.Systemic Phase. 2. Acute Phase. 3.Disease Control Phase. 4.Defenitive Phase.