Diagnosis and Treatment Planning in Completely Edentulous Patients PDF

Under Supervision of Dr.Hussein Eldawash. Assistant Professor of Removable Prosthodontics, Faculty of Oral & Head Of Department Dental Medicine,.zagazig university Dr.Eman Husseiny Mohammed. Lecturer of removable prosthodontics, Faculty of Oral & Dental Medicine, zagazig university. Dr. Mohamed Mahmoud Dohaim. Lecturer of removable prosthodontics, Faculty of Oral & Dental Medicine , zagazig university. 2021 ٣ Diagnosis and treatment planning in completely edentulous patient Introduction Diagnosis in complete dentures is a very important process and is not accom- plished in a short time. The dentist should be the first to recognize the problem and be ready to change the treatment plan to meet the new findings. Treatment does not terminate with the construction and delivery of complete dentures, and the patient should be so advised. Diagnosis and treatment planning are the most important parameters in the successful management of a patient. Inadequate diagnosis and treatment planning are the major reasons behind the failure of a complete denture. S.O.A.P. Subjective (What the patient tells us) Objective (What we see) Assessment (What we deduce) Plan (What we offer to do) (Tx Plan) The following items will be disscussed: Diagnosis -Patient Evaluation -Clinical History Taking -Clinical Examination of the Patient -Radiographic Examination Assessment Treatment Plan Prognosis Prosthodontic Care ٤ Definitions Diagnosis (1) The act or process of deciding the nature of a diseased condition by examination. (2) A careful investigation of the facts to determine the nature of a thing, (3) The determination of the nature, location, and causes of disease. Treatment planning is a consideration of all of the diagnostic findings, systemic and local, which influence the surgical preparations of the mouth, impression making, maxillomandibular relation records, occlusion to be developed, form and material in the teeth, the denture base material, and instructions in the use and care of dentures. The factors in these findings will be governed by (1) The patient's mental attitude, (2) The patient's systemic status, (3) Past dental history, and (4) Local oral conditions. ٥ The following factors should be evaluated to arrive at a proper diagnosis and treatment planning. 1-DIAGNOSIS: a-Patient Evaluation - Gait - Cosmetic Index - Complexion - Mental Attitude b-History taking: Personal history - Name - Race - Age - Location - Sex - Religion - Occupation Medical History — Debilitating Diseases — Neurological Disorders — Diseases of the Joints — Oral Malignancies — Cardiovascular Diseases Climacteric Conditions — Diseases of the Skin Dental History — Chief Complaint — Current Denture — Expectations — Pre-extraction Records — Period of Edentulousness — Diagnostic Casts — Pre-treatment Records: Denture Success — Previous Denture ٦ c- Clinical Examination of the patient Extraoral — Facial examination: — Lip Examination - Facial Form — TMJ Examination - Facial Features — Neuromuscular Examination — Muscle Tone - Speech — Muscle Development -Co-ordination — Complexion Intraoral: — Existing teeth (If any) — Redundant Tissue — Mucosa: — Hyperplastic Tissue - Colour of the mucosa — Hard palate - Condition of the Mucosa — Soft palate and palatal Throat Form -Thickness — Lateral Throat Form — Saliva — Gag Reflex — Residual Alveolar Ridge: — Bony Undercuts - Arch Size — Tori - Arch Form — Muscle and Frenum Attachments - Ridge Contour - Border Attachments of the Mucosa - Ridge Relation - Frenal Attachments - Ridge parallellism — Tongue - Inter-arch Space Floor of the Mouth G — Ridge Defects d- Radiographic Examination Bone Quality e- Examination of the Existing Prosthesis ٧ 2-TREATMENT PLANNING: Adjunctive care: Elimination of Infection Tissue Conditioning Elimination of Pathosis Nutritional Counselling Pre-prosthetic Surgery Prosthodontics care Patients destined to be edentulous: — Immediate or Conventional Denture — Definitive or Interim Denture — Implant or Soft Tissue Supported Denture Patients already edentulous: — Soft Tissue Supported — Selection of Teeth — Implant Supported(fixed or removable) — Anatomic Palate — Material of Choice ٨ 1-DIAGNOSIS Essential diagnostic data obtained from patient interview, definitive oral examination, consultation with medical and dental specialists, radiographs, mounted and surveyed diagnostic casts should be carefully evaluated during treatment planning. A - PATIENT EVALUATION The dentist should begin evaluating the patient as soon as he/she enters the clinic. This is to obtain a clear idea of what type of treatment is necessary for the patient.  Gait People with neuromuscular disorders show a different gait. Such patients will have difficulty in adapting to the denture.  Complexion and Personality Evaluating the complexion helps to determine the shade of the teeth. Executives require smaller teeth.  Cosmetic Index It basically speaks about the aesthetic expectations of the patient. Based on the cosmetic index, patients can be classified as: - Class I: High cosmetic index. They are more concerned about the treatment and wonder if their expectations can be fulfilled. - Class II: Moderate cosmetic patients. They are patients with nominal expectations. - Class III: Low cosmetic index. These patients are not bothered about treatment and the aesthetics. It is very difficult for the dentist to know if the patient is satisfied with the treatment or not. ٩  Mental Attitude of Patients A doctor should evaluate the patient's hair colour, height, weight, gait, behaviour, socio- economic status, etc right from the moment he/ she enters the clinic. A brief conversation will reveal his/her mental attitude. De Van stated, "meet the mind of the patient before meeting the mouth of the patient". Hence, we understand that the patient's attitudes and opinions can influence the outcome of the treatment. Based on their mental attitude, patients can be grouped under two classifications. 1-Dr. MM House proposed the first one in 1950, which is widely followed. House's Classification Dr.MM House in 1950 classified patient's psychology into four types: Class I: Philosophical a. Those who have presented themselves prior to the extraction of their teeth, have had no experience in wearing dentures, and do not anticipate any special difficulties in that regard. b. Those who have worn satisfactory dentures, are in good health, are a well- balanced type, and are in need of further denture service.Generally they can be described as mentally well adjusted, cooperative and confident of the dentist. These patients have excellent prognosis. Class II: Exacting a. Those who, while suffering from ill health, are seriously concerned about appearance and efficiency of artificial dentures. They are reluctant to accept the advice of the physician and the dentist and are unwilling to submit to the removal of their artificial teeth. b. Those wearing dentures unsatisfactory in appearance and usefulness, and who doubt the ability of the dentist to render a satisfactory treatment, and those who ١٠ insist on a written guarantee or expect the dentist to make repeated attempts to please them. These patients are precise, above average in intelligence, concerned in their dress and appearance, usually dissatisfied by their previous treatment, do not have confidence in the dentist. It is very difficult to satisfy them. But once satisfied they become the dentist's greatest supporter. Class III: Hysterical a. Those in bad health with long neglected pathological mouth conditions and who are positive in their minds that they can never wear dentures. They are emotionally unstable and tend to complain without justification. b. Those who have attempted to wear dentures but failed. They are thoroughly discouraged. They are of a hysterical, nervous, very exacting temperament and will demand efficiency and appearance from the dentures equal to that of the most perfect natural teeth. Unless their mental attitude is changed it is difficult to give a successful treatment. They have unrealistic expectations and want the dentures to be better than their natural teeth. They are the most difficult patients to manage. They show poor prognosis. Class IV: Indifferent Those who are unconcerned about their appearance and feel very little or no necessity for teeth for mastication. They are, therefore uncooperative and will hardly try to become accustomed to dentures. They will not maintain the dentures properly and do not appreciate the efforts and skills of the dentist. 2-other Classification Patients may also be classified under the following categories: a-Cooperative ١١ These patients represent the optimum group. They may or may not recognize the need for dentures but they are open-minded and are amenable to suggestion. Procedures can be explained with very little effort and they become fully cooperative. b- Apprehensive Even though these patients realize the need for dentures they have some problem, which cannot be overcome by ordinary explanation. The approach to all of these patients is to talk with them and to make them speak out their thoughts about dentures. Apprehensive patients are of different types namely:  Anxious: These patients are anxious and upset about the uncertainities of wearing dentures. They often put themselves into a neurotic state. In extreme and rare cases they may be psychotic.  Frightened: Some fear the development of cancer; others fear that they will not be able to wear the teeth; still others fear that the teeth will not look well. Extreme cases should be referred to a psychiatrist.  Obsessive or exacting: These persons are naturally of an exacting nature and are accustomed to giving directions to others. They state their wants and are inclined to tell the dentist how to proceed. Patients of this type must be handled firmly. They should be told tactfully at the outset that they would not be allowed to direct the denture construction.  Chronic complainers: They are a group of people who are habitually faultfinding and dissatisfied. Appreciating their cooperation and incorporating as many of their ideas as possible with good denture construction is the best way to handle them. It is best to have an understanding with such patients before work commences. In this way they are made to share responsibility for the outcome. ١٢  Self-conscious: The apprehension here centres chiefly on appearance. It is wise to give overt reassurance to the self-conscious patient and permit participation in the reconstruction as far as feasible in order to establish some responsibility in the result. c- Uncooperative These patients present themselves usually upon being urged by relatives or friends. They do not feel a need for dentures, though the need exists. Their general attitude is negative. They constitute an extremely difficult group of potential denture wearers and tax the dentist's patience to the limit. In many cases, an attempt to make dentures for these individuals is a waste of time. Along with analyzing the mental attitudes of the patient, the dentist must collect information about the patient's habits, diet, past dental history and the physical characteristics, etc. The expectations of the patient should be taken into consideration to achieve patient satisfaction. ١٣ B- HISTORY TAKING History taking is a systematic procedure for collecting the details of the patient to do a proper treatment planning. Personal and medical particulars are gathered to rule out general diseases and to determine the best form of treatment for that patient.  Personal history Name  The name should be asked to enter it in the record. When the patient is addressed by his name, it brings him some confidence and psychological security. The name also gives an idea about the patient's family and community. Age  Some diseases are limited to certain age groups. Hence, age can be used to rule out certain systemic conditions apart from determining the prognosis.  Patients belonging to the fourth decade of life will have good healing abilities and patients above the sixth decade will have compromised healing. Increasing age decreases the readiness to form new habits and also muscular efficiency is often impaired. Young people adapt themselves more readily than do the aged. They are usually more demanding in esthetics. Age has a definite relation to the selection of teeth, not only in their size, shape and color, but also in various degrees of abrasion, attrition and erosion. Sex  Generally the mentality of the patient is affected by the gender. Certain diseases are confined to a particular sex. so, sex can be used to rule out certain systemic conditions.  Male patients are generally busy people who appear indifferent treatment. They are only bothered about comfort and nothing else. On the other hand, female patients are more critical about aesthetics. ١٤ Factors such as menopause are an influencing factor in the overall success of dentures. Menopause is often reflected in symptoms of a burning mouth, which most patients will attribute to the prosthetic appliance rather than to systemic disturbances. Occupation  Executives and sales representatives require more idealistic teeth. While other people who work in places with high physical exertion require rugged teeth. And people with higher income have greater expectations. People who are very busy will be more critical about comfort.  This will frequently have a relation to the design of the dentures and the technique used in impression making, for example: a- With most professional men whose occupation entails intimate contact with their fellows, appearance and retention are more important than efficiency. They are more demanding of artificial replacements as they constantly deal with people. b- Public speakers and singers require perfect retention and particular attention to palatal shape and thickness because of the importance of these in phonation. Race  It helps to select the shade of the teeth. Location  Some endemic disorders like fluorosis are confined to certain localities. People from that locality may want characterization (pattern staining) in their teeth for a natural appearance. Religion and Community  Gives an idea about the dietary habits and helps to design the denture accordingly. ١٥ Diagnosis and treatment planning in completely edentulous patient  Medical History The following medical conditions should be ruled out before beginning the prosthetic treatment. Debilitating Diseases  Complete denture patients, most of whom are geriatric, may suffering from debilitating diseases like diabetes, blood dyscrasias and tuberculosis.  These patients require specific instructions on denture/tissue care. They also require special follow-up appointments to observe the response of the soft tissues to the denture.  Diabetic patients show excessive rate of bone resorption, hence, frequent relining may be necessary. And Epithelium is thinner, less keratinized and more sensitive to trauma. Result in Compromised, support and impaired tolerance of complete dentures.. In planning a denture for a diabetic, we should consider a reduced occlusal table, an increased amount of free way space together with frequent scheduled adjustments and recalls. The diabetic shows a tendency toward edema during periods of imbalance. This must be considered in scheduling impression procedures. Diseases of the Joints  The most common disease of the joint in old age is osteoarthritis. Complete denture patients with osteoarthritis affecting the finger joints may find it difficult to insert and clean dentures.  Osteoarthritis plays an important role in complete denture construction when it affects the TMJ. With limited mouth opening and painful movements of the jaw, it becomes necessary to use special impression trays. It may also become necessary to repeat jaw relations and make post-insertion occlusal adjustments due to changes in the joint. ١٦ Diagnosis and treatment planning in completely edentulous patient Osteoporosis  Although this condition has already been mentioned with respect to the denture- bearing tissues, it is appropriate to mention that it can lead to a hunched posture, or kyphosis, which requires the dentist to ensure that work is undertaken with the patient in the sitting position with the head and neck adequately supported. Cardiovascular Diseases  It is always advisable to consult the patient's cardiologist before commencing treatment. Cardiac patients will require shorter appointments. Angina  Angina can cause pain that is experienced around the left body of the mandible or even the left side of the palate. This usually occurs in association with chest pain and the onset is usually related to physical exertion. Congestive heart failure, chronic bronchitis and emphysema  Elderly patients with these conditions are likely to become breathless if the dental chair is tipped back into the supine position. Cerebro-vascular accident  The occurrence of a ‘stroke’ may result in unilateral paralysis of the facial muscles, making it more difficult for the patient to control dentures, especially the lower denture. The patient may also have difficulty clearing food which has lodged in the buccal sulcus.  Speech may be affected, making it difficult for the patient to communicate with the dentist. Diseases of the Skin  Skin diseases like Pemphigus have oral manifestations, which vary, from ulcers to bullae. Such painful conditions, make the denture use impossible without medical treatment. ١٧ Diagnosis and treatment planning in completely edentulous patient Neurological Disorders  Diseases such as Bell's palsy and Parkinson's disease can influence denture retention and jaw relation records. Patients should understand the difficulty in denture fabrication and usage. Anemia  The anemia results in poor nervous disorders reflecting lack of coordination and extreme irritability. Parkinson's disease affects the ability of the patient to wear dentures, and increase the hazards of denture procedures. Transmitted diseases:  Hepatitis, T.B., influenza, H.I.V.  Hazards From communicated blood, saliva, aerosol& instruments.  Impression should be immediately disinfected.(Chemical sterilization) Pemphigus Vulgaris:  Before 1959 the disease is fatal.  Bulla with gradual extension. Chronic ulceration withsubsequent scarring of the oral mucosa.  Acute phase: Oral discomfort& dryness of the mouth are common → pain& loose denture.  Limited denture extensions compromising support, stability, retention and tolerance of complete dentures. Borders should be smooth& polished to prevent irritation.  Post-insertion care. Oral Lichen Planus  Erosive lesions and subsequent scarring in the buccal shelf area limit denture extension in this region and make it difficult for some patients to tolerate their dentures.  Result - Compromised support and tolerance of the mandibular denture. ١٨ Diagnosis and treatment planning in completely edentulous patient Chronic Candidiasis  Low saliva flow rates lead to increased numbers off fungal organisms leading tto a high incidence of chronic candidiasis..  Burning and irritation of the denture bearing mucosa, making tolerance of complete dentures difficult. In addition the fungus is keratolytic, further compromising support and tolerance.  Treatment: Antifungal therapy*  Nystatin powder (100,000 units per gram). Apply to undersurface of denture three times per day for 3-4 weeks  Nystatin cream – Best used for lesions associated with the corners of the mouth  Reline or remake denture *Nystatin rinse is generally ineffective. Nystatin oral lozenges are reserved for fungal infestations that extend beyond the denture bearing surfaces. Parkinson disease:  Rhythmic contractions of the musculature (muscles of mastication).  Severe cases (Impossible for a pt. to insert& remove the denture).  Impression procedures may be compromised by the presence of excessive saliva in this case. Acromegaly:  Pt. may have a large Mandible.  Frequent examination to evaluate fit& function. Paget's disease:  Pt. with disease may have enlarged maxillary tuberosity (affects fit& occlusion).  Surgical re-contouring or relief.  Frequent recall appointments. ١٩ Diagnosis and treatment planning in completely edentulous patient Oral Malignancies  Some complete denture patients with oral malignancies may require radiation therapy before prosthetic treatment.  A waiting period should elapse between the end of radiation therapy and the beginning of complete denture construction. Only the radiotherapist determines this waiting period.  Tissues having bronze colour and loss of tonicity are not suitable for denture support. Once the dentures are constructed, the tissues should be examined frequently for radionecrosis. Climacteric Conditions  Climacteric conditions like menopause can cause glandular changes, osteoporosis and psychiatric changes in the patient. These can influence treatment planning and the efficiency of the complete denture. Other common manifestations in and around the oral cavity must be considered. These include tempromandibular joint disturbances, facial neuralgias, various types of neurosis, multiple sclerosis, coordination, intelligence, and even the desire to wear dentures. Nutritional deficiencies  Deficiencies of the vitamin B complex, folic acid and iron can lead to pathology of the mucosa and to widespread discomfort or burning. Psychiatric disorders  Depression is the most common mental disorder in later life. The prevalence of depression requiring clinical intervention in the over 65s is between 13% and 16%).  This condition can result in poor appetite and weight loss, and can adversely affect motivation and self-care. ٢٠ Diagnosis and treatment planning in completely edentulous patient Evaluating the effect of drugs on Dental& Prosthetic ttt: 1- Anticoagulants:  Medical consultation is required when surgical preparation for the prosthodontic restoration is required. 2- Antihypertensive Agents:  Syncope may occur when pt. change it's position suddenly into upright position (It occurs when the pt. rises from dental chair).  ↓ Saliva& dry mouth may be found. 3- Endocrine therapy:  Endocrine therapy may lead to Xerostomia& oral discomfort. 4- Saliva Inhibiting drugs:  Atropine& their derivatives (used to control excessive salivation).  These drugs should be avoided in Prostatic hypertrophy& Glaucoma and the salivary secretion controlled mechanically. Xerostomia is produced by certain antidepressants, diuretics, antihypertensives and antipsychotics. Lack of saliva adversely affects the retention of dentures, increases the possibility of oral infection and, through the absence of lubrication, can result in generalised soreness or even a burning sensation. Certain drugs, such as steroid inhalers used in the treatment of asthma, immunosuppressive drugs and broad-spectrum antibiotics used over a long period, can alter the oral flora thus predisposing to candida infection. Tardive dyskinesia is a condition characterized by spasmodic movements of the oral, lingual and facial muscles. These uncontrollable movements can make it extremely difficult, or even impossible, to provide stable dentures. The condition is brought on by extensive use of drugs such as antipsychotics and tricyclic antidepressants. ٢١ Diagnosis and treatment planning in completely edentulous patient  Dental History Although other sections in history are important, dental history is the most important all of them. Chief Complaint It should be recorded in the patient's own words. It gives ideas about the patient's psychology. Expectations The patient should be asked about his/her expectations. The dentist should evaluate the patient's expectations and classify them as realistic or attainable and unrealistic. If prior to being rendered edentulous, a partial denture was worn with comfort and efficiency, the same will be expected of complete dentures. It should be explained to such patients that, although partial denture experience is helpful in relation to complete dentures, the latter require a considerably greater degree of control because they are not, as were the partial dentures, retained or supported by the natural teeth. If complete dentures are already being worn and they have been comfortable and efficient, the same will be expected of the new dentures. If the old complete dentures were troublesome, the attitude may be expectant of better results with the new dentures or pessimism that nothing better can be hoped for. If no previous denture experience exists, friends or relations may have colored the patient's mind with their own attitudes. In such cases the efficient control and use of complete dentures depends to a very large extent on the formation of new habits and a new pattern of muscular movement. This demands time and some patience on the part of the wearer. Many complete denture troubles can be traced to the fact that no preparation of the patient's mind preceded the fitting of the dentures. Information regarding the loss of the natural teeth: A history of difficult extractions should be followed by a radiographic examination of the jaws to verify the absence of retained roots. ٢٢ Diagnosis and treatment planning in completely edentulous patient Questioning should be directed to eliciting the general order in which the teeth were lost. For example if all the posterior teeth were extracted some years before the anterior ones and no partial dentures were worn in the meantime, then a habit of eating with the front teeth will have been formed which, if persistent, will have a pronounced unstabilizing effect on complete dentures. A similar condition will exist in individuals who have been edentulous for a considerable length of time and have not worn dentures, as a result they are only able to approximate their jaws in the anterior region and consequently forward travel of the mandible is necessary all the time during eating. When there is a history of abnormal mandibular function or movement, then difficulty can be anticipated when registering the anteroposterior occlusal relationship. Period of Edentulousness This data gives information about the amount and pattern of bone resorption. The cause for the tooth loss should be enquired (caries, periodontitis, etc.) Pre-treatment Records The pre-treatment record is a very valuable information. Pre-treatment records include information about the previous denture, current denture, pre-extraction records and diagnostic casts Previous denture It denotes the dentures, which were worn before the current denture. The reason for the failure of the prosthesis should be enquired with the patient. The patients who keep changing dentures in a short period of time are difficult to satisfy and are risky to deal with. Current denture The existing denture, which is worn by the patient at present, should be examined thoroughly. The reason for wanting a replacement should be evaluated. This denture gives us information about the denture experience, denture care, dental knowledge and para-functional habits of the patient. ٢٣ Diagnosis and treatment planning in completely edentulous patient The following factors should be noted on the existing prosthesis: The period for which the patient has been wearing the denture should be determined. The amount of ridge resorption should be assessed to determine the amount of expected ridge resorption after placement of the new prosthesis. Anterior and posterior teeth shade, mould and material. Centric occlusion and also the patient profile in centric relation. (Centric occlusion is "the centered contact position of the occlusal surfaces of the mandibular teeth against the occlusal surfaces of the maxillary teeth"'-GPT). It should be marked as acceptable or unacceptable. Vertical dimension at occlusion. It should be marked as acceptable or unacceptable. Plane of orientation of the occlusal plane. Improperly-oriented plane will have teeth arranged in a reverse smile line. The tissue surface and the polished or cameo surface of the palate should be examined. Reproduction of rugae should be noted. The patient's speech pattern should be noted for any valving nasal twang. The posterior extension of the maxillarydenture should be noted. The posterior palatal seal should beexamined. It should be marked as acceptableor unacceptable. Proper basal seat coverage and adaptationshould be noted. It should be marked as acceptable or unacceptable The midline of the denture should be checked. At-least the maxillary denture should coincide with the facial midline. Characterization or purposeful staining of the denture for esthetics should be recorded. Wear or breakage. This may be an indication of bruxism. Denture wear can be classified as: 1. Minimal 2. Moderate 3. Severe. ٢٤ Diagnosis and treatment planning in completely edentulous patient Pre-extraction records It includes pre-extraction radiographs, photographs, diagnostic casts, etc. They can be used to reproduce the anterior aesthetics. Diagnostic cast Sometimes, intraoral examination may be inaccurate because the patient moving his jaws and altering ridge relationship. In such cases it may be necessary to prepare diagnostic casts and mount them in an articulator in a tentative jaw relation. This set-up serves to assess the inter-ridge space, ridge form and ridge shape. Denture success The patients should be asked about the aesthetics and functioning of the existing denture. Based on the patient's comment, the denture success should be classified as favourable or unfavourable. C- CLINICAL EXAMINATION OF THE PATIENT A-Extraoral Examination The patient's head and neck region should be examined for any pathological condition. Facial colour, tone, hair color and texture, symmetry and neuromuscular activity are noted. It includes facial examination, examination of muscle tone and development, lip examination, TMJ examination and neuromuscular examination.  Facial Examination ٢٥ Diagnosis and treatment planning in completely edentulous patient 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 as the person has been without teeth for sometime It includes the evaluation of facial features, facial form, facial profile and lower facial height. a-Facial Features The following features on the face should be noted during diagnosis of the patient:  Length of the lips.  Lip fullness.  Apparent support of the lips.  Philtrum.  Nasolabial fold.  Mentolabial sulcus or labiomental groove.  Labial commissures and modiolus.  Width of the vermillion border. It influences the degree of tooth display.  Size of the oral opening. It also influences the degree of tooth display.  Texture of the skin: (rough or smooth) All the above-mentioned factors aid to determine the shade, shape and arrangement of teeth ٢٦ Diagnosis and treatment planning in completely edentulous patient b-Facial form House and Loop, Frush and Fisher, and Williams classified facial form based on the outline of the face as square, tapering, square tapering and ovoid. Examining the facial form helps in teeth selection c-Facial profile Angle classified facial profile as: Class I: Normal or straight profile Class II: Retrognathic profile. Class III: Prognathic profile Examination of the facial profile is very important because it determines the jaw relation and occlusion. d- Lower facial height If the face appears collapsed, it indicates the loss of vertical dimension (VD). Decreased VD produces wrinkles around the mouth. Excessive VD will cause the facial tissues to appear stretched Determining the lower facial height is important to determine the vertical jaw relation. For those patients who are already wearing a complete denture, the lower facial height is examined under occlusion.  Muscle Tone House classified muscle tone as: Class I: Normal tension, tone and placement of the muscle of mastication and facial expression. No degeneration. It is common in immediate denture patients because all other patients generally show degeneration. 20 Mostafa Fayad ٢٧ Diagnosis and treatment planning in completely edentulous patient Class II: Normal muscle function but slightly decreased muscle tone. Class III: Decreased muscle tone and function. It is usually accompanied with ill-fitting dentures, decreased vertical dimension, decreased biting force, wrinkles in the cheeks and drooping of commissures. House classified muscle development as: Class I; Heavy Class II: Medium Class III: Light. Muscle tone can affect the stability of the denture. People with excessive muscle development have more biting force.  Complexion The colour of the eye, hair and the skin guide the selection of artificial teeth. Pale skin colour is indicative of anaemia and should be treated.  Lip Examination  Lip support: Based on the amount of lip support, lips can be classified as adequately supported or unsupported.  Lip mobility: Based on the mobility, lips are classified as  normal (class 1),  reduced mobility (class 2) and  paralysed (class 3).  Thickness of the lips: Thick lips need lesser support from the artificial teeth and the labial flange. Thus, the operator is free to place the teeth to his wishes. On the other hand, thin lips rely on the appropriate labiolingual position of the teeth, for their fullness and support. 21 Mostafa Fayad ٢٨ Diagnosis and treatment planning in completely edentulous patient  Length of the lips: It is an important determinant in anterior teeth selection.  Health of the lips: The lips are examined for fissures, cracks or ulcers at the corners of the mouth. If present these indicate vitamin B deficiency, candidiasis, or prolonged overclosure of the mouth due to decreased VD.  TMJ Examination The joint should be examined for range of movements, pain, muscles of mastication, joint sounds upon opening and closing. TMJ plays a major role in the fabrication of a CD. Severe pain in the TMJ indicates increased or decreased VD.  Neuromuscular Examination It includes the examination of speech and neuro-muscular coordination. Speech Speech is classified based on the ability of the patients to articulate and coordinate it. Type 1: Normal. Patients who are capable of producing an articulated speech with their existing dentures can easily accommodate to the new dentures. Type 2: Affected. Patients who have impaired articulation or coordination of speech with their existing dentures require special attention during anterior teeth arrangement (setting). Patients whose speech was altered due to a poorly-designed denture require more time to adapt to a proper articulated speech in the new denture. Neuromuscular coordination The patient is to be observed from the time he/she enters the clinic. The patient's gait, coordination of movements, the ease with which he moves and his steadiness are important points to be considered. 22 Mostafa Fayad ٢٩ Diagnosis and treatment planning in completely edentulous patient Any deviation from the normal will indicate that the patient is suffering from neuromuscular diseases like Parkinson's disease, hemiplegia, cerebellar disease or even the use of psychotropic drugs. These conditions also produce their manifestations on the face. Neuromuscular coordination of a patient can be classified as: Class I: Excellent. Class II: Fair. Class III: Poor. Patients with good neuromuscular coordination can easily learn to manipulate dentures. B- Intraoral visual Examination a- Existing Teeth : The condition of the existing teeth is of importance for single complete dentures. The state of the remaining teeth influence the success of tooth-supported overdentures. b- Mucosa Colour of the mucosa The mucosa should have a healthy pink colour. colour changes such as white patches or redness should be noted. White patches may indicate an area of frictional keratosis. Redness may indicates an inflammatory change. This may be due to ill-fitting denture, smoking, infection or a systemic disease. Inflamed tissues provide a wrong recording while making an impression. it may be due to inflammation caused by irritation, which may be due to mechanical, chemical or bacteriological causes. Common prosthetic causes: 23 Mostafa Fayad ٣٠ Diagnosis and treatment planning in completely edentulous patient 1- Overextension of the periphery of the denture: this is frequently seen as a bright red line, which may break down to ulceration if the irritation is continued. It may be due to overextension of the periphery of new dentures or the altered position of existing dentures due to alveolar absorption. In some cases this irritation if continued over a long period of time, will cause a proliferation of the mucous membrane, which is visible as a ridge, flap or series of flaps (Denture fissuratum). 2- Dirty, ill fitting dentures: the inflammation usually appears as an ill-defined red area, which varies with the extent of the mucous membrane most constantly in contact with the denture. 3- Continuous wearing of the denture: it may cause a chronic inflammation of the underlying mucosa. 4- Faulty articulation of teeth (traumatic occlusion): Inflammation may be found on the crest of the alveolar ridge if the occlusion is too heavy in one particular spot, or on the sides of the ridge if there is a lateral drag caused by cuspal interference. 5- Traumatic injury: the edentulous mouth frequently sustains injuries to the mucosa from sharp pieces of food such as crusts or small bones. 6- Small spicules of alveolar bone: sharp edges of both sockets not yet rounded by absorption frequently cause inflammation of Ire mucosa covering them. Also, small pieces of bone fractured during the extraction of the teeth ad in the process of being exfoliated may cause inflammation. 7- Allergy: it is very rare. Most of the cases are due to dirty, ill-fitting dentures. 8- Other causes of color variation: These are most frequently signs of some general systemic disturbances for which reference should be made to textbooks on oral pathology, and the only safe rule to follow is never to proceed with prosthetic work until the cause of color variation has been investigated. Condition of the mucosa House classified the condition of the mucosa as: 24 Mostafa Fayad ٣١ Diagnosis and treatment planning in completely edentulous patient Class I: Healthy mucosa. Class II: Irritated mucosa. Class III: Pathologic mucosa. Thickness of the mucosa The quality of the mucoperiosteum may vary in different parts of the arch. House classified thickness of the mucosa as: Class I: Normal uniform density of mucosal tissue (approximately 1 mm thick). Investing membrane is firm but not tense and forms ideal cushion for denture basal seat. Class II: It can be of two types: a. Soft tissues have a thin investing membrane and are highly susceptible to irri- tation under pressure. b. Soft tissues have mucous membranes that are twice the normal thickness. Class III: Soft tissues have excessively thick investing membranes filled with redundant tissues. This requires tissue treatment Variations in the thickness of mucosa make it very difficult to equalize the pressure under the denture and to avoid soreness Inflammatory Fibrous Hyperplasia (Epulis Fissuratum) Continued denture wear and irritation leads to inflammatory fibrous hyperpllasiia (epulliis ffiissurattum).. Therapy - surgical excision Inflammatory Papillary Hyperplasia 25 Mostafa Fayad ٣٢ Diagnosis and treatment planning in completely edentulous patient Papillary hyperplasia is secondary to ill-fitting maxillary dentures and is sometimes complicated by chronic candidiasis. Therapy: Antifungal medications applied topically. In extreme cases, surgical excision. c- Saliva All major salivary gland orifices should be examined for patency. The viscosity of the saliva should be determined. Saliva can be classified as: Class I: Normal quality and quantity of saliva. ideal cohesive and adhesive properties Class II: Excessive saliva. Contains much mucus. Class III: Xerostomia. Remaining saliva is mucinous. Thick ropy saliva alters the seat of the denture because of its tendency to accumulate between the tissue and the denture. Thin serous saliva does not produce such effects. Xerostomic patients show poor retention and excessive tissue irritation wheras excessive salivation complicates the clinical procedures. d- Residual Alveolar Ridge While examining the residual alveolar ridge the arch size, shape, inter-arch space, ridge contour, ridge relation and ridge parallelism should be noted.  Arch size : Arch size can be classified as follows: Class I: Large (ideal retention and stability) Class II: Medium (good retention and stability) 26 Mostafa Fayad ٣٣ Diagnosis and treatment planning in completely edentulous patient Class III: Small (difficult to achieve good retention and stability) Arch should be observed for two main reasons: Denture bearing area increases with arch size and in turn increases the retention. Discrepancy between the mandibular and maxillary arch sizes can lead to difficulties in artificial teeth-arrangement and decrease the stability of the denture resting in the smaller one of the two arches.  Arch form : House classified arch form as: Class I: Square Class 11: Tapering Class III: Ovoid This plays a role in support of a denture and in tooth selection.Discrepancies between the maxillary and mandibular arch forms can create problems during teeth setting.  Ridge contour :Ridges should be both inspected and palpated. The ridge should be palpated for bony spicules which produce pain on palpation. Ridges can be classified as based on their contour as: High ridge with flat crest and parallel sides (most ideal) Flat ridge Knife-edged ridge There is another classification for ridge contour. According to that classification, the maxillary and mandibular ridges are classified separately. Classification of maxillary ridge contour: Class I: Square to gently rounded. Class II: Tapering or 'V shaped. Class III: flat. 27 Mostafa Fayad ٣٤ Diagnosis and treatment planning in completely edentulous patient Classification of mandibular ridge contour: Class I: Inverted 'U' shaped (parallel walls, medium to tall ridge with broad ridge crest) Class II: Inverted 'U' shaped (short with flat crest) Class III: Unfavourable Inverted W Short inverted V Tall, thin inverted V Undercut (results due to labioversion or linguoversion of the teeth  Ridge relation Ridge relation is defined as, " The positional relation of the mandibular ridge to the maxillary ridge" - GPT. Ridge relation refers to the anterior posterior relationship between the ridges. Angle classified ridge relationship. Class I: Normal Class II: Retrognathic Class III: Prognathic While examining ridge relation, the pattern of resorption of the maxillary and mandibular arches should be remembered (maxilla resorbs upward and inward while the mandible resorbs downward and outward).  Ridge parallelism Ridge parallelism refers to the relative parallelism between the planes of the ridges. The ridges can be relatively parallel or non-parallel. Teeth setting is easy in relatively parallel-ridge  Inter-arch space Inter-arch space The amount of inter-arch space should be measured and recorded. 28 Mostafa Fayad ٣٥ Diagnosis and treatment planning in completely edentulous patient Inter-arch space can be classified as follows: Class I: Ideal inter-arch space to accommodate the artificial teeth (Fig. 2.38). Class II: Excessive inter-arch space (Fig. 2.39). Class III: Insufficient inter-arch space to accommodate the artificial teeth Increase in inter-arch space will be due to excessive residual ridge resorption. These patients will have decreased retention and stability of their dentures. Decrease in inter-arch space will make teeth-arrangement a difficulty. However, stability of the denture is increased in these patients due to decrease in leverage forces acting on the denture e- Ridge Defects Ridge defects include exostoses and pivots that may pose a problem while fabricating a complete denture. f- RedundantTissue It is common to find flabby tissue covering the crest of the residual ridges. These movable tissues tend to cause movement of the denture when forces are applied. This leads to loss of retention. g- HyperplasticTissues The most common hyperplastic lesions are epulis fissuratum, papillary hyperplasia of the mucosa and hyperplastic folds. Treatment for these lesions includes rest, tissue conditioning and denture adjustments. Surgery is considered if the above mentioned treatments fail. h- Hard Palate The shape of the vault of the palate should be examined. Hard palates can be classified as: 29 Mostafa Fayad ٣٦ Diagnosis and treatment planning in completely edentulous patient U-shaped: Ideal for both retention and stability V-shaped: Retention is less, as the peripheral seal is easily broken Flat: Reduced resistance to lateral and rotatory i- Soft Palate and Palatal Throat Form While examining soft palates, it is important to observe the relationship of the soft palate to the hard palate. The relationship between the soft palate and the hard palate is called palatal throat form. On this basis, soft palates can be classified as: Classification of soft palates Class I: It is horizontal and demonstrates little muscular movement. In this case more tissue coverage is possible for posterior palatal seal Class II: Soft palate makes a 45° angle to the hard palate. Tissue coverage for posterior palatal seal is less than that of a class I condition (Fig. 2.45). Class III: Soft palate makes a 70° angle to the hard palate. Tissue coverage for posterior palatal seal is minimum It should be observed here that a class—III soft palate is commonly associated with a V- shaped palatal vault and class—I or class—II soft palates are associated with a flat palatal vault. j- Gag Reflex and Palatal Sensitivity Some patients may have an exaggerated gag reflex, the cause of which can be due to a systemic disorder, psychological, extraoral, intraoral or iatrogenic factors. House classified palatal sensitivity as: Class I: Normal Class II: Subnormal (Hyposensitive) Class III: Supernormal (Hypersensitive) 30 Mostafa Fayad ٣٧ Diagnosis and treatment planning in completely edentulous patient The management of such patients is through clinical, psychological and pharmacological means. If the patient lacks progress he/she should be referred to a specialized consultant. k- Bony Undercuts Bony undercuts do not help in retention, rather they interfere with peripheral seal. Bony undercuts are seen both in the maxilla and the mandible. In the maxillary arch, they are found in the anterior region and laterally in the region of the tuberosities. In the mandibular arch, the area under the mylohyoid ridge acts as an undercut. In case of maxillary arch, surgical removal of the undercut is not necessary, providing relief is enough. In case of the mylohyoid ridge, surgical reduction or repositioning of the mylohyoid attachment can be done. Bilateral undercuts should be eleminated. l- Tori Tori are abnormal bony prominences found in the middle of the palatal vault and on the lingual side of the mandible in the premolar region. It is not necessary to remove maxillary tori surgically unless they are very big. On the other hand, lingual tori are a constant hindrance to complete denture construction and have to be removed surgically. In order to prevent injury to the thin mucosa covering the tori, adequate relief should be provided in that region during complete denture fabrication. Rocking of the denture around the tori will occur in cases with excessive residual ridge resorption. m- Muscle and Frenal Attachments 31 Mostafa Fayad ٣٨ Diagnosis and treatment planning in completely edentulous patient Muscular and frenal attachment should be examined for their position in relation to the crest of the ridge. In cases with residual ridge resorption, it is common to see the maxillary labial and lingual frenal attachments close to the crest of the ridge. These abnormal attachments can produce displacement of the denture during muscular action. These muscular and frenal attachments should be surgically relocated. n- Tongue The tongue should be examined for the following: Size: Presence of a large tongue decreases the stability of the denture and it is hind- rance to impression making. Tongue-biting is common after insertion of the denture. A small tongue does not provide adequate lingual peripheral seal. Movement and coordination: Tongue movements and coordination are important to register a good peripheral tracing. They are also necessary in maintaining the denture in the mouth during functional activities like speech, deglutition and mastication, etc. o- Floor of the Mouth The relationship of the floor of the mouth to the crest of the ridge is crucial in determining the prognosis of the lower complete denture.In some cases, the floor of the mouth is found near the crest of the ridge, especially in the sublingual and mylohyoid regions. This decreases the stability and retention of the denture. The floor of the mouth can be measured with a William's probe. The patient should touch his upper lip with the tongue to activate the muscles of the floor of the mouth. C-Intraoral Digital Examination Before starting to explore the mouth with the fingertips the patient should be asked to indicate immediately if any pain is felt and the cause of such pain must be found. Any 32 Mostafa Fayad ٣٩ Diagnosis and treatment planning in completely edentulous patient area, which is painful to the pressure of a soft finger, is unlikely to tolerate the pressure of a hard denture. 1- Firmness of the ridge: Placing a finger on each side of the ridge and applying alternate lateral pressure most conveniently tests this. Flabby fibrous ridge may be encountered in all parts both of upper and lower jaws. 2- Regularities of the alveolar ridge: Alveolar absorption is never uniform and hard nodules, sharp edges, spikes and irregularities are frequently felt and pain on pressure over these areas is common. The prosthodontist must at this stage decide whether surgical correction is needed, whether they will remedy themselves in time in course of normal absorption or whether relief of the denture alone will be satisfactory. 3- Variations of mucous membrane: The ideal mucosa on which to seat complete dentures should be: a- Firmly bound down to the sub-adjacent bone by union with the periosteum, which will thus prevent the denture and mucosa moving together in relation to the supporting bone. b- Slightly compressible: this will allow the denture to bed comfortably into place because the mucosa will adjust itself slightly to the fitting surface of the denture. This will very materially increase the retention by adhesion and cohesion because the film of saliva between the denture and the mucous membrane will be very thin. It will also allow maximum retention from atmospheric pressure because the denture bedding slightly into the tissue will prevent air leaks. In addition such mucosa will act as a cushion to the normal stresses of mastication and prevent the development of sore spots and painful areas from pressure on the underlying bone. c- Even thickness: this condition is never realized. Thin mucosa covering a well- defined torus palatinus and flanked by thick compressible membrane will result in a 33 Mostafa Fayad ٤٠ Diagnosis and treatment planning in completely edentulous patient denture, which rocks during function causing pain to the patient and frequently fracture of the denture due to the repeated flexure the base is required to undergo during mastication. 4- Maxillary tuberosities: There may be found on visual examination to be bulbous and to have a definite undercut area above them, but only by palpation can it be determined whether the bulbous portion is composed of hard or soft tissues. 5- Mylohyoid ridges: Some of these ridges are felt to be pronounced and sharp and others are felt ill-defined and rounded. 6- Lingual pouch: The extent of the pouch with the tongue at rest and with the tongue protruded sufficiently to lick the lips and also during the act of swallowing should be noted. This is done by gently inserting the index finger into the pouch and asking the patient to perform the above actions. Determination of functional depth of alveolingual sulcus Carefully examine the retromylohyoid space to determine the floor of mouth posture. After placing the mirror in the retromylohyoid space, instruct the patient to move the tongue to opposite side. The less your mirror is displaced the more favorable the floor of mouth posture and the longer the distal lingual flange can/should be. 34 Mostafa Fayad ٤١ Diagnosis and treatment planning in completely edentulous patient D- RADIOGRAPHIC EXAMINATION The radiograph of choice for the examination of a completely edentulous patient is panoramic radiograph because they image the entire mandible and maxilla. Considerations During Radiographic examination The jaws should be screened for retained root fragments, unerupted teeth, rarefaction, sclerosis, cysts, tumours and TMJ disorders The amount of ridge resorption should be assessed. Wical and Swoope devised a method for measuring ridge resorption. According to them, the distance between the lower border of the mandible and the lower border of the mental foramen multiplied by three will give the original alveolar ridge crest height. The lower edge of the mental foramen divides the mandible into upper two- thirds and lower one-third. The quantity and quality of the bone should be assessed. Radiographic Assessment of Bone Resorption The amount of resorption can be classified as follows: Class I: (mild resorption) loss of upto one-third of the vertical height. Class II: (moderate resorption) loss of upto two-thirds of the vertical height Class III: (severe resorption) loss of more than two-thirds of the vertical height. Radiographic Assessment of Bone Quantity and Quality Branemark et al classified bone quantity radiographically as Classes A,B,C,D and E. He classified bone quality radiographically as Classes 1,2,3 and 4. 35 Mostafa Fayad ٤٢ Diagnosis and treatment planning in completely edentulous patient Ideally a panoramic or cephalometric X-ray examination should be made of every edentulous patient prior to starting denture construction, when it is considered that the routine is uneconomic or too time-consuming. X-ray photographs should still be taken to confirm or assist in diagnosis in the following cases: 1- Buried roots. 2- Sinuses. 3- Unilateral swellings. 4- Rough alveolar ridges. 5- Areas painful to pressure. 6- Impacted teeth. 7- Cysts. E- Examination of the Existing Prosthesis Extra-oral examination of the dentures The dentures are removed from the mouth and a detailed and systematic extra-oral examination is made of their impression, polished and occlusal surfaces. Any relevant findings are recorded. Impression surface The presence or absence of a post-dam and palatal relief. Width of borders. The amount and distribution of plaque, an important cause of denture stomatitis. Painting disclosing solution on the impression surface will help to visualize the plaque. Evidence of adjustments, relines or repairs. Surface roughness. Polished surface Shape and inclination. In essence, is the shape such that it will allow the muscles to help rather than hinder the control of the denture? 36 Mostafa Fayad ٤٣ Diagnosis and treatment planning in completely edentulous patient Condition and general cleanliness of the denture material. Occlusal surface Amount of wear; presence of shiny facets. Teeth – acrylic or porcelain; size, shape and colour. Intra-oral examination of the dentures Each denture is then placed in the mouth separately and examined for: Stability Retention Border extension. The dentures are then examined together to assess the: Occlusion Occlusal vertical dimension Appearance. Additionai Diagnostic Iníormatíon Diagnostic casts They are very helpful to further evaluate the anatomy and condition of the residual ridges. Generally diagnostic casts are made from preliminary impressions made wiüi irreversible hydrocolloid (alginate) in stock trays. Good diagnostic casts should include the retromolar pads and border tissues as well as the pterygomaxillary notch and the posterior palatal seal area Prosthodontic Diagnostic Index (PDI). Another tool to help the dentist identify' the complexity of their denture patient is called the Prosthodontic Diagnostic Index (PDI). The American College of Prosthodontists has recommended that practioners use the PDI to classify edentulous patients. This system is said to help better identify difficult denture patients. [For details see: introduction] 37 Mostafa Fayad ٤٤ Diagnosis and treatment planning in completely edentulous patient 2-Prosthodontic assessment -Clinical factors influencing stability, retention, and support of complete dentures - Previous denture assessment 3- TREATMENT PLAN Elimination of Infection Sources of infection like infected necrotic ulcers, periodontally weak teeth, and nonvital teeth should be removed. Infective conditions like candidiasis, herpetic stomatitis, and denture stomatitis should be treated and cured before commencement of treatment. Elimination of Pathology Pathologies like cysts and tumours of the jaws should be removed or treated before complete denture treatment begins. The patient should be educated about the harmful effects of these conditions and the need for the removal of these lesions. Some pathologies may involve the entire bone. In such cases, after surgery, an obturator may have to be placed along with the complete denture. Preprosthetic Surgery Preprosthetic surgical procedures enhance the success of the denture. Some of the common preprosthetic procedures are:  Alveolectomy  Labial frenectomy.  Reduction of genial tubercle.  Lingual frenectomy.  Reduction of mylohyoid ridge.  Excision of denture granulomas.  Excision of tori.  Excision of flabby tissue.  Vestibuloplasty.  Reduction of enlarged tuberosity.  Lowering the mental foramen.  Excision of hyperplastic  Ridge augmentation procedures. retromolar pad.  Implants  Alveoloplasty. 38 Mostafa Fayad ٤٥ Diagnosis and treatment planning in completely edentulous patient Tissue Conditioning The patient should be requested to stop wearing the previous denture for at least 72 hours before commencing treatment. He/she should be taught to massage the oral mucosa regularly. Special procedures should be done in patients who have adverse tissue reactions to the denture. Denture relining material should be applied on the tissue side of the denture to avoid denture irritation. Treatment dentures or acrylic templates can be prepared to carry tissue-conditioning material during the treatment of abused tissues. Nutritional Counseling Nutritional counseling is a very important step in the treatment plan of a complete denture. Patients showing deficiency of particular minerals and vitamins should be advised a proper balanced diet. Patients with vitamin B2 deficiency will show angular cheilitis. Prophylactic vitamin A therapy is given for xerostomic patients. Nutritional counseling is also done for patients showing age-related changes such as osteoporosis. Following the diagnosis, a treatment plan is formulated. Possible treatment options include: No treatment. Preparatory treatment such as denture adjustment or a short-term reline Definitive denture modifi cations such as reline, rebase, repair or cleaning. Replacement dentures. 39 Mostafa Fayad ٤٦ Diagnosis and treatment planning in completely edentulous patient There are several approaches to designing and constructing complete dentures. Thedentist should make a positive decision at the treatment plan stage as to which is appropriate for the patient. (1) Copy dentures. Where dentures have provided satisfactory service for the patient in the past, it may be advisable to base the design of replacement dentures on the well- accepted features of the old ones. Although such an approach is particularly appropriate for the treatment of elderly patients who have a reduced ability to adapt, it can also be of value in a number of other clinical situations. A potentially accurate method of maintaining the well-accepted features of existing dentures is to use a copy technique. (2) Carving record rims. The shape, or design, of the dentures may be determined by the dentist carving the record rims as described in Chapter 11, so that the upper rim provides adequate lip support and the lower rim lies in the neutral zone. (3) Biometric guides. Another approach to design involves the use of biometric guides measurements from certain anatomical landmarks which allow the denture teeth and base to be placed in positions similar to those formerly occupied by the natural teeth and alveolar bone. The desirability of so doing has been a source of controversy for many years but has received a considerable measure of support. Anatomical guidelines have now been researched which assist the dentist in trying to achieve this aim. (4) Functional neutral zone impression. When there are particular problems in achieving stability of a lower denture – for example, if there is abnormal muscular activity or intra-oral anatomy – the dentist can record the neutral zone by getting the patient to mould a soft record rim into a position of stability between the tongue and cheeks and lips by means of swallowing and speaking. A lower denture is then produced whose shape is derived from the neutral zone impression. This clinical technique has been shown to enhance the tongue’s retentive ability over a conventional design. 40 Mostafa Fayad ٤٧ Diagnosis and treatment planning in completely edentulous patient 4- PROGNOSIS It based upon: Bearing surface anatomy, tongue position and floor of mouth posture Neuromuscular control Denture history Psychological classification After reviewing the Complete Denture Evaluation, Diagnosis, and Treatment Planning Form as well as the Prosthodontic Diagnostic Index (PDI) the practitioner should be able to make some judgment about the prognosis of their patient. A patient who has a Class 1 antero-posterior ridge relationship, has proper size and function of the tongue, has normal quality and quantity of saliva, has U-shaped (cross-section) edentulous ridges that approximate the opposing arch, has successfully worn complete dentures in the past, and is a philosophical patient (PDI I) will have a good prognosis. A patient who is in very poor health, has a Class II antero-posterior ridge relationship, a retracted tongue, maxillary posterior bilateral undercuts in need of pre- prosthetic surgery; ropy saliva, and an indifferent attitude (PDI 1V) will have a poor prognosis. 41 Mostafa Fayad ٤٨ Diagnosis and treatment planning in completely edentulous patient 5- PROSTHODONTIC CARE The type of prosthesis, denture base material, anatomic palate, tooth material and teeth shade should be decided as a part of treatment planning. Depending upon the diagnosis made, the patient can be treated with an appropriate prosthesis. For example: For a patient with few teeth, which are likely to be extracted an immediate or conventional, definitive or interim, implant or soft tissue supported dentures can be given. For a patient who is already edentulous a soft tissue supported or implant supported denture can be given. For patients with acquired or congenital deformities, a denture with an obturator can be given. 42 Mostafa Fayad ٤٩ IMPRESSION MAKING IMPRESSION MAKING IN COMPLETE DENTURE Developing an analogue\ substitute for denture bearing area “Ideal impression must be in the mind of the dentist before it is in his hand. He must literally make the impression rather than take it” - M.M. Devan The impression procedure is a means of recording the detail of the basal seat area so that a stone replica can be poured.The impression should cover the maximum possible area without interfering with normal muscle movements. The Objectives of an Impression Are to Provide:- 1- Preservation of the remaining residual alveolar ridge: - The impression technique and impression material have an effect on the accuracy of denture base, which has an effect on the continued health of both the soft and hard tissues of the jaws. Patients with special cases need some precautions during impression making to prevent tissue damage. 2- Support: - maximum coverage distributes applied forces over as wide an area as possible. 3- Stability close adaptation to the undistorted mucosa is most important for stability of the denture to resist horizontal movement. Stability decreases with the loss of the vertical height of the ridges or with the increase in flabby, movable tissue. 4- Esthetic: - border thickness should be varied with the needs of each patient in accordance with the extent of the residual ridge loss. Impression should perfectly reproduce the width and height of the entire sulcus for the proper fabrication of the flanges. Mostafa Fayad 1 ٥٠ IMPRESSION MAKING 5- Retention: - it should be readily seen that if the other objectives are achieved, retention will be adequate. [see retention] Requirements for an impression: 1- The tissues of the mouth must be healthy. 2- Proper space for the selected impression material should be provided within the impression tray. 3- A physiological type of border-molding procedure should be performed. 4- The border must be in harmony with the anatomical and physiological limitations of the oral structures. 5- The impression should extend to include all of the supporting and limiting tissues. 6- The impression must be removed from the mouth without damage to the mucous membrane of the residual ridges. 7- The tray and the impression material should be made of dimensionally stable materials. 8- The external shape of the impression must be similar to the external form of the complete denture. BIOLOGIC CONSIDERATIONS FOR MAXILLARY IMPRESSIONS The anatomy of the supporting and limiting structures must be understood for these are the foundations of the denture bearing areas, as their role determines : 1. The selective placement of forces by denture bases on supporting tissues 2. The form of the denture borders that will be harmonious with normal function of limiting structures around them. Mostafa Fayad 2 ٥١ IMPRESSION MAKING 3. The fibrous band running along the residual ridge is the vestige of the palatal gingivae and, like the incisive papilla, remains relatively constant in position during the remodeling of the ridge which follows extraction of the natural teeth. These two structures can therefore be used as landmarks allowing teeth on complete dentures to be placed in positions similar to those of their natural predecessors. This biometric approach requires specific design features to be incorporated into the impression trays Diagram of the upper arch showing average distances from the palatal gingival vestige of the furthest horizontal extent of the denture flange in the incisal (A), canine (B), premolar (C) and molar (D) regions (the biometric approach). The line (X–X) passing through the posterior border of the incisive papilla can be used as a guide to positioning the tips of the canines. Mostafa Fayad 3 ٥٢ IMPRESSION MAKING  The anatomical landmarks in the maxilla are: Supporting Structures: Limiting structures: Relief areas Buccal anatomical relations of the upper denture BIOLOGIC CONSIDERATIONS FOR MANDIBULAR IMPRESSIONS The considerations for the mandibular impressions are generally similar to that for those of maxillary impressions and yet there are many differences owing to the following facts: – The basal seat of mandible is different in size and form from the maxillary counterpart. – The submucosa in some parts of mandibular basal seat contains anatomic structures different from those in the upper jaw. – The nature of the supporting bone on the crest of residual ridge usually differs between the two jaws. Mostafa Fayad 4 ٥٣ IMPRESSION MAKING – The presence of the tongue complicates the impression procedures. – The available area of support from an edentulous mandible is 14 cm2 while the same for the edentulous maxilla is 24cm2. – The supporting and the peripheral sealing areas will be in contact with the dentures fitting or impression areas. The support for the mandibular denture is derived from the body of mandible. – The anatomical landmarks in the mandible are: – Supporting Structures: – Limiting structures: – Relief areas: Mostafa Fayad 5 ٥٤ IMPRESSION MAKING Anatomy of the sulcus tissues Anatomical relations of the lower denture. Mostafa Fayad 6 ٥٥ IMPRESSION MAKING Impression can be classified as : 1. depending on the theories of impression making: a. mucostatic/passive impression. b. Mucocompressive/functional impression c. Selective pressure impression. 2. depending on the technique: a. open mouth technique b. closed- mouth technique 3.Based on the method of manipulation for border molding. 1. Hand manipulation 2. Functional movements 4. depending of the type of tray: a. stock tray impression b. custom tray impression 5. depending on the purpose of the impression : a. diagnostic impression b. primary impression c. secondary impression 6. depending on the material used: a. reversible hydrocolloid impression e. wax impression b. irreversible hydrocolloid impression f. silicone impression c. modeling plastic impression g. Thiokol rubber impression. d. plaster impression Mostafa Fayad 7 ٥٦ IMPRESSION MAKING Preparation of the Mouth The oral tissues should be healthy before impressions are made. Any distortion or inflammation of the denture foundation tissues must be eliminated before the impressions are made as the following:- 1- patients should leave their dentures out of the mouth for 48 hours prior to impressioning. If the patient inserts a denture for even five minutes the tissues may be quickly distorted, and proper tissue recovery may require two or more additional hours of not wearing the denture. Therefore patient should not "just wear their dentures into the dentist's office." 2- For patients who are wearing complete dentures requiring refabrication, ensure soft tissue health by serially relining with a 10- to 14-day period of conditioning with soft acrylic resin every 3 to 4 days. 3- Oral Physiotherapy 4- Anti-microbial agents 5- Surgical removal of abused tissues Mostafa Fayad 8 ٥٧ IMPRESSION MAKING Preliminary (primary) Impressions A preliminary impression is an impression made for the purpose of diagnosis or for the construction of a tray 1- The Position of the Patient:- For most prosthetic operations the dental chair is set in the upright position. When the patient is seated the chair should be adjusted so that the head and neck, are in line with the trunk. If the head is allowed to bend backwards from the neck the supra and infrahyoid muscles will be tense and difficulty in swallowing will result, also should a fragment of impression material break away from the main impression, it can more easily fall into the throat and possibly cause obstruction in the airway. A suitable covering in the form of apron or large towel should be provided to protect the patient's clothing and also, a warm, flavored mouth wash with which remaining fragments of impression can be rinsed away on instruction from the operator. Position of the operator for maxillary impression When making a mandibular impression, the operator should be standing between the 9 o’clock and 12 o’clock position - The patient’s upper jaw should be approximately between the level of the operator’s elbow and shoulder Position of the operator for mandibular impression When making a mandibular impression, the operator should be standing between the 6 o’clock and 9 o’clock position. - The operator’s elbow should be approximately level with the patient’s lower jaw ٥٨ IMPRESSION MAKING 2- Selection of the Stock Tray:- The alveolar ridges and palate are examined for shape and size, and from a selection of previously sterilized stock trays a suitable upper and lower ones are chosen and tested in the mouth for their approximation to the oral structures. It may be necessary to bend the tray slightly with pliers to provide adequate space and in others to cut and trim the flange to accommodate frena and prevent pressure on bony structures such as the zygomatic process of the maxilla. Stock Tray Selection: 1. According to impression materials: 1. Compound : solid tray 2. Alginate : perforated tray 3. Agar agar : water coolant tray 2. According to patient mouth: Based on size of the arch select the tray size which must be large enough to cover all supporting areas and seal areas with about 2 mm space and shorter about 5mm from the full depth of the sulcus. 3. According to presence of teeth For dentulous patients: The tray has flat floors, high flanges and the handle is in- line with the floor of the tray. For edentulous patients : The trays having round floor and short flanges to conform the shape of the ridge. The handle is bent in the form of L-shaped and ٥٩ IMPRESSION MAKING joined at right angle to the floor of the tray to clear the lip and allows proper border moulding in the labial portion of the impression. For partially-edentulous patients: In this type, part of the tray has flat floor and high flanges in the dentulous area and the other part has rounded floor and short flanges in the edentulous area. Shortness in the flanges can be corrected by the addition of a little warmed composition, or wax attached to the flanges of the dried tray. The corrected tray is reinserted in the mouth and the periphery is moulded. If the tray is too large, this will:- 1- Distort the tissues around the borders of the impression. 2- Pull the soft tissues under the impression away from the bone. 3- Distort the dimensions of the sulcus. If it is too small:- The border tissue will collapse inward onto the residual ridge. 3- The Preliminary Impression:- Impression materials generally used for preliminary impression: 1- Impression compound. 2- Irreversible hydrocolloid (alginate). ٦٠ IMPRESSION MAKING I- Impression compound The composition is heated in a water bath at 55 to 70o C. Since the material has a low thermal conductivity, it must be immersed in the water bath for sufficient time to ensure complete softening. The composition is, then, removed from the water bath and kneaded, the composition is placed in the tray and placed into the mouth and the patient is asked to do functional movements. The tray is held in place for one minute or two, removed and chilled thoroughly in cold water. In general, composition is not considered as an accurate impression material and it should never be reused because of fear of cross infection. The surface of the compound can be lightly flamed to improve its fl ow, tempered in warm water and coated with petroleum jelly In case of the maxillary impression; the material is formed into a ball, dried and loaded in the center of the palate of the tray after warming it over a flame. Then spread the compound over the tray and shaping it roughly like arch. In case of mandibular impression; the material is formed into a roll, dried and loaded in the tray after warming it over a flame. Then spread the compound over the tray and shaping it roughly like arch Advantages of compound impression:: 1- Addition and correction can be done. 2- Ease of manipulation. 3- Well tolerated by the patients. 4- Accuracy is not essential for primary impressions ٦١ IMPRESSION MAKING II - The alginate wash impression (Prosth ttt of Edentulous Patient& HAYAKAWA) When the dentist might require a more accurate picture of the mucosa so that the potential denture-bearing area can be visualised more easily. This can be achieved by refining the initial compound impression with a wash impression in alginate as follows: Obtain the best possible impression in compound and dry it thoroughly. Trim back the borders and the fitting surface of the impression by 1–2 mm with a sharp knife. Apply a thin layer of alginate adhesive to the impression surface. Load the compound impression with a small amount of low viscosity alginate, seat it fully on the tissues and complete border trimming as before. III- the alginate impression The alginate impression material can be used as a preliminary and final impression material. Indications for its use in completely edentulous cases: 1- Some authors recommend the use of alginate for all completely edentulous cases. 2- Severe undercuts. Contra-indications: ٦٢ IMPRESSION MAKING 1- Nausea to the patient. 2- Flat ridges. Advantages: 1-Alginate produces excellent surface detail. 2-It is elastic and can be withdrawn over undercuts. Disadvantages: 1- It cannot be added to if faulty. 2-Dimensional instability: a-Even in the humidor, imbibition may take place. b-The stresses induced in the material are released slowly, and the sooner it is cast, the less the stresses will have been released and so the less it will have warped. 3- The alginates will not adhere to the tray of their own accord. Attachment of the alginate to the tray is essential because if it pulls away a distorted impression will result which may easily pass unnoticed since the detail of the surface will remain unchanged. Some properties of alginate impression material 1- Compatibility with gypsum: A- Saliva and blood interfere with the setting of gypsum during impression pouring, and if free water accumulates, it tends to collect in the deeper parts of the impression and dilute the model material, yielding a soft, chalky surface. ٦٣ IMPRESSION MAKING B- lf the alginate impression is stored for a half hour or more before preparing the model, it should be rinsed with cool water to remove any exudate on the surface caused by syneresis of the alginate gel because it will retard the setting of gypsum. C- The set gypsum model should not remain in contact with the alginate impression for periods of several hours because contact of the slightly soluble calcium sulfate dihydrate with the alginate gel containing a great deal of water is detrimental to the surface quality of the model. 2- Disinfection The effect of disinfection in 1% sodium hypochlorite or 2% potentiated glutaraldehyde solutions on accuracy and surface quality has measured after 10- to 30-minute immersion. Statistically significant dimensional changes were observed; however, the changes were 0.1%, and the quality of the surface was not impaired. Such changes would be insignificant for clinical applications such as preparation of study models and working cast. 3- Adherence to the tray Fixation may be effected by one of the following methods: 1- Small holes may be bored in the tray through which some of the alginate will flow securing the impression firmly to the tray. 2- Ready made adhesive solutions or spray can be applied to the inside of the tray. ٦٤ 3- Rim lock tray. Time should be allowed after application of the adhesive for it to become tacky, a process which can be speeded up considerably by dispersing the adhesive over the surface of the tray with a stream of air from a triple syringe. A thin layer of adhesive is applied to the internal surface of the tray and should extend several millimeters beyond the borders of the tray. The adhesive is allowed to dry for at least 15 minutes prior to the impression procedure. Also, it is important to remember that each adhesive is specific to the impression material (ie, a polysulfide adhesive can not be used with an addition silicone impression material) Impression procedure The lower impression is usually taken first as it is easier for the patient to tolerate than the upper. When the impression is seated in the mouth the patient is asked to raise the tongue to contact the upper lip and to sweep the tongue to touch each cheek in turn before returning to maintain contact with the upper lip until the alginate has set. Buccal and labial border moulding is achieved by firm stretching of the relaxed lips and cheeks with the fingers. Precautions for alginate impression: When alginate is used as an impression material the following points should be observed in order to obtain the best results: 1-The clearance between the tray and the model should be approximately 4-5 mm. The extension of the border of the tray is corrected by compound, if underextended. Also, the palatal Mostafa Fayad 16 ٦٥ portion of the try is build by compound in case of high palatal vault. 2-The container of powder should be shaken before use to get an even distribution of constituents. 3-The powder and water should be measured, as directed by the manufacturer. 4-Room temperature water is usually used, slower or faster setting time can be achieved, if required, by using cooler or warmer water, respectively. 5-There should be vigorous mixing-by spreading the material against the side of the bowl-for the spatulated time, usually one minute. 6- Prior to inserting the impression tray, the patient should be asked to swallow to eliminate excess saliva. Impression material should be placed, by finger, into any areas that the clinician feels may not be adequately reached by the impression tray. These areas often include the palatal vault, retromylohyoid spaces, and/or buccal vestibules. If the sulci buccal to the maxillary tuberosities are deep, air may be trapped as the loaded impression tray is inserted. To overcome this problem, these areas can be prepacked with alginate before seating the tray. The labial and buccal vestibules can be molded by asking the patient to suck down onto the tray. in addition , the patient should be asked to move the mandible from side to side then open widely During setting of the material it is important that the impression should not be moved. The reaction is faster at higher temperature, and so the material in contact with the tissues sets first. Any pressure on the gel due to movement of the tray will set up stresses within the material, which will distort the alginate after its removal from the mouth. ٦٦ IMPRESSION MAKING 7-An alginate impression, when sets, develops a very effective peripheral seal so before trying to remove it from the mouth this seal should be freed by running the finger round the periphery. 8-An alginate impression should be displaced sharply from the tissues this sudden displacement ensures the best elastic behavior. A gen

Diagnosis and Treatment Planning in Completely Edentulous Patients PDF

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