Chapter 1 Diagnosis & Examination PDF

Chapter 1 Diagnosis & Examination CHAPTER 1 Examination, Diagnosis and Treatment planning 1 Chapter 1 D...

Chapter 1 Diagnosis & Examination CHAPTER 1 Examination, Diagnosis and Treatment planning 1 Chapter 1 Diagnosis & Examination Examination is the first clinical step in complete denture treatment. To have an excellent prognosis for any dental treatment requires proper preplanning, which will include thorough extra and intra oral examination, diagnosis, and a treatment plan. After the examination is completed and all diagnostic information has been evaluated, only then should a final diagnosis, treatment plan, and prognosis be formalized and discussed with the patient. Patients may require pre-prosthetic surgery, antifungal therapy, or soft relines to obtain better tissue health before definitive treatment can be initiated. As most edentulous patients are old, the examination must be carried out not only regarding the condition of the oral cavity but also in relation to their general health. Diagnosis It is the determination of the nature, location and causes of diseases. M. M. Devan said "we must meet the mind of the patient before we meet the mouth of the patient." Edentulous patients come to us looking for solutions to their problems, and often these problems are both physical and psychological. A good initial interview is very critical to the diagnostic process. Clinicians must allow patients to communicate their chief complaint in their own words and take note of how patients present themselves. This might include how patients dress, their concern for their physical appearance, and their overall attitude and expectations concerning treatment. 2 Chapter 1 Diagnosis & Examination Objectives: 1) Assessment of the patient's general health condition. 2) Evaluation of the condition of the oral tissues before making prosthesis. 3) Psychological & mental evaluation of the subject under treatment. 4) Determination of the possible difficulties expected for the case. 5) Reaching the highest level of success for the definite case. Diagnostic procedures: 1. History taking: 1. Patient’s history 2. Past medical history 3. Past dental history 2. Clinical examinations: 1. Extra-oral examination. 2. Intra-oral examination. 3. Pre-extraction record and helpful aids: 1. Some investigations. 2. X-rays. 3. Models. 4. Photographs. 5. Biopsy. 4. Treatment plan. 3 Chapter 1 Diagnosis & Examination I- History taking 1-Patient’s History: Taking the history of the patient provides important information that should be considered for successful denture construction. These information are better obtained either through patient interview or by asking the patient to fill a questionnaire (examination chart) that is kept as a record, this includes: a- Personal and Social Details. b- Reason for attendance (Patient's requests). c- Dental history. d- Medical and surgical history. a-Personal &Social Details: - Name, address and occupation: -This information is important for future contact with the patient. - Age: -The ability of learning and co-ordination diminishes with age, therefore a younger patient will be expected to develop denture skills and adapt faster than an old patient. - Young patients will be more concerned with esthetics. - The oral and facial tissues are usually less elastic and less resilient in old patients. - The age of the patient is a determining factor in the selection of teeth regarding the color, size and the degree of attrition. - Sex: -Men are usually busier and hence less fussy than women. 4 Chapter 1 Diagnosis & Examination -Females are usually concerned with esthetics. -Menopause is usually associated with burning mouth which most patients attribute to the new appliance. - Occupation and Socio-economic Class: -The occupation of the patient will entail the design and technique of denture construction. -Public speakers and singers require dentures that are perfectly retained. Special attention to the shape and thickness of the denture palatal portion is necessary for proper pronunciation and phonation.. - Wind instrument players require dentures with special modification for the shape and position of anterior teeth. -Types of patient in the dental clinic: Discussions are carried out with the patient during diagnosis and history taking to determine the patient's attitude in the dental clinic, which affect the prognosis and treatment plan. 1. Philosophic patient 2. Exacting patient. 3. Indifferent patient. 4. Hysterical patient. 1-The philosophic patient (Truth-seeking): -Patients in this class have an ideal attitude for successful treatment and good prognosis. -They have the best mental attitude, definite way of thinking and ability to adjust rapidly. -They are caring, kind, cheerful and co-operative. -They accept their oral situation and accept the dentist's advice. 5 Chapter 1 Diagnosis & Examination 2- Exacting Patients (Demanding): -Patients in this group are not easy to please as the philosophical ones. -They need great care, effort and explanations. -They usually criticize what is done for them and might doubt the ability of the dentist to provide a good prosthesis. -A firm control of these patients is essential to obtain successful treatment and good prognosis. 3-Indifferent Patients (Uncaring, cool): -Indifferent patients are passive, uninterested, uncooperative, depressed and lack motivation. -They have little concern for their teeth, or health and even for the general appearance. -They are usually pushed for treatment by their families and therefore they give up quickly on facing problems with new dentures. -They even have little appreciation for the dentist's effort and usually their prognosis is unfavorable 4-Skeptical antagonistic or Hysterical patients (Panic- stricken): -Skeptical patients are unstable, excitable, apprehensive and nervous. -They are always worried and usually in poor health. -These patients usually need kind and sympathetic help. Sometimes they need medical consultation during and after treatment. -More time should be given in explaining details about the required treatment and in relieving the patient's grief. This will help in giving the patient confidence in his dentist. 6 Chapter 1 Diagnosis & Examination b-Reason for Attendance: ▪ Restore Appearance. ▪ Restore Function. ▪ Maintain Health ▪ Replace teeth. ▪ Replace restorations. 2-Past Medical History: A good medical history questionnaire combined with verbal qualification by the patient is essential to any dental treatment plan. Any medical or psychological condition that is a deviation from "the norm" must be noted and evaluated for its potential effect on patient treatment. Uncontrolled diabetics, patients with cardiovascular disease and subsequent treatment with blood dyscrasias, and avitaminosis affect the mucosal response to dentures. It is thus preferable to postpone prosthetic treatment until the acute phases of these disorders are under control. Diabetes results in decrease in the salivary flow which may lead to impaired denture retention, and impaired oral and denture hygiene. It also results in increased rate of alveolar bone resorption which may necessitate frequent relining of dentures. Dentures for diabetic patients should exhibit teeth with reduced occlusal table and an increased amount of freeway space to reduce pressure on denture supporting structures. 7 Chapter 1 Diagnosis & Examination Patients with hormonal disorders such as acromegaly and hyper parathyrodism may need frequent denture adjustments and even new dentures. A history of movement disorders such as Parkinson's disease affects the ability of patients to wear and control dentures. Temporo-mandibular joint disorders, arthritis and facial neuralgia cause difficulty in obtaining jaw relation records. One condition that could alter routine treatment is a history of head and neck radiation which could complicate any need for pre-prosthetic surgery and also result in xerostomia for the patient. It is essential to update the patient's medical history at each follow-up appointment to ensure that the patient is truly being appropriately followed for their medical conditions and that they are correctly taking any prescribed medications. A good written medical questionnaire and verbal interview is essential for the dentist to help determine the patient's diagnosis and subsequent treatment plan as well as the projected prognosis for the complete denture patient. Some Some systemic Some other Some drugs dangerous diseases might transmissibl might affect trans affect the outline e diseases the outline of missible of treatment but not treatment diseases dangerous 8  Chapter 1 Diagnosis & Examination 1) Jaundice 1) Cardiac 1) Influenza 1) Anticoagulants 2) AIDS patients 2) Rhinitis 2) Dilantin Na 3) TB 2) Diabetes 3) Bronchitis 3) Meduretics 3) Osteoporosis 4) Antihyperten 4) Osteo-arthritis sive drugs 5) Endocrine therapy 6) Saliva inhibiting drugs 3-Dental History: The patient's previous dental history provides the prosthodontist with important information. The reason and sequence for loss of natural teeth provides information about the underlying supporting tissues and the alveolar bone. Patients who had generalized periodontal disease are expected to exhibit rapid bone changes and consequently require frequent relining and occlusal adjustment. People who have retained their anterior teeth for a long time become nibblers due to using anterior teeth for mastication. Eating with new dentures is a problem for such people. A patient with recent extractions will be expected to experience more immediate changes to the residual ridge than a patient who has been missing teeth for many years. Training on proper masticatory habits is required to avoid leverage and instability of dentures. 9 Chapter 1 Diagnosis & Examination The patient experience with old dentures is a good guide for success and limitations of new dentures. Esthetics, speech and gagging reflex are important experiences that should be considered during denture construction. II- Examinations Examinations should begin with an extra-oral assessment of facial form and symmetry, then an intra-oral inspection should be carried out. ❖ Clinical Examination Extra-oral Examination: 1- General look of the patient 2- Facial appearance 3- TMJ examination 4- Pathological lesions. Intra-Oral Examination: Visual, digital and radiographic inspections of the mouth include: Denture bearing area: 1- Arch size & form 2-Oral Mucosa. 3-Ridge type. 4-Intermaxillary space. 5-Jaw relationship. 6-The palate. 7-Maxillary tuberosity 8-Tori 9-Undercuts 10 Chapter 1 Diagnosis & Examination Some other factors: 1-Tongue size & type 2- muscle tonicity 2-Floor of the mouth 3-saliva 4-Oral lesions a. Sharp bony spicules b. Simple ulceration of the mucous membrane c. Hyperplasia d. Remaining roots/impacted teeth e. Sinuses, Cysts and neoplasmic changes Extra-oral Examination: o 1-General look of the patient and Facial appearance: The front and profile views of the patient's face provide many diagnostic clues: (Fig 1:3) 1- Patients without teeth for long time exhibit exaggerated facial wrinkles and mental tip, deepened folds and distorted philtrum. The fullness and normal contour of the upper lip is lost due to lack of tooth support and the vermillion border is also changed. 2- The profile view may show a decrease or an increase of the vertical dimension, especially in old denture wearers. 3- Class ll. and class III angle's classification are evident from the patient's profile view and from the curvature of the mento-labial sulcus. 4- Angular cheilitis is an indication of closed vertical dimension and inadequate nutrition. 5- Care should be given to the color and form of the denture base in patients having short upper lips. 11 Chapter 1 Diagnosis & Examination Fig. 1: A: The fullness and normal contour of the upper lip is lost due to the lack of support by the loss of teeth. The normal lip line and natural vermilion border of the upper lip is changed due to this falling in and the philtrum looks unsupported.. The nasal folds are deepened, the mental tip is exaggerated and facial wrinkles may result if the person has been without teeth for sometime. Fig. 1: B: Increased vertical dimension. : Fig.2:Front facial view Fig.3 :Arch Relationship 12 Chapter 1 Diagnosis & Examination Complete Denture Examination, Diagnosis and Treatment Planning Form Patient: Date: 1. Chief complaint (patient's own words): 2. Past Dental History: a. Date of last visit to dentist: b. Reason for last visit and treatment received: c. Date of last extraction: d. Previous prosthesis type(s): e. Number of previous complete dentures: f. Ability to adjust to previous dentures: 3. Evaluation of Present Dentures: a. Esthetics: b:Phonetics: c. VDO. d. Base extension: Stability: retention: e. Occlusion: f. Occlusal plane height: g. Pattern of tooth wear: h. Denture hygiene: i. Patient expectations of new denture: j. Compare your observations with the patient's comments: k. Problems noted: l. Can improvements be made? 4. Soft Tissue Examination: (note areas of potential pathology): 5. Hard Tissue Examination (Radiographic exam): pre-pros surgery required? ( ) 6. Saliva: amount: excessive ( ) scanty ( ) average ( ) consistency: thick ( ) thin ( ) average ( ) 7. Facial Appearance: frontal: square ( ) tapering ( ) ovoid ( ) combination ( ) profile: straight ( ) curved( ) combination ( ) 8. lip form: length: long ( ) short ( ) average ( ) thickness: thick ( ) thin ( ) average ( ) 13 Chapter 1 Diagnosis & Examination 9. Maxillary Ridge Form: Mandibular Ridge Form: a. shape a. shape : square, tapering, ovoid, combo. b. size b. size large, medium, small c. width c. width broad, narrow, average d. cross section , d. cross section square, trapezoid, triangular, flat 10. Ridge relationship: CI I (normal), CI II (retro), CI III (prog) normal, unilat cross-bite, bilat cross-bite 11. Tuberosities R L (bone/soft tissue) large, medium, small, undercut 12. Inter-ridge space: large ( ) small ( ) average ( ) 13. Tongue: size: large ( ) small ( ) average position; retracted ( ) normal ( ) control: can move to follow directions ( ) cannot ( ) 14. Hard Palate Form: high vault ( ) shallow vault ( ) average ( ) v-shaped ( ) 15. Soft Palate Form: (gradual) ( ) (moderate) ( ) (steep) ( ) 16. Floor of mouth: location: high ( ) low ( ) average ( ) mobility: mobile ( ) immobile ( ) average ( ) 17. Ability of patíent to repeat CR position: easy ( ) hard ( ) may be impossible ( ) 18. Patients Mental Attitude: philosophical ( ) exacting ( ) hysterical ( ) indifferent ( ) senile ( ) Treatment Prognosis: good ( ) fair ( ) poor ( ) Treatment Plan and Sequence: 14 Chapter 1 Diagnosis & Examination A good clinical exam form is helpful in accomplishing this. The patient's range of mandibular movement should be observed for any type of irregular movement or deviation. The muscles of mastication and facial expression should be observed during movement and conversation as well as palpated to locate any muscle tenderness or dysfunction. 2-TMJ examination: (Fig 4-8) Uncoordinated mandibular movement or temporo-mandibular disorder/pain could certainly complicate any attempt to obtain accurate interocc!usal records and might help determine that a simple occlusal scheme should be selected for this patient. The temporo-mandibular joint is examined by asking the patient to open his mouth widely and close it slowly to check the joint's ligament and capsule. An audible click may indicate loosening of the ligaments or shift of the mandible which may cause some difficulties in recording centric occluding relations. Special considerations should be followed in impression procedures and in recording the vertical dimension if the patient has a history of condylar dislocation. The neck should be palpated for any lumps, masses, or enlarged lymph nodes. The lips and skin should be evaluated for any type of non healing lesions or unusual nevi. The commissures of the lips should be examined and any evidence of angular cheilitis noted. The lip length, thickness, and curvature.should be noted with the patient's existing prosthesis in place. The face should be observed and noted in frontal and profile facial form. The patient's facial midline should be noted. Does the middle of the philtrum of the lip and the patient's midline on their existing maxillary prosthesis coincide? 15 Chapter 1 Diagnosis & Examination Radiographic Interpretation: - Panoramic. - Corrected Cephalometric Tomography. - Transcranial Radiography. - Computerized Tomography. - MRI. Fig.4 a, b: Palpation of the TMJ and facial muscles. Pain or tenderness over the joint is an indication of an inflammation in the joint capsule or within the joints. Fig. 5 a-d: Evaluation Of Mandibular Function (mandibular range of motion). Measure the space between the upper and lower front teeth when the mouth is open to its widest position (normal is 35-50 mm). 16 Chapter 1 Diagnosis & Examination Fig. 6: Lateral and distal palpation of the TMJ Fig.7: Test for the endfeel: difference between passive and active maximum mouth opening to measure jaw opening capacity. Fig. 1-8 a - d: Muscle’s Examination. Palpation of the temporalis and the masseter muscles. The suboccipital area and posterior cervical region. Palpation of the sternocleidomastoid, and trapezius muscles 17 Chapter 1 Diagnosis & Examination 3-Extra-oral Pathological lesions: (Fig 9 -12) The examination should also include an extra-oral assessment of any pathological lesions such as abscesses, cysts, herpes, ulcers or any facial asymmetry. Fig. 9: Acute dentoalveolar abscess Fig.10: extra-oral lesion Fig. 11: a, b: deviation of this patient’s mandible to the left on closing indicates possible disharmony which should be investigated. Fig: 12: Tongue, skin and mucous membrane involvement 18 Chapter 1 Diagnosis & Examination Intra-Oral Examination: Visual and digital intra-oral examinations and Radiographic Examination are necessary to detect the following: 1-The arch size and form: (Fig 13, 14) -The form, size and condition of the bony foundation greatly affect the support, retention and stability of complete dentures. Therefore, proper examination is essential in planning and designing the denture. -The size of the mandibular and maxillary arches determines the support available for complete dentures. The greater the size the more the support. -The larger the size, the more the area covered by the denture, the better the retention and stability. - The residual ridge shape is classified as square, tapering, or ovoid. The shape is probably most important as it relates to the opposing arch because mismatched arch shapes can make tooth arrangement challenging. Fig: 13: v- shaped maxilla 19 Chapter 1 Diagnosis & Examination Fig.14: Different arch forms & ridge Contour. 2-The Oral Mucosa: (Fig 15-20) A) Denture bearing mucosa: - The color, texture, contour and continuity of the oral mucosa should be checked. Healthy mucosa should be firm but slightly resilient non edematous, of even thickness and pink in color. - The oral mucosa may exhibit inflammation, abrasion, cuts or sore spots which may result from over or under extended denture borders or due to old dentures exhibiting improper occlusion. The oral mucosa may also be distorted or abused from old ill- fitting dentures. These conditions should be eliminated before impressions for new dentures. - This is done by following a tissue health rehabilitation program. For good prognosis, the cause should be first removed. Tissues are then allowed to rest and recover either by simply keeping the dentures out of the mouth or by using soft lining denture materials. Surgery may sometimes be required to ensure the presence of healthy foundation tissues. 20 Chapter 1 Diagnosis & Examination - Palpation is necessary to detect the resiliency and displaceability of the oral tissues. - Denture supporting tissues should exhibit 1-2 mm resiliency which is necessary to aid in denture retention. Non displaceable tissues are unfavorable for attaining denture retention and easily damaged by pressure from the denture. Localized areas of non resilient tissues require relief. - However, tissues exhibiting more than 2 mm displaceability presents an unstable denture foundation. These tissues are either in the form of flabby tissues overlying ridge crests or hypertrophied tissues forming tissue folds. - Localized areas of flabby tissues and localized areas of non resilient tissues require suitable impression technique usually selective pressure impression technique should be planned. Cuspless teeth should also be used to eliminate horizontal forces. In cases of excessively thick flabby tissues surgery should be considered. B) Border tissues: - The oral vestibule should be examined to insure the presence of displaceable tissues at the mucous reflection area. The border of the denture flange should lie on slightly displaceable tissues to provide adequate peripheral seal necessary for denture retention. - Encroachment of the denture border on non resilient tissues results in soreness and instability. This usually occurs if the denture is over extended in the area of the zygoma. 21 Chapter 1 Diagnosis & Examination C) Frenuli: (Fig 21) - Examination of the frenal attachments is necessary. A broad frenum occupying a position near the ridge crest requires surgical correction (frenectomy) rather than excessively relieving the denture by a deep and wide v-shaped notch. Excessive relief in this area causes loss of peripheral seal and results in a weak denture base prone to midline fracture. a b c d Fig. 15 a:d: First we must look at, carefully observe and then palpate the alveolar ridge and location of muscle attachments Fig. 16: overextended labial flange Fig. 17: Flabby anterior gums leads to hyperplastic tissue. 22 Chapter 1 Diagnosis & Examination Fig. 18: Fibroma caused by Fig. 19: Papillomatosis caused by ill-fitting wearing of an ill fitting denture and improperly cleaned dentures. Fig.20: Epulis fissuratum Fig. 21: Broad frenum Fig. 22: The ridge form affects the retention and stability of complete dentures. It also influences the choice of the impression technique and type of artificial teeth. 23 Chapter 1 Diagnosis & Examination 3-Types of alveolar ridge: -The alveolar ridge is either: Normal ridge, Flat ridge, Undercut ridge, Knife edge ridge or Flabby ridge The ridge form affects the retention and stability of complete dentures. It also influences the choice of the impression technique (Fig 22). -The U-shaped ridge is the most favorable because its height resists lateral displacement and the parallelism of its sides resists vertical displacement. -Flat severely resorbed ridges lack lateral stability due to the absence of ridge height. The mental foramen usually attains a position near the ridge crest and hence should be relieved. A special impression technique is usually required. -The crest and slopes of knife edged ridges offer poor prognosis due to lack of proper denture supporting foundation area. Selective pressure impression may be required to eliminate pressure on the ridge crest. 4-The inter-ridge space: - A moderate space should exist between upper and lower ridges. It is rather difficult to detect the inter-ridge space by visual examination and is better diagnosed by mounted study casts. -Insufficient inter-ridge distance is usually accentuated between the maxillary tuberosity and the retromolar pad area. Although insufficient inter-ridge distance enhance denture retention and stability, it presents a problem during setting-up of teeth, hence it is advisable to use teeth which chemically binds to the denture base. -If the inter-ridge distance is too large, the prognosis is poor because the denture base will be subjected to leverage resulting in lack of denture stability. In such condition, proper selection and placement of teeth is necessary. Posterior teeth are preferably set near the mandibular ridge to enhance denture stability. 24 Chapter 1 Diagnosis & Examination 5-Maxillomandibular Arch relationship: - Angle class I - Angle class II ( retrognathia) - Angle class III (Prognathia) -Normal relationship between maxillary and mandibular arches indicates favorable prognosis. Disharmony in jaw sizes may be due to genetic factors or due to improper growth and development. -Angle's class II (retruded mandible) and class III (protruded mandible) present a problem in the placement of teeth. This problem should be recognized and handled during denture construction. Surgical correction may sometimes be required to correct extreme protrusion of either ridge to enhance the prognosis of the denture. -Maxillary protrusion (class II) is the least favorable because the area covered by the mandibular denture is always less than that of the maxillary. -Mandibular protrusion (class Ill) causes marked trauma to the anterior maxillary ridge due to concentration of biting and masticatory forces in this area. As the residual ridge resorbs, the maxillary ridge resorbs upward and inward, and the mandibular ridge resorbs downward and outward. The crest of the anterior mandibular ridge resorbs four times more than the anterior crest of the maxilla in the first seven years after teeth are extracted, therefore significant changes should be expected particularly when contemplating immediate dentures. Essentially the maxilla is getting more narrow and shorter, and the mandible is getting longer and wider tending to make the patient appear prognathic in the anterior and to have a crossbite ridge relationship in the posterior. 25 Chapter 1 Diagnosis & Examination 6-The palate: a. Hard palate. b. Soft palate. a-Hard Palate: The Palatal Vault The hard palate is usually classified as a high, average, shallow, or V- shaped. An average U-shaped palate is ideal. A V-shaped palate or high vault can compromise the seal of the denture. The most favorable palatal vault form is the one with medium depth and exhibiting a well defined rugae area. - A flat palatal vault presents insufficient resistance to forward movement of the maxillary denture, loss of stability and hence loss of retention. Such dentures can be easily dislodged by lateral or anteriorly directed forces. Balanced occlusion is necessary for these dentures (Fig 23). - A high narrow palatal vault is also unfavorable for denture retention. The denture presses against the sides of the vault and becomes un retained and loose. Good peripheral seal is required to retain such dentures (Fig 24). Fig. 23: Flat palatal vault Fig. 24: High narrow palatal vault 26 Chapter 1 Diagnosis & Examination b- Soft palate and Throat Form: The throat form is classified according to the curvature of the soft palate into three classes. The soft palate with gentle curvature is the most favorable for obtaining adequate post darming, while the soft palate with sharp curvature (curtain type) provides a narrow posterior palatal seal area which adversely affects denture. Types of soft palate:(Fig 25) Class I → soft palate of gentle curve gives broad posterior palatal seal (P.P.S). Class II → Medium.. Class III → Abrupt curvature with narrow P.P.S. Fig. 25: Types of soft palate Methods of differentiation between hard & soft palates:(Fig 26-27) 1. Visual 2. Palpation 3. Anatomical landmarks: a. Hamular notches b. Fovae palatinus c. The vibrating line 27 Chapter 1 Diagnosis & Examination Fig. 26:The vibrating line Fig. 27: The edge of a mouth mirror drops into the hamular notch 7-Maxillary Tuberosity: - The maxillary tuberosities provide support and retention to the upper denture, hence the denture should completely cover them. Large tuberosities are usually associated with undercut areas that may interfere with denture insertion. - If large undercuts are present bilaterally, one of them should be surgically eliminated. - If large bilateral undercuts are present together with undercuts on the labial slope of the anterior ridge, it is usually more conservative to remove the two opposing underucts in the tuberosity areas. - A unilateral undercut can be avoided by inserting and removing the denture in a rotating path. This enhances the denture retention (Fig 28). -.A large unilateral tuberosity undercut should sometimes be surgically reduced to avoid resistance exerted by the coronoid process on the denture flange in this area. - The maxillary tuberosity may often extend inferiorly to occlude with the retromolar pad obliterating the inter-ridge space in this area. In such cases surgical removal of the tuberosity is necessary. 28 Chapter 1 Diagnosis & Examination - The maxillary tuberosity may sometimes be covered with large pendulous fibrous tissues that may contribute to excessive vertical and horizontal movement which in turn affects denture retention and stability. These fibrous tissues should be surgically removed. Fig. 28: Planned path of insertion of maxillary denture: When there is a unilateral undercut, the denture can be inserted and removed by rotating it into position. It will even enhance denture retention. 8-Tori: (Fig 29) - Tori are hard bony protuberances covered by thin, non resilient soft tissues which can be easily irritated. - Small tori are usually relieved to avoid rocking and instability of dentures. While large tori are surgically removed or reduced in size. 9-Undercuts: (Fig 30) The presence of undercut areas interferes with denture retention and insertion. Large, sharp, extensive, numerous or bilaterally opposed undercuts present problems in denture construction which may sometimes necessitates surgical elimination. 29 Chapter 1 Diagnosis & Examination Fig. 29: enlarged torus palatinus Fig. 30:Undercut maxillary ridge Some other factors: 1-Muscle tonicity: Muscle tonicity may be strong and vigorous in healthy persons or may be weak and flaccid due to poor health or advanced age. In old age, wrinkles and folds appear in the muscles of face, lips and cheeks. Impeded mandibular control may also occur due to changes in the tonicity of the muscles of mastication. 2-The Tongue size and type: (Fig 31, 32) - The tongue is a muscular organ whose size, form, position and function influences impression making and affects the prognosis of complete dentures. A broad thick tongue helps in creating a good peripheral seal. However, an abnormal tongue may hinder proper denture construction. Abnormal tongue conditions can be improved by patient education. - The tongue seems to become larger and more powerful when a person has been wearing an inadequate denture. A very large tongue can be seen in patients who have been edentulous with no replacement prosthesis for an extended period 30 Chapter 1 Diagnosis & Examination - An extremely large tongue (macroglossia) presents difficulty in impression making and cause denture instability. However, a small narrow tongue contributes to easy impression procedures but jeopardizes the lingual peripheral seal of lower dentures resulting in impaired retention. - The ideal position of the tongue was with the apex of the tongue slightly below the incisal edges of the mandihular incisors and with the dorsmn of the tongue visible above the teeth in all parts of the mouth. If the tongue position is low in relation to the ridge crest or retruded in relation to the anterior ridge, poor denture retention will be expected. Tongue movement, whether, too fast, slow or little affects border molding of the mandibular lingual flange. 3-Floor of the mouth: (Fig 33) -The floor of the mouth should be examined to insure the presence of displaceable tissues at the mucous reflection area. The border of the denture flange should lie on slightly displaceable tissues to provide adequate peripheral seal necessary for denture retention. - Encroachment of the denture border results in soreness and instability. 4-Saliva: The saliva should be evaluated both in amount and consistency. A normal amount and thickness of saliva is paramount in the ability of most patients to comfortably wear dentures. The saliva acts as a lubricant and also serves as the interface between the denture base and tbe tissue 31 Chapter 1 Diagnosis & Examination allowing for denture retention. A patient with xerostomia or excessive saliva containing much mucous can have difficulty obtaining an adequate seal for their prosthesis. A patient with normal salivary flow will benefit from its adhesive and cohesive qualities. Patients with dry mouth not only have poor denture retention but also a greater tendency for oral mucosa tenderness and easily traumatized. -Through aging, salivary flow decreases and its contents change. The quantity and quality of saliva are among the important diagnostic data because of their effect on denture retention. -The diminution in salivary flow will not moisten the oral mucosa and will interfere with the functions of mastication, swallowing and phonetics. In some cases, the use of artificial saliva or medications promoting salivary secretion should be recommended. - Copious thick ropy saliva interferes with the accuracy of the impression procedures, initiates nausea and gagging reflex and hinders denture retention. A hypersensitive gag reflex can complicate successful fabrication of a complete denture. 5-Oral lesions: a. Sharp Bony Spicules (Fig 34). b. Simple ulceration of the mucous membrane c. Hyperplasia d. Remaining roots/impacted teeth e. Sinuses f. Cysts g. Neoplasmic changes 32 Chapter 1 Diagnosis & Examination Sharp Bony Spicules Bony spicules should be surgically removed before impression procedures because they should be undesirable sources of tissue injury and patient discomfort. Abnormal soft tissues - Exmination is necessary to detect abnormalities in the soft tissues such as fibrous tuberosities, papillary hyperplasia in the palatal vault, and epulis fissuratum in the su1cular epithelium resulting from ill-fitting denture flanges or hypermobile ridge tissues covering atrophic knife-edge ridges (Fig 35). - These abnormalities are first treated by a conservative method in which the cause for this abnormality is eliminated, tissues are allowed to rest. A soft liner conditioning material may then be used to allow tissues to collapse and regain their form. Surgical removal of abnormal tissues will only be indicated in cases resisting conservative treatment. a b Fig. 31 a,b: The tongue with fissured appearance and papillary lesions in dorsal face. a b Fig.32 a,b: Tongue movement, affects border molding of the mandibular lingual flange. 33 Chapter 1 Diagnosis & Examination a b Fig.33 a,b: Testing the tension forces with a finger or a mouth mirror. Fig. 34 : Abnormal residual ridge contour. Fig.35: Displaceable tissue III- Pre-extraction Records and Helpful aids Records are taken from the patient before reaching complete edentulism. These records are a useful guide in restoring the patient's natural appearance and facial contour, these records include: 1- Radiographs. 2- Photographs of the patient's face before extraction of teeth. 3- Record of the shade and color of the natural teeth will help and guide in proper tooth selection. 4- Diagnostic casts are very helpful to further evaluate the anatomy and condition of the residual ridges. Generally diagnostic casts are made from preliminary impressions made with irreversible hydrocolloid (alginate) in 34 Chapter 1 Diagnosis & Examination stock trays which may or may not be mounted on an articulator. Mounted casts will help to visualize the position and the inter-relationship between teeth. They also help to evaluate the inter-ridge space. 5- Measurements made between landmarks on the patient's face. 6- Contoured wire profile or silhouettes. 7- Face masks obtained by making a hydrocolloid impression of the facial structures especially around the mouth, chin and nose. 8- Some investigations (blood pressure, blood and sugar analysis… etc.). 9- Biopsy. Roentgenographic Examination: Radiographs of the residual ridge are useful and important clinical diagnostic aids. They help in the detection of: - Retained roots and root fragments as well as Impacted teeth that should be removed prophylactically in young people to prevent their possible transmission to a cyst. However, they are not necessarily removed in cases of advanced age or poor physical condition, but the patient should be informed of their presence. They should not also be removed if their removal will leave a large surgical defect as in thin porous mandibular bone. - The quality of bone; where bone of good quality exhibits decrease in size of the trabecular pattern (bone condensation). This is an indication of favorable bone response to occlusal stresses and to the amount of expected bone resorption. - The presence of rough or irregular alveolar ridges may necessitate either alveoloplasty or the choice of a suitable impression technique. 35 Chapter 1 Diagnosis & Examination - The condition of bone, the degree of bone resorption and rough alveolar ridges. - The mucosal thickness along the crest of the ridge. - Bony spicules IV-Development of the Treatment Plan Proper Diagnosis is the Key of Best Prognosis Data collected during diagnosis and the observations made during examination should be thoroughly studied and analyzed to develop the best possible and suitable treatment plan. Once all information has been obtained, a formal treatment plan should be discussed with the patient. This would include how treatment will be sequenced as well as an estimate of the length of time to complete the treatment. An estimate of cost for the treatment should also be discussed and approved by the patient. Prosthodontic Care: The choice of the procedures should be made in convenience with the oral condition of the patient. Data concerning the condition of the denture foundation tissues will help in determining the impression technique, the technique and the records required for jaw relation registration and the suitable occlusal scheme. 36