Patient Evaluation, Diagnosis, and Prognosis for Complete Dentures PDF

Patient Evaluation, Diagnosis, and Prognosis for Complete Dentures Dr. Nada Najjar Prosthodontist (Fixed and Removable) Faculty of Dentistry / Al-Quds University  In the construction of complete dentures, success or failure may depend upon a clear understandi...

Patient Evaluation, Diagnosis, and Prognosis for Complete Dentures Dr. Nada Najjar Prosthodontist (Fixed and Removable) Faculty of Dentistry / Al-Quds University  In the construction of complete dentures, success or failure may depend upon a clear understanding of the limits and possibilities of each case  A thorough history and systematic examination of all the conditions of the mouth and of the patient is essential.  AGE ❑ Adaptability Young people adapt themselves with greater ease and therefore are more likely to have successful denture experiences. ❑ Physiological Conditions of Supporting Structures Endocrine glands and sex hormones Calcification of bone and calcium metabolism  SEX ❑ Males and Females have different esthetic demands women may regard appearance even above the function of the replacement teeth. ❑ Sex hormones have different influences on the supporting structures Menopause and the withdrawal of some of the ovarian secretions affect the alveolar ridges adversely (Bone and overlying mucosa). (Menopause).  OCCUPATION Special attention should be given to design and impression making techniques. Appearance and retention are often more important than efficiency when treating People having intimate contact with their fellows at work. Public speakers and singers require not only perfect retention but also attention to palatal shape and thickness (for proper phonetics) Wind instrument players…. Modification of anterior teeth.  GENERAL HEALTH Many chronic, debilitating diseases offer a poor prognosis. And these may have early oral manifestations or symptoms. The symptoms may be subjective as pain or burning sensations; or they may be objective i.e. actually involving tissue changes in both bone and overlying covering.  Pain or burning sensations may be caused by anemia, diabetes, or other endocrine or nutritional disorders. Actual tissue changes may be caused by syphilis, tuberculosis, blood dyscrasias, diabetes, endocrinopathies, neoplasms… Caution should be exercised while constructing a denture for a patient after radiation therapy. ❑ Arthritis ▪ Limited movement of the mandible during impression making. ▪ Difficulty in the jaw relation registrations. ▪ Occlusal corrections must be made frequently ❑ Diabetes ▪ The patient must be under medical control ▪ Maximum physiologic compatibility of the denture base with the supporting tissues (impression technique) ▪ These patients are susceptible to infections. ▪ Occlusal corrections and interferences should be removed. ▪ Instructions on eating habits and oral hygiene. ▪ Frequent evaluations of the dentures. ❑ Bell’s Palsy ▪ Retention is often hard to achieve, adhesives may be necessary. ▪ Tissue support becomes a problem for the paralyzed musculature (esthetics and function) ▪ Education in mastication and oral hygiene. ❑ Parkinson’s Disease ▪ Control of the patient during denture fabrication may be achieved by sedatives. ▪ Retention may be a problem. ▪ Removal of the dentures when they are not in use. ❑ Anemia ▪ Medical care ▪ Construct efficient dentures, since diet is important. ▪ A small occlusal table with maximum supporting area to keep the supporting tissue from being over stimulated is a major goal. ▪ Good oral hygiene. ❑ Radiation ▪ No abrasion or irritation to the supporting tissues. ▪ An open lesion may be the start of a serious condition , namely osteonecrosis. ▪ It is best not to use dentures at all over irradiated tissue, but if dentures are necessary, they should not be used until at least two years after radiotherapy. ❑ Acromegale ▪ A periodic check of the prosthesis is needed to determine whether the continuing growth of the mandible and maxilla necessitates any adjustment or reconstruction. DENTURE HISTORY – DENTURE WEARING EXPERIENCE  INFORMATION REGARDING THE LOSS OF THE NATURAL TEETH ▪ A history of difficult extractions should be followed by radiographic examinations. ▪ The order in which the teeth were lost is important. 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 anterior teeth will have been formed which will have a pronounced unstabilizing effect on the complete dentures, and an abnormal anterior travel of the mandible would be noticed. Retained natural teeth opposite edentulous spans restored by removable prosthetics  THE PATIENTS ATTITUDE TO APPEARANCE ▪ Extra time and care must be given ▪ Pre-extraction records ▪ Customization of teeth and gengivea ▪ Staining THE PATIENTS MENTAL ATTITUDE TO DENTURES Patients seeking prosthodontic care arrive with an accumulation of experiences and resulting attitudes. These may range from optimism to despair. Danger is present at both ends of the positive – negative spectrum. (?!!)  Mental attitudes are divided into four classifications: Class I – Philosophical Those who had no experience in wearing dentures, and do not anticipate any special difficulties in that regard. Those who have worn satisfactory dentures, are in good health, are a well-balanced type, and are in need of further denture service. Class II – Exacting Those wearing artificial dentures unsatisfactory in appearance and usefulness, and who doubt the ability of the operator to render a service which will be satisfactory. They ask for guarantees They refuse the advice of the physician and the dentist. Class III – Hysterical Those who have attempted to wear artificial dentures but failed and are thoroughly discouraged. They are of a hysterical, nervous, very exacting mentality and will demand efficiency and appearance from the dentures equal to that of the most perfect natural teeth. Class IV – indifferent Those who are unconcerned about their appearance and feel no necessity for teeth for mastication. They are therefore inconvenient to become accustomed to dentures. Patients may be also classified as: Cooperative Apprehensive Uncooperative  EXAMINATION EXAMINATION OF OLD DENTURES VISUAL EXAMINATION OF ORAL TISSUES DIGITAL EXAMINATION OF TISSUES RADIOGRAPHIC EXAMINATION EXAMINATION OF OLD DENTURES  As the dentures age, the teeth wear and the residual ridges that support the denture resorb, causing the distance between the nose and chin to collapse. As constant wearing of posterior denture teeth continues, creating space between them leading to premature contact on the anterior teeth bringing the lower jaw come forward. The present patient also suffered from the same sequelae of denture wearing. To add to this, day and night wearing of dentures also could have led to severe resorption of the residual ridges. The denture flanges were already short, so dentures did not appear overextended inspite of severe ridge resorption. VISUAL EXAMINATION  ALVEOLAR MUCOSA Class I, Normal ▪ No signs of abrasion or irritation ▪ Adequate keratin layer and evenly distributed over the ridge. Class II, Atrophic ▪ The mucosal covering is thin ▪ Keratin is absent or deficient ▪ Usually seen in geriatric patients ▪ Presents problems with retention and sorness. Class III, Hypertrophic ▪ Thickened mucosa ▪ Sometimes white or grayish ▪ Fibrous and hyperplastic soft tissue is most often seen in the maxillary anterior area (lower anterior teeth opposed by upper denture, ill-fitting dentures, excessive vertical dimension, allergies… ▪ Corrective measures should be taken before impression making.  The irritated mucosa, may appear dark red, hyperemic, exhibiting an abraded and raw appearance, stretched and swollen  ARCH FORM SQUARE TAPERING OVOID  The square arch is more favorable for retention and stability. The ovoid is slightly less favorable and the tapering arch is the least favorable. A combination of forms may be present. (Cross bite, Prognathism)  ARCH SIZE Large jaws offer the greatest advantage for retention, Stability and efficiency. Also arch size gives a quick estimate of tooth size necessary. If arch size and face size are not in harmony, the esthetics may be a problem.  VAULT FORM A flat vault has good vertical support but provides no resistance to lateral shifts. A high or ‘V’ shaped vault resists lateral shifts well, but vertical displacement tends to break the seal. A rounded or ‘U’ shaped is the most favorable.  RIDGE RELATION Class I, Normal Favorable stress distribution and esthetics Class II, Retrusive Require careful occlusion registration. TMJ problems may be found Class III, Protrusive Cross bite relation ships  DEPTH OF SULCI When ever a very shallow and broad sulcus is encountered a careful impression technique will be required in order to obtain adequate peripheral seal and so utilize physical forces to the full as an aid to retention.  PHYSICAL FORM ❑ Contours presenting minor difficulties but may be eliminated by mechanical relief to the localized area. ❑ Contours unfavorable… surgical interference is absolutely necessary. Tuberosities ▪ Large tuberosities provide good support and retention ▪ Bilateral undercuts should be corrected surgically. ▪ Extremely long tuberosities interfere with the interarch space. ▪ The coronoid process and the tuberosity relations should be tested.  Undercuts along the buccal aspect of both ridges anterior to the tuberosity. Undercuts on the lingual side of the lower Tori….. Palatal Torus (?!!) Mandibular Torus (?!!) Frenum Attachment Significant if near the crest of the ridge Ridge Form ▪ Evenness of the ridge surface… Rounded and smooth is the most favorable (?!!) ▪ Cross sectional form… Flat…. Difficult but with good tongue position and a wide buccal shelf it can be managed. Knife edge… most seen with a tapered arch and narrow buccal shelves and Sharp MHR.  THROAT FORM Takes in consideration the post dam area. A wider post dam area… better retention. Class I…. Large immovable tissue present with low palatal Vault and small tuberosities. (Best) Class II… the junction is more acute Class III… no immovable tissues posterior to the hard palate. Right angle. Least favorable. Displacability of the post dam tissues determine a lot in the denture retention.  TONGUE POSITION Normal position… favorable for maintaining the lingual seal and retention Broad flattened position… difficult in impression making. Retruded position… has four forms: 1.Apex curls downwards while the radix elevated 2.Apex curls up 3.Apex seems to disappear into the body of the tongue giving it a square appearance. 4.Body of the tongue depressed. POOR LOWER DENTURE PROGNOSIS  MOUTH OPENING Large… favorable for impressions Small… unfavorable, especially with large Ridges.  LIP SIZE Long Lip… no esthetic problem Short Lip… attention to esthetics FACE FORM SQUARE TAPERING OVOID DIGITAL EXAMINATION  MUSCULAR TONE A marked loss of tonicity occurs in the absence of natural teeth or dentures or from wearing grossly inefficient dentures.  RESORPTION Average Resorption Bulky Ridges Excessive Resorption Shape, Height, Breadth and denture space are interacting factors.  MYLOHYOID AND RETROMYLOHYOID FORM The more distant the muscle attachment from the ridge crest, the more favorable is the out look for successful denture construction. Distal Inferior extention of the denture flange PALATE SENSITIVITY – GAG REFLEX  SALIVA Thin Watery… affects retention negatively Thick ropy… complicates impression making Deficient saliva is usually seen in the geriatric patient and certain systemic disorders… poor prognosis in retention and comfort. RADIOGRAPHIC EXAMINATION TYPE OF OSSEOUS STRUCTURE It is generally believed that dense bone with thick cortical layer is the most favorable foundation for denture support. TMJ SYMPTOMS OR PATHOLOGY