Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients

1. Examination, Diagnosis and Treatment Planning for Edentulous or Partially Edentulous Patients Rola M. Shadid, BDS, MSc

2. Procedures Carried Before Denture Treatment • General information • Chief complaint & patient expectations • Medical history & current medication • Dental history • Visual & manual examination of the mouth and head and neck • Radiographic examination

3. Continue • Referring for additional tests or medical consultation • Referring for second opinion • Making alginate impressions & preparing mounted study models • Discussion of diagnosis, treatment planning & prognosis with patient • Finalizing the fees & obtaining a signed consent

4. The First Meeting • Most important • Prior to meeting, you should review general information • Your confidence is as important as the treatment itself • You should be a good listener • Your communication should be in a simple & truthful manner

5. Recording General Information • Name • Race • Occupation • Address and telephone no. • Previous dentist

6. Age With advancing age*: • Decrease capacity of tissue to tolerate stress • Tissue takes longer time to heal • Many diseases are prevalent in older age • Women at postmenopause may have psychological disturbances (exacting or hysterical) • Men at this age may be concerned with only comfort & function (indifferent)

7. Psychological Evaluation (House Classification of Denture Patients) • Philosophical patient: well motivated, cooperative, calm & composed even in difficult cases. • Exacting (critical): likes each step in detail, makes alternative treatment for dentist, makes severe demands.*

8. Continue • Indifferent: not very interested in treatment, blames the dentist for any mishap, not follow instructions, been coerced to come by friend, relative….*

9. Continue • Hysterical: easily excited, highly apprehensive, unrealistic expectations* • Skeptical: bad results from previous treatment, doubtful, often have severely resorbed ridges and poor health, might have psychological disturbances from recent personal trajedy #

10. Chief Complaint & Patient Expectations • Patient’s own words • Why he is seeking prosthodontic treatment • You should assess if patient expectations are realistic or not • If not realistic, you should educate pt and scale them down

11. Medical History* • Diabetes Mellitus • Cardiovascular diseases • Diseases of joints: osteoarthritis • Diseases of skin: pemphigus ? • Neurological disorders (Bells balsy and Parkinson) • Sjogren’s syndrome • Transmissible diseases

12. Radiation Therapy Vs. Dentures • Consequences of Radiation therapy • Preprosthetic surgery • Wearing of previous denture * • Denture Fabrication #

13. Denture Fabrication in Radiation Therapy Patient • Avoid impression material that dry tissue (impression plaster) or heavily flavored materials (ZOE) • Consider non-anatomic teeth • Teeth set in neutral zone • Slight reduction in vertical dimension • Soft liners are controversial due to porosity and possibility of candida

14. Current Medication • Insulin * • Anticoagulants • Antihypertensive: dryness & postural hypotension • Corticosteroids: dryness, confusion & behavioral changes • Antiparkinson agents like Norflex and Akineton: dryness, confusion & behavioral changes

15. Dental History • History of tooth loss: cause, time* • Edentulous period

16. Beware of Patients Who Have A “Bag of Dentures” *

17. Extraoral Examination • General appearance (healthy, signs of proper nourishment?) • Facial symmetry • Skin: color, deep wrinkles • Palpation of the head & neck (lymph nodes & muscles)

18. Extraoral Examination • Muscle tonus • Neuromuscular coordination* • TMJ examination

19. Classification of Frontal Face Forms(House, Frush & Fisher) *

20. Classification of Lateral Face Forms • Normal • Retrognathic • prognathic

21. Lips • Length* • Thickness • Mobility • Smile line

22. Lip (smile) line * High smile line Normal smile line

23. Intraoral Examination Cheeks, tongue, floor of the mouth (FOM), maxillary tuberosity, hard palate, soft palate, arch relationship, residual ridge form, saliva, undercuts

24. Cheeks • Draping of the cheeks over the buccal flanges essential for peripheral seal • Opening of Stenson’s duct • Location for many lesions (lichen planus, submucosal fibrosis, leukoplakai, malignancies as sqauamous cell carcinoma (SCC))

25. Leukoplakia

26. The Tongue • Favorable tongue is average sized, moves freely, covered by healthy mucosa • Normally, it should rest in a relaxed position on lingual flanges, this will retain denture & contributes to denture stability by controlling it during speech, mastication & swallowing.

27. Tongue Size • Normal • Large *

28. How to Manage Large Tongue? • Lower the occlusal plane • Use narrower teeth • Increase the intermolar distance • Grind off the lingual cusps • Avoid setting a second molar

29. Tongue Position • Normal: normal size and function. Lateral borders rest at level of mandibularocclusal plane while dorsum is raised above it. Apex rests at or slightly below the incisal edges of mandibularanteriors

30. Tongue Position • Retruded tongue position deprives pt of border seal of lingual flange in sublingual crescent and also may produce dislodging forces on distal regions of lingual flange

31. Tongue Mucosa The specialized mucosa covering the tongue is said to be a “window” on systemic diseases. *

32. Frenal Attachments • Fold of mucosa found at different locations in the sulcus region of upper & lower ridge • Classification Class I: sulcal or low attachment Class II: midway betw. sulcus & crest of ridge Class III: crestal attachment (frenectomy)

33. Floor of the Mouth • If FOM is near the level of the ridge crest, retention & stability of denture is less. • Hyperactive FOM reduces retention & stability • If great ridge resorption, FOM in sublingual and mylohyoid regions spills on the ridge • Patency of submandibular ducts *

34. Maxillary Tuberosity* If enlarged: • the posterior occlusal plane may be placed too low • no enough space to set all molars

35. Maxillary Tuberosity Palpate for undercuts - if extreme, denture might not seat

36. The Hard Palate • Class I: U shaped, most favorable for retention & stability • Class II : V shaped: Not very favorable* • Class III: Flat or shallow vault: Not very favorable, accompanied by resorbed ridges, poor resistance to lateral forces

37. V-shaped hard palate

38. Tori * • Palatal torus • Mandibulartori

39. Bony Prominences • Midpalatal raphe • Sharp ridge crest • Sharp mylohyoid ridge • Prominent genial tubercles • Bony fragments & fractured root pieces • Tori

41. The Soft Palate (Palatal Throat Form) House’s classification * • Class I: the soft palate is almost horizontal curving gently downwards • Class II: the soft palate turns downward at about 45 angle from the hard palte • Class III: the palate turns downward sharply at about 70 angle to the hard palate.

42. Palatal Throat Form Maxilla I II III

43. Undercuts The contour of a cross section of a residual ridge that would prevent the placement of a denture or other prosthesis

44. Undercuts • Unilateral or bilateral; labial or lingual; mild, moderate or severe • Common locations: • Labial portion of maxillary anterior ridge • Buccal to maxillary tuberosity • Retromylohyoid area of residual ridge • Labial or lingual slopes of mandibular anterior ridge

45. Undercuts Management • Isolated anterior undercut- not present any problem • Unilateral posterior undercut- may not present much of a problem as path of insertion is varied • Bilateral undercut-surgical removal of the more severe one is indicated

46. Residual Alveolar Ridge Arch form (House’s classification) Class I: square Class II: tapered (V-shaped), associated with high arched palate, less retention & stability Class III: ovoid (less common)

47. Residual Alveolar Ridge (Cross Sectional Contour) * • U shaped • V shaped • Knife edged • Flat • Inverted • Undercut

48. Soft Tissue Support of the Ridge • Firm & resilient • Flappy and hypermobile: poor support because denture base shifts during masticatory function • Management of flappy ridge ranges from modified impression techniques to surgery

49. Anterior Arch Relationships *

50. Intraoral Examination • Posterior arch relationships • Interridge space • Residual ridge size