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Diagnosis and treatment planning in complete denture patients

BY FATEEMA PRIYAM FEROZ,FINAL YR PG ,PROSTHODONTICS

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Diagnosis and treatment planning in complete denture patients

  1. 1. 1 Diagnosis and Treatment planning for Complete denture patients FATEEMA PRIYAM SECOND YR P.G
  2. 2. Contents `  Introduction  Important terminologies  Diagnostic procedure  Patient evaluation  History taking  Personal data  Chief complaint and dental history  Medical history  Clinical evaluation 2
  3. 3.  Radiographic examination  Prognosis  Treatment planning  Prosthodontic diagnostic index  Discussion  Summary  References 3
  4. 4. 4
  5. 5. Success in complete denture prosthetics 1.The patient’s attitude to dentures and his ability and willingness to learn to use them. 2. The condition of the mouth. 3. The skill of the clinician. 4. The technical assistance available. 5
  6. 6. IMPORTANT TERMINOLOGIES 6
  7. 7.  Examination: Scrutiny or investigation for the purpose of making a diagnosis or assessment. GPT-9 7
  8. 8.  Diagnosis: is the examination of the physical state, evaluation of the mental or psychological makeup, and understanding the needs of each patient to ensure a predictable result. -SHELDON Winkler  The determination of the nature of a disease -GPT-9 8
  9. 9.  Diagnosis is the act or process of deciding the nature, location and cause of a diseased condition by examination and careful investigation. Heartwell 9
  10. 10.  Treatment plan: is the sequence of procedures planned for the treatment of a patient after diagnosis. -GPT-9  Means developing a course of action that encompasses the ramification and sequelae of treatment to serve the patient needs -Sheldon Winkler 10
  11. 11.  Prognosis: A forecast as to the probable result of a disease or a course of therapy. -GPT-9  To forecast the likelihood of a successful outcome to prosthetic treatment - D J Neil 11
  12. 12. 12
  13. 13.  To gain the necessary information about the patient, the clinician should: – Conduct a thorough examination – Listen to what the patient has to say – Be alert to things patient may leave unsaid – Record details of information in a logical sequence 13
  14. 14.  Diagnostic procedure can be broadly divided into: Patient evaluation History taking Clinical evaluation Extraoral Intraoral 14
  15. 15. 15
  16. 16.  Physical characteristics  Appearance and presentation  Handshake – Dead fish handshake – Normal firm – Vicelike handshake – Sweaty,clammy and cold hands 16 Kranti,Meena et al Psychological considerations for edentulous patients JIPS 2007
  17. 17. Gait  Insight into patients motor skills and systemic diseases Stooped shoulder-Spinal changes Tremor of head-Parkinson disease Dragging of one leg-Stroke Staggering-Alcohol(excessive) Damage to brain and spinal cord, medications 17
  18. 18. Motor skills  Whether patient is able to move alone or with assistance  Dizziness  Vertigo  Breathing  Facial movements  Speech defects 18
  19. 19. Mental Attitude/ Personality House classified patients as:  Philosophical  Exacting  Indifferent  Hysterical 19
  20. 20. Philosophical • The best mental attitude for denture acceptance • Rational, sensible, calm and composed in difficult situations. • Confident, easy going and cooperative. • Overcomes conflicts and organizes his time and habits in an orderly manner. • Eliminates frustrations and learns to adjust rapidly. 20
  21. 21. Exacting • He may require extreme care, effort and patience on clinician’s part. • Methodical, precise and accurate and at times makes several demands. • Once satisfied, an exacting patient may become the practitioner’s greatest supporter. 21
  22. 22. Indifferent Patient • Presents a questionable or unfavourable prognosis. • Exhibits little concern if any; he is uninterested and lacks motivation. • Pays no attention to instructions, will not cooperate and is prone to blame the dentist for poor dental health. • An education program in dental conditions and dental treatment is the recommended treatment plan 22
  23. 23. Hysterical • Emotionally unstable, excitable, excessively apprehensive and hypertensive. • This patient must be made aware that his/her problem is primarily systemic and that many of his symptoms are not result of dentures. • Prognosis is poor. 23
  24. 24. Simon Gamer et al “M. M. House mental classification revisited: Intersection of particular patient types and particular dentist’s needs” J Prosthet Dent 2003;89:297-302  Reasons that the House classification requires reevaluation Some of the terminology is antiquated, falling out of use, or no longer carries the same meaning within psychiatry eg: hysterical House classification pertains to the patient in isolation. House provided little attention to how the patient’s reactions and behaviors are codetermined by the treatment and behavior of the dentist. 24
  25. 25. PROPOSED CLASSIFICATION Based on 2 factors:  the level and quality of the engagement or involvement of the patient toward the dentist (including such issues as domination, submission, and idealization and devaluation of the dentist) and  the level of willingness to submit (trust) to the dentist. Gamer et al 2003 25
  26. 26. 26
  27. 27. 27
  28. 28. IPWCDO CLASSIFICATION FACTORS PRODUCING ADAPTIVE RESPONSE  Confidence in the dentist  Previous favorable experiences  Positive attitude  Good physical health and coordination  Realistic expectations  Good learning capacity and cooperative  Awareness to the limitations of a complete denture 28
  29. 29. MALADAPTIVE RESPONSE  Lack of trust in the dentist  Poor communication  Previous negative experience  Inadequate tissue tolerance and muscle coordination  Disapproval to dentures by people who are important to the patient 29
  30. 30. WINKLERS CLASSIFICATION  HARDY ELDERLY  SENILE AGED SYNDROME  SATISFIED OLD DENTURE WEARERS  GERIATRIC PATIENTS WHO DO NOT WANT DENTURES 30
  31. 31. ALAN MACK’S CLASSIFICATION  Ectomorph-worrying types  Endomorph-Care free type  Mesomorph-Passive type 31
  32. 32. BLUMS CLASSIFICATION  REASONABLE OR REALISTIC  UNREASONABLE OR UNREALISTIC 32
  33. 33. FRANKELS CLASSIFICATION  DEFINITELY NEGATIVE BEHAVIOUR  NEGATIVE  POSITIVE  DEFINITELY POSITIVE 33
  34. 34. 34
  35. 35. Personal Data  NAME  AGE  SEX  OCCUPATION 35
  36. 36.  Address  Helps in future communication  Socio-economic status  Setting up appointments  Endemic diseases 36
  37. 37.  Habits – Pan chewing, smoking, chronic alcoholism – Habits like pencil and nail-biting – Para functional habits 37
  38. 38.  Nutritional history – Record dietary history • Well-nourished patient • Mal-nourished patient 38
  39. 39. DENTAL HISTORY 39
  40. 40. Chief complaint  The patient should be questioned regarding his or her chief complaint such as-  Inability to chew  Impaired speech  Poor appearance  Others. 40
  41. 41. History of presenting illness/ Dental history  Duration and sequence of the edentulous state: Gives information about bone resorption patterns and progression, as well as the timing of tooth loss.  Reasons for loss of teeth: 41
  42. 42.  Previous Denture Experience: The patient should be questioned regarding the number & types of previous dentures  Patients should be made to comment on the reasons for replacement and should be educated regarding the realistic limitations. 42
  43. 43.  Existing Or Current Dentures: • The patient should be questioned about the length of time for which the dentures have been worn. • Careful clinical observation may provide valuable information about denture experience • patient should be asked about the esthetics and function of existing dentures 43
  44. 44.  The existing denture should be checked for tooth shade,mold and material .  Eshetics,phonetics,retention,stability,extensions, contours,vertical dimension of occlusion and orientation of the occlusal plane.  Characterization or staining,comfort of the patient.  Motivation to clean dentures must be assessed. 44 Ashok.K et al Journal of Orofacial sciences-2010
  45. 45. MEDICAL HISTORY 45
  46. 46. Debilitating diseases  Diabetes, tuberculosis, blood dyscrasias etc should be under medical control.  Diabetes: An uncontrolled diabetic or poorly controlled diabetics may pose problems of: (i) Bacterial, viral and fungal infections – including candidiasis. (ii) Xerostomia: 46
  47. 47.  Poor wound healing,increased bone resorption,muscle atrophy,xerostomia.  Appointments should be short and should not interfere with meal times.  Tissues need functional rest so patients should be advised less denture wear.  Frequent relining and rebasing may be required. 47 Ashok .K et al Journal of Orofacial Sciences-2010
  48. 48. Tuberculosis Deep fissures in the tongue; the mucosa of check; round, undermined ulcers that are very painful and firm nodules. Efficient dentures are necessary as diet is important in treatment. Oral hygiene is important 48
  49. 49. . Blood dyscrasias:  proper history should be taken  blood tests/ consultation prior to treatment  care to be taken while planning for pre prosthetic surgery  these patients get easily bruised 49
  50. 50. Cardio vascular diseases:  Prophylactic antibiotic coverage for all dental procedures . – Convenient morning, short appointment. – Premedication with diazepam 5-10 mg to reduce apprehension. – Nitroglycerine tablets to be made available in dental office 50
  51. 51. Diseases of joints:  Particularly osteoarthritis.  Under the age of 45, men and women are affected in the ratio of 2 : 1. 51
  52. 52. Considerations  When terminal joints of fingers are arthritic it is difficult to insert & clean dentures.  Osteoarthritis of TMJ presents problem in CD construction as mandibular movements are painful and jaw relation records are difficult to record and repeat. 52
  53. 53.  Occlusal correction must be made often because of subsequent changes in joints.  Special impression trays necessary due to limited access from reduced ability to open jaws. 53
  54. 54. Diseases of skin:  Pemphigus - extremely painful.  Constant use of dentures is contraindicated - primarily indicated for mental comfort.  Vesicles and bullae on the mucous membrane as well as on skin. 54
  55. 55. Neurological disorders:  Patients with Bell’s palsy and Parkinson’s disease etc. can be given prosthetic treatment.  Denture retention, maxillo-mandibular relation records and supporting musculature pose denture problems. 55
  56. 56. Epilepsy  The base of complete dentures should be metal or should be reinforced with metal as acrylic base may fracture ,increasing the risk of aspiration or dislodgement into the esophagus 56 Taskin Gurbuz Novel aspects of Epilepsy,2011
  57. 57. Radiation treated patients  Patients treated by radiation of head and neck tend to develop problems like i) Mucositis ii) Xerostomia iii) Loss of taste iv) Constricture of muscles (trismus) v) Secondary infections (Candidiasis) 57
  58. 58.  If prognosis is favorable,but still the tissues have a bronze color and lack tonus-delay denture construction.  Watch for tissue necrosis.  Use on a limited time basis-depending on the reaction of the tissues. 58
  59. 59. CLIMACTERIC  Females-menopause  Generally seen as osteoarthritis,mental disabilities,burning palate,burning tongue,tendency to gag,vague areas of pain.  Medications,psychiatric treatment. 59
  60. 60. Allergies and Angioneurotic edema  H/o of allergy -drugs or denture materials  Edematous swelling of lips, cheek etc after contact with an antigen like acrylic / metal.  Emergency treatment: 0.3 – 0.5 ml epinephrine 1:1000 1M, support respiration / obtain medical assistance. 60
  61. 61. 61
  62. 62. Extra oral examination  The head and neck region is examined for the presence of any pathological condition relating to non dental or systemic condition  Face and neck palpated to check for enlarged nodes or masses. 62
  63. 63. Facial form  Put forward by House & Loop, Frush &Fisher & Williams.  Williams claims that the shape of upper Central Incisor bears a definite relation with the shape of the face. 63
  64. 64. Facial Profile (Acc. To Angle): 64
  65. 65. Facial Symmetry  Gross asymmetries are recorded.  Can be due to: – Congenital defects – Hemifacial atrophy – Unilateral condylar ankylosis and hyperplasia. 65
  66. 66. Muscle tone (According to House) • Class I: The patient exhibits normal tone and placement of the muscles of mastication and facial expression. • Class II: The patient displays approximate normal function but slightly impaired muscle tone. • Class III: The patient exhibits greatly impaired muscle tone and function. • . 66
  67. 67. Complexion  Skin colour also indicates the presence of underlying systemic diseases: – Pallor may indicate anaemia – Ruddy complexion: sign of polycythemia or neoplasm. – Bronzed skin occurs in Addison’s disease. – Lemon-yellow complexion of jaundice 67
  68. 68. Lip  Lips are examined in relation to  Lip support  Lip mobility  Lip thickness  Lip length  Lip health 68
  69. 69.  Lip support  Lack of proper lip support - collapsed appearance and wrinkling.  A rolled-in vermilion border - inadequate lip support.  Adequately supported/unsupported 69
  70. 70. Lip health  Lips should be examined - cracking fissures at corners and ulceration.  Candidal infection, vitamin deficiency, incomplete or over closure, either due to existing dentures / edentulous, or neoplasm 70
  71. 71.  Lip thickness  A thin lip presents special problems as a slight change in labiolingual tooth position alters the lip fullness/ support.  A thick lip gives more freedom to the dentist in teeth setting 71
  72. 72. 72
  73. 73. 73
  74. 74.  Lip length Normal- 19-22mm Short- <18mm Long- >23mm 74
  75. 75. 75
  76. 76.  Lip mobility Class I-Normal Class II-reduced Class III-Paralysis 76
  77. 77. Temporomandibular joint:  Good prosthodontic treatment bears a direct relation to the temporomandibular articulation since occlusion is one of the most important parts of the treatment of complete dentures. 77
  78. 78. Patient presenting with one / more of the following symptoms are considered to be suffering from TMJ disorder. (1) Pain and tenderness in muscles of mastication and TMJ. (2) Sounds during condylar movements (3) Limitations of mandibular movements 78
  79. 79.  Examination 79
  80. 80.  Prosthetic considerations: - Unhealthy TMJ complicates jaw relation records. - Centric relation depends on structural and functional harmony of osseous structures, intra articular tissue and capsular ligaments. - Difficulty to give correct & repeatable centric relation. - Occlusal corrections often needed.  Patient educated 80
  81. 81. Speech : • Patients who are capable to articulate speech with existing dentures usually have no problems producing articulate speech with new dentures. • Speech is classified as : “normal” or “affected”. 81
  82. 82.  Sometimes speech aids in classification of a patient  -Rapid, jerky speech-hysterical patient  Forcefulness and abrupt speech,demanding- Exacting patients  Monotone ,lack of interest,absence of enthusiasm- Indifferent patients 82 JIADS 2010;1(2):15
  83. 83. Intraoral examination Oral mucosa:  Color of mucosa ranges from healthy pink to fiery red indicating:  inflammation,  ill-fitting denture,  infections,  systemic disease or  chronic smoking. 83
  84. 84.  Mucosa thickness: (Classification by House) 84
  85. 85.  Mucosa condition Class I: healthy Class II: irritated Class III: pathological 85
  86. 86. Arch size: (According to House)  The size of the maxilla and mandible ultimately will determine the amount of basal seat available for denture formation.  The greater the size, greater the support, larger the contact surface, greater the retention.  Also, arch size provides a quick estimate of the tooth size required. 86
  87. 87.  Class 1: Large ( best for retention and stability)  Class 2: Medium (good retention and stability but not ideal)  Class 3: Small (difficult to achieve good retention and stability) 87
  88. 88. Arch form (according to House)  Class 1: Square  Class 2: Tapered  Class 3: Ovoid 88
  89. 89.  The opposing arch may or may not have the same form.  If the arch form is not the same in both the arches some problems in tooth arrangement can be anticipated.  The arch form influences support of denture by offsetting rotational movement of denture base. 89
  90. 90. Ridge form(arch contour)  cross-sectional contour as a whole arch.  The ridge form affects the retention and stability.  Its height resists lateral displacement, and the parallelism of its sides maintains the seal for a considerable distance to resist vertical displacement 90
  91. 91. Maxillary ridge form is classified as: (According to House)  Class 1: U shaped  Class 2: V-shaped  Class 3: Flat residual ridge 91
  92. 92.  Mandibular ridge form Class 1: Inverted U shaped (parallel walls from medium to tall with broad crest) Class 2: Inverted U shaped (short with flat crest) Class 3: Unfavorable Inverted W Short inverted V Tall, thin inverted V Undercut 92
  93. 93. Atwood & Howels classification  Order I: pre-exraction  Order II: post extraction  Order III: high- well rounded  Order IV: knife- edged  Order V: low well rounded  Order VI: Depressed 93
  94. 94. Defects:  Ridge defects, such as exostoses, may pose problems for complete denture patients or may warrant pre-prosthetic surgery. 94
  95. 95. Hyperplastic tissue  Papillary hyperplasia 95
  96. 96.  Epulis fissuratum 96
  97. 97. Tori:  Benign bony enlargements  Found at midline of hard palate or on lingual aspect of mandible mostly in premolar region.  Small ones may be accommodated by relief of denture base.  Large enough to interfere with denture design are surgically removed. 97
  98. 98. 98
  99. 99.  Torus palatinus:  Ridge resorption can cause denture to settle over torus palatinus causing rocking of prosthesis and soreness.  A torus in midline of maxilla can be relieved but if it fills palate to occlusal level, or extends beyond vibrating line, it should be removed / reduced in size. 99
  100. 100.  Mandibular tori :  Occur just above floor of mouth.  Difficult to provide relief without breaking border seal of denture.  Surgical removal is necessary for successful denture construction 100
  101. 101.  Class I: Tori absent or minimal in size. Do not interfere with denture construction  Class II: Tori of moderate size. Pose mild difficulties in denture construction. Surgery not required.  Class III: Tori large, compromise the fabrication and function of dentures. Require surgical recontouring or removal. 101
  102. 102. Interarch Space  Space between the maxillary and the mandibular arches. Normally it should be 20mm.  Excessive amount of space due to resorption results in poor stability and retention.  Reduced interarch distance will make teeth setting and free way space maintenance difficult. 102
  103. 103. 103
  104. 104. Ridge parallelism: 104
  105. 105. Ridge relationship:  Laney Smith described ridge relationship as the antero-posterior position of the mandibular ridge relative to the maxillary residual ridge when the jaws are in centric relation and separated by the distance they will be separated by the prosthesis. 105
  106. 106. 106
  107. 107. Lateral throat form:  Ewell Niel defined lateral throat form as the contour of the hard lingual surfaces of the mandibular ridge in the molar area and the velum like tissue distal to the mylohyoid ridge in the retromylohoid fossa as it functions under the influence of tongue. 107
  108. 108.  Examination: With the index finger passively contacting the curved wall of mucosa in the retromolar fossa with the tongue at rest, patient is instructed to protrude the tongue. 108
  109. 109. Class I: 0.5 inch of space exists between mylohyoid ridge & floor of mouth. Class II: Less than 0.5 inch space exists Class III: Mylohyoid fold is at the same level as mylohyoid ridge. Retention of lower denture is difficult. 109
  110. 110. 110 KDJ - Vol.33, No. 1, January 2010 Lateral throat form- design of a measuring instrument Sadhvi K.V., Chandrasekharan Nair K., Jayakar Shetty
  111. 111. Palatal throat form (Classification according to House) 111
  112. 112. Milsap’s classification  Class I: it is horizontal & and makes 10o angle to the hard palate &most advantageous  Class II: soft palate makes a 45o angle to the hard palate  Class III: soft palate makes a 70o angle to the hard palate. Milsap C H “ The posterior palatal seal area for complete dentures” DCNA 1964; 1: 663-73. 112
  113. 113. 113
  114. 114. 114
  115. 115. Hard Palate:  U Shaped: It is most favorable for retention and lateral stability  V Shaped: It is less favorable for retention because slightest movement of denture base will cause the seal to be broken with a resultant loss of retention  Flat palatal vault: Is unfavorable. Usually accompanied by resorbed ridges 115
  116. 116. 116
  117. 117. Palatal sensitivity: (According to House) Gag reflex is a normal defense mechanism designed to prevent foreign bodies from entering the trachea.  Can be caused by (1) Systemic disorders (2) Psychological factors (3) Extra and intra oral physiologic factors (4) Iatrogenic factors.  Assessed by (1) oral examination (2) medical history 117
  118. 118. Class I: normal Class II: subnormal (hyposensitive) Class III: supernormal (hypersensitive) 118
  119. 119. Border attachments: (According to House) Class I: attachments are high in maxilla or low in mandible with relation to ridge crest (0.5 inches or more between the level of attachment and the crest of the ridge). Class II: attachment height in relation to the crest of the ridge is between 0.25 and 0.5 inches. Class III: attachment height is less than 0.25 inches from the ridge crest. 119
  120. 120. 120
  121. 121. Frenum attachments:(Classification according to House) Class I: High in the maxilla or low in the mandible with respect to the crest of the ridge Class II: Medium Class III: Freni encroach on the crest of the ridge may interfere with the denture seal. Surgical correction may be required 121
  122. 122. 122
  123. 123. Saliva:  Amount and Consistency of saliva affects denture construction and retention.  Saliva consistency:  thin, serous or  thick ropy.  Quantity  Dry mouth-increased potential for soreness  Excessive saliva -complicates denture construction, especially impression making123
  124. 124.  Saliva can be classified as: (House) Class I: Normal quality and quantity of saliva. Cohesive and adhesive qualities of saliva are normal. Class II: Excessive; contains much mucus Class III: Xerostomia; remaining saliva is mucinous. 124
  125. 125. Tongue:  Tongue size: (Classification according to House) Class I: Normal in size, development and function. Class II: Teeth have been absent long enough to permit a change in the form and function of the tongue. Class III: Excessively large tongue. All teeth have been absent for an extended period of time- abnormal development of the size of the tongue. 125
  126. 126.  The large tongue completely - fills floor of mouth and - Covers alveolar ridges - Making of impression difficult - Denture stability difficult to attain because dentures move with movement of tongue  A small tongue on the other hand facilitates impression making but might jeopardize the lingual seal. 126
  127. 127.  Tongue position:  In 1949 Wright classified tongue position as follows:  Class I: Normal • The tongue fills the floor of the mouth and is confined by the mandibular teeth. • The lateral borders rest on the occlusal surfaces of the posterior teeth and the apex rests on the incisal edges of the anterior teeth. 127
  128. 128.  Class II: Retracted • The tongue is retracted. The floor of the mouth pulled downward is exposed back to the molar area. • The lateral borders are raised above the occlusal plane and the apex is pulled down into the floor of the mouth. 128
  129. 129.  Class III: Retracted • The tongue is very tense and pulled backward and upward. • The apex is pulled back into the body of the tongue and almost disappears. • The lateral borders rest above the mandibular occlusal plane. 129
  130. 130. DIAGNOSTIC AIDS 130
  131. 131. Pre-extraction records: • Pre-extraction photographs, radiographs, casts and facial measurements may prove helpful in denture therapy. • These adjuncts may be used to recreate anterior esthetics and facial support and aid in evaluation of vertical dimension of occlusion. 131
  132. 132. Radiographic examination  It is an essential part of diagnosis and treatment planning in patients seeking prosthodontic care.  Panoramic radiographs offer an advantage over periapical radiographs as they are: (1) Faster (2) Reduce patient exposure to radiation (3) Image the entire maxilla and mandible 132
  133. 133.  Interpretation of panoramic radiograph should follow a 5-step analysis as outlined by Chomenko:  Step I: Screening the jaw for  Defects in structure and reactive new bone formation  Bone enlargements / expansion  Displacement of jaw parts  Unerrupted teeth / retained root fragments  Foreign bodies  Radiolucencies and radiopacities, rarefaction or sclerosis  Well-defined or ill-defined lesions 133
  134. 134. Step 2: Appearance of lesion, physical bony changes including location, size, shape, number and radiographic pattern is elaborated. Step 3: Radiographic findings correlated with clinical, historical and lab findings. Step 4: Differential diagnosis is done. 134
  135. 135. Step 5: Rate of growth of lesion estimated - Slow growing shows sclerosis, expansion and displacement of adjacent structures. - Fast growing shows gross bone destruction and lack of proliferative response. 135
  136. 136.  Wical and Swoope described a useful system of classification. Class I: Mild resorption – Loss of 1/3 of original height Class II: moderate – loss of 1/3rd to 2/3rd of original height Class III: Severe – Loss of 2/3rd or more of original height 136 Wikal,Swoope C.C Studies of residual ridge resorption J Prosthet Dent 1974
  137. 137. PROGNOSIS 137
  138. 138.  Defined as the forecast as to the probable result of a disease or a course of therapy.  After all the intra oral and general physical and dental conditions have been recorded and radiographs, casts and other visual aids are at hand, they can be interpreted and diagnosis arrived at. 138
  139. 139. 139
  140. 140.  It is the process of matching possible treatment options with patient needs and systematically arranging the treatment in order of priority but in keeping with a logical or technically necessary sequence. 140
  141. 141. 141 Enables patient to Informed consent Treatment Time Fees Patient receives Delivered care Patient specific Enables dentist to Estimate Operating time Laboratory time Fees Dentist delivers Treatment plan Addresses patient’s needs Lists specific treatment Specifies logical sequence
  142. 142.  Adjunctive care – Elimination of infection – Elimination of pathology – Preprosthetic surgery – Tissue conditioning – Nutritional counseling  Prosthodontic care 142
  143. 143. 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 the commencement of treatment. 143
  144. 144. Elimination of pathology  Pathologies like cysts and tumors of the jaws should be removed or treated.  Some pathologies may involve the entire bone. In such cases, after surgery, an obturator may have to be placed along with the complete denture. 144
  145. 145. Pre-prosthetic surgery  Enhance the success of the denture.  Some of the common preprosthetic procedures are: Frenectomy, Excision of denture granulomas, Excision of flabby tissue, Reduction of enlarged tuberosity, Vestibuloplasty, Alveoloplasty, Alveolectomy etc. 145
  146. 146. TISSUE CONDITIONING  The patient should be requested to stop wearing the previous denture for at least 72 hours before commencing treatment.  Should be taught to massage the oral mucosa regularly.  Denture relining material should be applied on the tissue side of the denture to avoid denture irritation. 146
  147. 147. Nutritional counseling  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. 147
  148. 148. PROSTHODONTIC DIAGNOSTIC INDEX 148
  149. 149.  Developed by American college of prosthodontics.  4 diagnostic criteria – Mandibular bone height – Maxillomandibular relationship – Maxillary residual ridge morphology – Muscle attachments 149
  150. 150. Class I (ideal or minimally compromised)  Residual mandibular bone height of 21mm  Maxillomandibular relationship permitting normal tooth articulation and an ideal ridge relationship  Maxillary ridge morphology  Muscle attachments conducive 150
  151. 151. Class II (moderately compromised)  Residual mandibular height- 16-20mm  Maxillomandibular relationship- normal tooth articulation and appropriate ridge relationship  Maxillary residual ridge morphology  Muscle attachments that exert limited compromise 151
  152. 152. Class III (substantially compromised)  Residual mandibular height – 11-15mm.  Limited interarch space  Maxillary residual ridge morphology providing minimal resistance  Muscle attachment results in compromised denture stability and retention 152
  153. 153. Class IV ( severely compromised)  Residual mandibular height – 10mm or less  An angle class I ,II or III relation with compromised interarch space  Maxillary residual ridge morphology provides no resistance  Muscle attachment that significantly compromises denture base. 153
  154. 154. 154
  155. 155. 155
  156. 156. SUMMARY 156
  157. 157. REFERENCES 157
  158. 158. Text books 1. Zarb Bolender, “Prosthodontic Treatment for Edentulous Patients” ,2004,12 Ed,Mosby Inc 2. Winkler ,”Essentials of Complete Denture Prosthodontics” 1996,2nd Ed,AITBS Publishers. 3. Sharry , “Complete Denture Prosthodontics” ,1962,Mcgraw-Hill Book Company 4. Heartwell, “Syllabus of Complete Dentures”,1992,4th Ed,Varghese Publishing House. 158
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