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

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

• Rola M. Shadid, BDS, MSc

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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

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• 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

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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

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Recording General Information

1. Name
2. Race
3. Occupation
4. Address and telephone no.
5. Previous dentist

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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)

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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.

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

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• 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

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Chief Complaint Patient Expectations

• Patients 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

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Medical History

• Diabetes Mellitus
• Cardiovascular diseases
• Diseases of joints osteoarthritis
• Diseases of skin pemphigus ?
• Neurological disorders (Bells balsy and
  Parkinson)
• Sjogrens syndrome
• Transmissible diseases

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Radiation Therapy Vs. Dentures

• Consequences of Radiation therapy
• Preprosthetic surgery
• Wearing of previous denture
• Denture Fabrication

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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

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Current Medication

• Insulin
• Anticoagulants
• Antihypertensive dryness postural hypotension
• Corticosteroids dryness, confusion behavioral
  changes
• Antiparkinson agents like Norflex and Akineton
  dryness, confusion behavioral changes

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Dental History

• History of tooth loss cause, time
• Edentulous period

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Beware of Patients Who Have A Bag of Dentures
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Extraoral Examination

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

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Extraoral Examination

• Muscle tonus
• Neuromuscular coordination
• TMJ examination

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Classification of Frontal Face Forms (House,
Frush Fisher)
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Classification of Lateral Face Forms

• Normal
• Retrognathic
• prognathic

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Lips

• Length
• Thickness
• Mobility
• Smile line

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Lip (smile) line
High smile line
Normal smile line
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Intraoral Examination

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

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Cheeks

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

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Leukoplakia
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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.

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Tongue Size

• Normal
• Large

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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

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Tongue Position

• Normal normal size and function. Lateral
  borders rest at level of mandibular occlusal
  plane while dorsum is raised above it. Apex rests
  at or slightly below the incisal edges of
  mandibular anteriors

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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

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Tongue Mucosa

• The specialized mucosa covering the tongue is
  said to be a window on systemic diseases.

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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)

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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

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Maxillary Tuberosity

• If enlarged
• the posterior occlusal plane may be placed too
  low
• no enough space to set all molars

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Maxillary Tuberosity

• Palpate for undercuts - if extreme, denture might
  not seat

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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

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V-shaped hard palate
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Tori

• Palatal torus
• Mandibular tori

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Bony Prominences

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

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The Soft Palate (Palatal Throat Form)

• Houses 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.

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Palatal Throat Form
Maxilla
I
II
III
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Undercuts

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

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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

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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

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Residual Alveolar Ridge

• Arch form (Houses classification)

• Class I square
• Class II tapered (V-shaped), associated with
  high arched palate, less retention stability
• Class III ovoid (less common)

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Residual Alveolar Ridge (Cross Sectional Contour)

1. U shaped
2. V shaped
3. Knife edged
4. Flat
5. Inverted
6. Undercut

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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

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Anterior Arch Relationships
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Intraoral Examination

• Posterior arch relationships
• Interridge space
• Residual ridge size

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Saliva

• Consistency
• Thin serous provides an insufficient film
  for denture retention.
• Thick mucus thick ropy saliva tends to
  displace denture.
• Mixed
• Amount
• Normal ideal for denture retention
• Excessive make denture const. messy
• Reduced reduced retention and increased
  soreness salivary substitutes may be prescribed

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Drugs Causing Xerostomia

• Diuretics
• Antihistamines
• Atropine
• Anticholinergic
• Antihypertensive
• Antiparkinson (Norflex)
• Corticosteroids

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Examination of an Old Denture Wearer

• Esthetics, lip fullness, symmetry, amount of
  display during smiling, phonetics, teeth
  position, size, excessive wear
• Fracture, cracks, porosity, denture hygiene
• Occlusal vertical dimension (due to excessive
  occlusal wear, OVD may have reduced)

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Reduced vertical dimension
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Examination of an Old Denture Wearer

• Epulis fissuratum
• Angular cheilitis
• Papillary hyperplasia
• Flappy hyperplastic ridge
• Combination syndrome

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Epulis Fissuratum
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Inflammatory Papillary Hyperplasia
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Angular Cheilitis (Perleche)
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Combination (Kellys) Syndrome
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Radiographic Examination

• A routine radiographic exam. must be ordered to
  rule out any bony conditions that could affect
  the treatment
• Panomaric radiograph is usually ordered for
  denture cases

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Radiographic Examination

• Fractured roots or roots lying close to the
  surface should be removed if pt is fit for
  surgery deep seated retained teeth or root
  fragments may be left if they are asymptomatic
• Supplemental radiographs may be prescribed if
  required such as periapical, occlusal, and
  lateral cephalometric

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Panoramic Radiograph
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Additional Tests Medical Consultation

• Routine blood test, blood urine sugar levels
• Medical consultation
• Dental consultation

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Diagnosis

• A specific evaluation of existing conditions
• Involves thorough examination of all factors
  which are bound to affect the success of
  treatment
• This includes both systemic local factors the
  mental condition of the patient

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Treatment Plan

• The sequence of procedures planned for the
  treatment of a patient following diagnosis
• Explained to the patient in a simple and
  straightforward manner including all of the
  factors that might complicate the treatment

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Alternate Treatment Plan

• May be less than ideal but is often necessary for
  various reasons

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Refusal of Treatment

• The patients demand may be unreasonable or
  against professional judgment or ethics so may
  refuse treatment or refer him (bag of dentures)

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Prognosis

• A forecast to the probable result of a disease or
  a course of therapy
• After considering all the factors, you should be
  able to predict the degree of success that can
  be expected the patient should know of what
  can and cannot be achieved.

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Fees Signed Consent

• When patient agreed on treatment including fees ,
  he must sign a written consent to prevent later
  misunderstanding

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Prescription, Nutritional Supplements, Tissue
Conditioning

• Assess if nutritional deficiency
• Recommend finger massage of oral tissues
• If old denture wearer, tissue conditioner placed
  to condition abused soft tissue
• Instruct patient to discontinue wearing denture
  48 hrs prior making final impression

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• A good clinician is one who is able to
  diagnose potential problems during the initial
  examination suggest the best possible treatment
  plan compatible with the age, physical, mental
  financial status of the patient

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Any Question
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• References
• Complete Denture Prosthodontics, 1st Edition,
  2006 by John Joy Manappallil, Chapter 2.
• Zarb. Prosthodontic Treatment for Edentulous
  Patients, 12th edition. Chapter 7.