Transcript Diagnosis and Treatment Planning of Complete Denture [PPT]

DIAGNOSIS AND TREATMENT
PLANNING OF COMPLETE DENTURE
Presented by:
Dr.Kamleshwar singh
Assist. Prof.
Deptt. Of Prosthodontics
Gpt—(5)
• Diagnosis is defind as determination of nature of disease.
• Treatment planning is defind as the sequence of procedures
planned for the treatment of a patient after diagnosis
Boucher –
•diagnosis consists of planned observation to determine & evaluate the
existing conditions, which lead to decision making based on the
condition observed.
•Treatment plans should be developed to best serve the needs of each
individual patient.
→
Dr Carl Boucher said that:"The 1st 5 minutes spent with a pt. represent the most important period of dentist-patient
interaction. Pt. should feel that dentist is really interested in him& in help to solve dental
problems".
→ Dr M. M. Devan Said that:-
"We should meet the mind of the pt. before we
meet the mouth of
the pt."
Diagnostic Procedues
To make the correct decisions, certain steps should be followed
in an orderly sequence, and this is preferable done in two
appointments.
The first appointment
To establish the rapport …
allow the dentist and the patient to become acquainted with each other
and allow the dentist to obtain essential information from the patient.
This information consists of a thorough history, a radiographic
survey, and diagnostic casts.
The Second Appointment
After through consideration of the diagnostic information, the
dentist discuses the proposed treatment with the patient at the second
appointment, along with the sequence in which this treatment will be
carried out and the anticipated fee for service.
Mental attitude of the patient
One of the most important factors in the diagnosis of prosthodontic
patients is their mental attitude. This is not a mechanical or biological
problem. It requires understanding of people and the ways in which
they may react to situations. Dentists can use their training in
psychology to detect patients' attitudes and reactions during
diagnostic appointments.
They can then modify their own attitudes and reactions so that
mutual confidence can be established.
Personality Types
A patient's satisfaction is strongly related to his personality and to
his relationship with the dentist.
Dr. M. M. House classified patients' psychology into four types:
Class I: Philosophical
Philosophical patients anticipate the need for treatment with
dentures and are willing to rely on the dentist's advice for diagnosis
and treatment.
These patients will follow the dentist's advice when advised to replace
their dentures.
Class II: Exacting
Exacting patients are usually in poor health and need a great deal of
treatment, but they are unwilling to accommodate suggestions from
the dentist to extract hopeless teeth and become denture wearers.
Exacting patients also doubt the dentist's ability to make dentures
that would satisfy their esthetic and functional needs. Often, the
exacting patient demands extraordinary efforts and guarantees of
treatment outcome at no additional cost.
Class III: Hysterical
Hysterical patients are neglectful of their oral health, dentophobic
and unwilling to try to adapt to wearing dentures.
Although these patients may try to wear dentures, they often fail to
use the prosthesis because they expect it to look and function like
natural teeth.
Class IV: Indifferent
Indifferent patients tend not to care about their self-image and are
not motivated to enjoy eating.
They have managed to survive without wearing dentures.
Why The House Classification Requires Reevaluation?
Terminology Is Antiquated, Falling Out Of Use, No Longer
Carries The Same Meaning Within Psychiatry.
The Classification Pertains To The Patients In Isolation.
Ideal
A patient who accepts whatever treatment is
given to him by the dentist but after his query
has been answered. he is engaged in his treatment
and trusts the dentist
Submitter
A patient who submits to what the dentist says
without any questions asked.
Reluctant
A patient who feels that no person can help him
and reluctantly follows instructions.
Indifferent
A patient who is not engaged in
the treatment and does not follow
the dentist’s instructions.
Resistant
A patient who challenges the
dentist and feels that the dentist
is incompetent and will cheat him.
The Doctor's Behavior
• A warm relationship should be generated at the greeting before the
initial interview starts. This is accomplished by empathetic,
nonverbal and verbal communications, a skill some doctors have
intuitively while others have to acquire them over time.
2. The manner in which the patient opens his month is an indication of
his attitude towards dental treatment
Left: The show-off Center: The
cooperative patient.
Right: The uninterested and
uncooperative patient
GENERAL INTRODUCTION OF THE PATIENT AND EVALUATION
• Name -patient identification, for addressing.
• Sex: patient expectations in the denture differ with sex. Female
patient are more concern with the esthetics and male patient are
more concern with comfort and mastication.
• Address
• Age -the age of the patient has a definite bearing on diagnosis
for complete dentures
• Occupation
These information may also indicate the socioeconomic level of
that patient.
1.Public speakers and singers require not only perfect retention but
also particular attention to palatal shape and thickness because of
the importance of these in phonation.
2.Wind instrument players often require a special modification of
the shape and position of the anterior teeth.
Patient Chief Complaint
• By This The Dentist Should Know ,What The Patient Really Wants
,And Whether The Patient,s Goals Are Realistic.
• What Problems They Had With Old Dentures Regarding –
Speech
Mastication
Comfort
Aesthetics
With This Information The Dentist Will Come To Know Which Part Of
The Procedure Will Be Most Clinical.
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Dental history
• Cause Of Loss Of Teeth: Due To –
Periodontal Disease
Dental Caries
Any Other
• Period Of Edentulous
•Sequence Of Loss Of Teeth
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Medical Status of the Patient-
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Diabetes Mellitus
Oral complications.
The oral complications of uncontrolled diabetes mellitus may include:
•Xerostomia, (reduced salivary output which significantly reduces the ability of a patient
to wear a prosthesis with comfort..)
•Infection,
•Poor healing,
•Increased incidence and severity of periodontal disease
•Burning mouth syndrome.
•Diabetic neuropathy may lead to
oral symptoms of tingling,
numbness, burning, or pain
in the oral region.
•Residual alv bone resorption
•Osteoporosis.
•May also present with Macroglossia and
the tongue may appear red and sore,
Diabetes Mellitus
Diabetes Mellitus
Food intake and appointment scheduling. To preventing insulin shock from
occurring:
•Verify that the patient has taken medication as usual.
•Verify that the patient has had adequate intake of food.
•Schedule appointments in the morning, since this is a time of high glucose and
low-insulin activity. Afternoon appointments are a time of low-glucose and
high-insulin activity which may predispose the patient to a hypoglycemic
reaction.
Diabetes Mellitus
•Instruct patients to tell the dentist if at any time during the
appointment they feel symptoms of an insulin reaction occurring.
•A source of sugar, such as orange juice, must be available in the
dental office should the symptoms of an insulin reaction occur.
Thyroid diseases
Thyroid diseases
Cardiovascular System
Myocardial infarction:
Pt with h/o MI avoid treatment for 6 mts.
Physician consultation & reassurance of pt to reduce anxiety.
Infective bacterial endocarditis:
Pt with artificial heart valves, valvular heart disease prone to
develop.
Prophylactic Ab therapy prior to surgical procedures.
Blood Dyscrasias
Anaemia:
Types of Anaemia:
Iron def. Anaemia:
increased loss of iron, increased physiological
requirement,malabsorbtion of iron as in hypochlorhydria.
Oral Manifestations:
•atrophic mucous membrane,
•loss of normal keratinization.
Megaloblastic anaemia:
deficiency of vit B-12 & folic acid.
Oral Manifestations:
angular chelitis
Pernicious anaemia:
It is autoimmune disorder.atrophic gastric mucosa with loss of
parietal cells ,decreased vitB-12 absorption
Oral manifestations
Bald tongue atrophy of papilla
Glossitis
Burning sensation in the mouth.
Infectious Diseases
Bacterial, Viral,Fungal
Tuberculosis
Syphilis
Herpes simplex
Hepatitis A&B
Infectious mononucleosis
HIV
Candidiasis
Precautions:
Prevent cross contamination
Self precaution &protection of assistant
Disposable instruments
Disinfections of impression
Diseases Of Bone & Joints
Osteoarthritis:
Affects elderly above 45 yrs of age M:F ratio 2:1(age related
degenerative joint disease less frequently affects TMJ),weight
bearing joints
Characterized by deteriorations of articular cartilage remodeling
of underlying bone.
C/f:-pain & crepitation during mandibular
-restricted movements
-muscles of mastication tender.
-Advanced stage shows disability & atrophy of associated muscles.
Difficulty in wearing and cleaning of denture.
Impression making, jaw relation recording difficult.
Frequent occlusal corrections should be made.
Rheumatoid Arthritis
Inflammatory disease affecting joints.
C/f –Affects small joints of hands,feet symmetrically first
followed by wrists, elbows, ankles,knees.
TMJ-pain ,crepitations, limited movements, stiffness,
anterior open bite, vertical facial height increased.
C/f— chronic disease,pt above 40 yr & older age group-bone pain
,head ache, deafness compression of cochlear n, blindness
involvement of optic n, dizziness , facial paralysis, weakness &
mental disturbance.
O/m-maxilla>mandible 2.3:1.
- -maxilla progressive enlargement, alv ridge widened, palate
flattened.
Ed pt c/o inability to wear dentures.
Paget’s Disease(osteitis deformans)
This relatively rare disease occurs in patients beyond the 4th decade of
life and is recognized by its characteristic clinical and
roentgenographic manifestations.
It is called as a bone maintenance disorder because of the almost
simultaneous occurrence of a pronounced resorptive process and
accelerated formation of new bone.
Maxilla is more commonly involved. (enlargement of tuberosities)
Subsequent prosthodontic treatment is complicated by limited space
for the completed prosthesis and by difficulties in tray
fabrication,impression making,development of occlusal
schemes,esthetics,and maintenance of dentures.
Frequent recall program
Acromegaly
• In the acromegalic
patients,continued endochondral
growth lengthens the mandibular
ramus,alveolar bone apposition
increases the VDO ,tongue
enlarges.
• Frequent exams to evaluate fit and
function of removable prosthesis
Central Nervous System
Emotional disturbances:
Mild anxiety to anxiety neurosis, depression, phobias,
disoriented.
Patient motivation & reassurance.
Require longer appointments
Epilepsy
• Removable dentures may be
contraindicated if they are small and
seizures are frequent and severe:
choking
• If patient takes phenytoin (common
drug to take), make sure that CD
does not irritate gingival tissues.
Bell`s palsy
Facial .n palsy because of cold, trauma, injection of L.A drugs,
nerve impingement ,injury of the n during the parotid gl surgery.
C/f :-unilat eral facial paralysis.
-Mask like face, drooping of mouth corner.
-inability to close eyes.
-loss of forehead wrinkles .
Difficulty in making impression .
Difficulty in eating & speech.
To avoid cheek biting over contouring denture base on the affected
side. Excessive horizontal overlap in posteriors.
Parkinson`s disease
It is a degenerating disease affecting basal ganglia,
decreased dopaminergic output so inhibitory action on
sub thalamic nucleus decreased.
C/f –expressionless face with staring look
-soft rapid speech, fixed posture, impaired balance, altered
gait, muscle rigidity, impaired fine movements, tremors in
mandible, tongue,fingers, hands.
Difficulty in making impression , jaw relation recording
Pt should be educated about the difficulty in eating,speech
&retaining mandibular denture.
Trigeminal neuralgia
Disease involving the ns supplying the face,teeth,jaws
&associated structures.
C/f –searing,stabbing ,lancinating type of pain initiated on
touching trigger zone.
In such pts prosthodontic
treatment becomes difficult.
Pts should be first treated for
Trigeminal neuralgia then continued
with prosthodontic treatment
Diseases Of Skin With Oral Manifestations
Lichen planus/feldman’s syndrome
O.m:white or grey velvety thread like papules in a leniar,annular,
retiform arrangement forming typical lacy,reticular patches, rings
, streakes over the buccal mucosa, lesser extent on tongue
&palate,lips,floor of the mouth(Wickham’ s striae)
Erosive (premalignant), vesicular or bullous forms also causes
burning sensation
Pemphigus:
Auto immune disease
Intercellular antibodies in epithelium of skin,oral mucosa.
Serious chr disease appearance of vesicles, bullae,& blisters.
Oral manifestations:
Isolated vesiculo bullos lesions ruptures to leave ulcers
Oral lesions with rugged borders covered by white blood tinged
exudate follows by crusting
Severe pain,burning sensation. Inability to eat
Sjögren syndrome
Sjögren syndrome is the second most common autoimmune disease, affecting as
many as 3% of women aged 50 years or older.
The sex predilection is profound: approximately 90% of patients are female.
Oral changes in Sjögren syndrome include
•difficulty in swallowing and eating,
•disturbances in taste and speech,
• and a predisposition to infection, all due to a decrease in saliva.
These changes are nonspecific for Sjögren syndrome because they may occur in
any condition associated with diminished saliva production.
Gastrointestinal Diseases
The oral cavity is the portal of entry to the GI tract.
Lined by stratified squamous epithelium, the tissues of the mouth are often
involved when individuals have conditions affecting the GI system.
The peak incidence is in the second and third decades of life, with a second peak
occurring in the sixth and seventh decades.
Crohn disease
Gastrointestinal Diseases
Crohn disease is an idiopathic disorder that can involve the entire GI tract
with transmural inflammation, noncaseating granulomas, and fissures.
Orofacial symptoms of Crohn disease include
(1) diffuse labial, gingival, or mucosal swelling;
(2) cobblestoning of the buccal mucosa and gingiva;
(3) aphthous ulcers;
(4) mucosal tags; and
(5) angular cheilitis.
Noncaseating granulomas are characteristic of orofacial Crohn disease
Ulcerative colitis
Ulcerative colitis is an inflammatory condition with some
similarities to Crohn disease.
However, it is restricted to the colon and is limited to the mucosa and
submucosa, sparing the muscularis.
Aphthous ulcers or angular stomatitis occurs in as many as 5-10% of
patients.
Drug History
Indicate systemic disease,adverse reaction affecting oral
conditions.
Drugs- antihistamines,antihypertensive,
antiparkinson`s,antidepressants, atropine cause xerostomia.
Sialorrhoea-- cholinesterase,epinephrine,sialogouges.
Orthostatic hypertension—
antihypertensives,antidepressants,centrally acting skeletal muscle
relaxants.
Drug induced Parkinson like syndrome by tricyclic
antidepressants,phenothiazine.
Hypoglycemic shock-Insulin.
Behavioral changes &confusion-antidepressants,corticosteroids,
antiparkinson`s, antihistaminic,digitalis.
Clinical
Examination
Clinical Examination...
• Extra Oral Examination
• Intra Oral Examination
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EXTRA ORAL
EXAMINATION
Facial
Examination
Facial form
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Facial form
• This is a useful aid in tooth selection.
• According to Ritchie Gm And
Mavroskoufis F( Jpd 1980) The face
–form as a guide for the selection of
maxillary central incisors and should be
harmony between facial size , form and
shape .
Facial form
Identification of facial form
may be impaired in the
edentulous patient due to
inadequate soft tissue support
and loss of vertical dimension of
occlusion. For this reason,
determination of facial shape
should occur only when the
occlusion rims are in the mouth
and the appropriate vertical
dimension and the patient is in
centric relation.
•Square
•Ovoid
•Tapering
•Square tapering.
Facial profile
and
contour of features
Facial profile and contour of features
Facial Profile: 3 Types –Acc to angle –
Class I-Straight profile
Class II-Receding mandible(Convex
profile)
Class III-Concave profile(Prognathic )
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Facial profile and contour of features
• The patient’s profile is an early indicator of of the patient’s jaw
classification .
• A receding chin and convex profile mean that the upper jaw is
larger than the lower ,and occlusion will have a class II
disharmony in centric relation .
• If the chin is prominent ,the
profile will be concave , and the
occlusion will have a characteristic
class III disharmony.
Lip Examination
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Lip Length
• The length of the lip will affect how much tooth will be exposed
,with a short lip any expression on the part of the patient will
expose most of the tooth and even part of the denture base .
• So special attention and care must be given to the color and form
of the denture base
Long—hides denture & most of tooth
Medium
Short---teeth& denture base exposed.
Lip Length
LONG LIP
SHORT LIP
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Lip Fullness
• It is directly related to the support it gets from the mucosa or
denture base.Denture with an accessible thick labelled flange
could make the lip to be too full.
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Lip mobility
Normal
Limited
Paralysis
Neuromuscular Evaluation
Neuromuscular Evaluation
Neuromuscular co-ordination-
Excellent
-fair
-poor
Poor neuromuscular co-ordination affects impression recording &
jaw relation recording. Advise for tongue & mouth exercises.
Jaw movements.
Speech Evaluation- affected
- normal
Intraoral examination
Intraoral examination
• An overview of the oral mucosa should be obtained before a specific
examination of the denture bearing area .
• The dentist should be looking for abnormalities or pathological
lesions .
• The tongue is pulled forward to expose the lateral borders.At the
same time anterior and posterior tonsillar pillar area should be
examined
Oral mucous membrane
Examined for inflammatory lesions , pathological lesions like
precancerous lesions ,oral malignancies ,papillary hyperplasia
,epulis fissuratum,ulcers.
o The color of the mucosa may range from a healthy pink to an angry
red.
o The redness is indicative of inflammation and can be related to illfitting denture , underlying infection, a systemic disease such as
diabetes or chronic smoking .It is important to determine the cause
and remove the irritant becoz successful impression making is not
possible until the inflammation is undercontrolled.
Arch size
o The size of the maxilla and mandible determines the ultimate
support available for complete dentures. Large jaws provides more
support than small jaws.
Large MediumSmall-
ideal
good
poor
Maxillary may be larger than mandibular or reverse because of the
resorption pattern, disturbance in growth & development,genetic
factor.
Arch form
• The arch may be square,ovoid or tapered .
• The form of the ridge will influence the support of the denture
and arrangement of the tooth.
Ridge contour
The ideal ridge is a high ridge with a flat crest and parallel side. This
type of ridge will give a maximum amount of support and stability (
horizontal resistance to movement )
o Knife edge ridges or ridges with multiple spicules offer the
poorest prognosis because they are incapable of withstanding much
occlusal force and can easily become sore .
o Relief has to be provided for this in impression procedure.
High well rounded
Ridge can be classified as.
Low well rounded
Knife edge.
Flat ridge.
Ridge Parallelism
Refers to relative parallelism between planes of the ridge.
Class I-Both ridges are parallel to occlusal plane.
Class II-Mandibular plane diverts from the occlusal plane
anteriorly.
Class III-Either the maxillary ridge diverts from
occlusalplane anterioly or both ridges divert.
Inter Arch Space
– Normally 16-20mm adequate for
the accommodation of artificial
teeth.
– Excessive inter arch space –
increased resorption. -Poor
stability.
Inter Arch Space
– Inadequate space
Localized
O/m:mucosa thin ,pale due to loss of vascularity and elasticity.
Tongue stiff board like, restricted movements.
Lips thin rigid partially fixed
Decrease in mouth opening
Distortion of buccal and labial vestibules
Difficulty in impression making & jaw relation recording
Post insertion probs: soreness, ulceration require constant adjustments
& even remaking
Hard palate
o U shaped palatal vault is most favorable for retention and lateral
stability .
o V shaped palatal vault is less favorable for retention .The
slightest movement of the denture base will cause the seal to be
broken with a resultant loss of retention
o A flat palatal vault is also unfavorable
.As it is usually associated with
resorbed ridges and there is poor
resistance to lateral forces.
Soft palate
The classification is given by M M HOUSE according to the
angle that it makes with hard palate and and the width of the
palatal seal area.
Class I rather horizontal and is most favorable
becoz it allows for more tissue coverage for
palatal seal .
Class II is turn downward at about a 45 *
angle to the hard palate and the amount of
palatal tissue coverage is less than class I
Class III turn downward sharply at
about a 70* angle just posterior to
hard palate.
Lateral throat form (Retromylohyoid space)
• NEIL classified the lateral throat form according to the extent
of anterior movement of the retromylohyoid curtain as the tongue is
extended anteriorly beyond the vermillion border of the lower lip .
ClassI-Deep
ClassII-Moderate
ClassIII-Shallow
Tongue size:
House classified.—
ClassI-Normal ,development ,function.
ClassII-Change in form & function.
ClassIII-Excessively large.
Tongue size can be --Hypertrophic.
Atrophic.
Normal.
Radiographic examination
o It is an essential part of diagnosis and treatment planning for
for all dental patients .
o Panoramic radiographs are faster ,reduce patient exposure to
radiation,and image the entire maxilla and mandible .this is a
distinct advantage when screening the edentulous jaws for
pathology or determining the amount of ridge resorption .
o The screening should also include any unerupted tooth, retained
root fragment ,radiolucencies, radioopacities or any well defined
or ill defined lesion.
Treatment Plan
Addresses patient’s
needs
Informed consent
Lists specific treatment
Specifies logical
sequence
-- Treatment
Enables patient to give
-- Time
-- Fees
Patient receives
Enables dentist to
Delivered Care
Estimate
•Operating Time
•Laboratory time
•Calendar time
•Fees
Dentist delivers
-- Patient specific
Patient Education
Purposes
•Apprise the patient of their dental health & its significance
•Give the patient understanding of significance of edentualism
•Harmonize the patients expectation with reality of treatment
potential
•Identify alternative treatment & their consequence
Will help patient understand
Should facilitate
•Acceptance of treatment
•Acceptance of fees
•Continuing care
•Diagnostic procedures
•Diagnostic results
•Treatment plan
•Treatment to be provided
•Use of prosthesis
•Continuing care
•Fees
Conclusion
Diagnosis and Rx planning form the first important milestone
for the successful accomplishment of the Rx &favorable
prognosis as the potential problems are identified & treatment
plan is framed accordingly.
Q1-Hysterical patients defined as a patient which
a. Are neglectful of their oral health, dentophobic and unwilling to try
to adapt to wearing dentures.
b.Are usually in poor health and need a great deal of treatment, but
they are unwilling to accommodate suggestions from the dentist to
extract hopeless teeth and become denture wearers.
c. Are anticipate the need for treatment with dentures and are willing
to rely on the dentist's advice for diagnosis and treatment.
d. Are not to care about their self-image and are not motivated to
enjoy eating and they have managed to survive without wearing
dentures
Q2.According to Winkler “Tolbuds” defined as a
trait
a. Patients who could tolerate prosthesis
backwards, upside down or sideways.
b. Patients who could tolerate prosthesis with
some degree of adjustment
c. Patients who could tolerate nothing.
d. none
• 3. Submitter patient defined as a
• a. A patient who accepts whatever treatment is
given to him by the dentist but after his query
has been answered.
• b. A patient who submits to what the dentist
says without any questions asked
• c. A patient who feels that no person can help
him and reluctantly follows instructions.
• d. A patient who challenges the dentist and feels
that the dentist is incompetent and will cheat
him
•
•
•
•
•
4. Hypothyroidism lead to
a. Anorexia and wasting
b. Atrial fibrillation and
c. Congestive heart failure.
d. Macroglossia
•
•
•
•
•
5. Perleche(angular cheilosis) caused by
a.bacteria
b.virus
c.fungus
d.parasite
•
•
•
•
•
6. Amyloidosis caused by disturbance in
a. protein metabolism
b. carbohydrate metabolism
c. fat metabolism
d. lipid metabolism
7. According to The American College of Prosthodontists
(Mcgarry Etal J Of Prosthodontics 1999) class 1 bone
height described as
• a. Residual bone height of 21mm or greater measured
at the least vertical height of the mandible
• b. Residual bone height of 16 to 20 mm measured at
the least vertical height of the mandible
• c. Residual alveolar bone height of 11 to 15 mm
measured at the least vertical height of the mandible
• d. Residual vertical bone height of 10 mm or less
measured at the least vertical height of the mandible
8. According to M.M. HOUSE (JPD 1958) the class
1 salivary flow and consistency can be classified
as –
• a. Is an abundance of semiviscid, ropy, saliva.
• b. Is normal in quantity and quality. The
cohesive and adhesive qualities of saliva are
ideal as a sealing medium.
• c. Is excessive in amount and contains much
mucous .
• d.none
9. Normally adequate space for the accommodation
of artificial teeth.
•
•
•
•
A.16-20mm
B.10-14 mm
C 18-22 mm
D 22-26 mm
10.according to Wical & Swoope Class1. Ridge
resorption is
• a. is a loss of upto 1/3 rd of original vertical
height
• b. loss of 1/3 rd to 2/3/ rd of vertical height
• c. loss of 2/3rd or more of the vertical height
• d. loss of 3/4th or more of the vertical height
Thank you