DIAGNOSIS & TREATMENT DIAGNOSIS & TREATMENT PLANNING OF PLANNING OF

EDENTULOUS PATIENTSEDENTULOUS PATIENTS

Dr Saransh MalotDept of Prosthodontics

CONTENTS:CONTENTS:• IntroductionIntroduction• DefinitionDefinition• General introduction to the patientGeneral introduction to the patient• Principles of perception & Diagnostic procedurePrinciples of perception & Diagnostic procedure• House classification House classification • Observation of the patientObservation of the patient• Health historyHealth history• Clinical & radiographic examinationClinical & radiographic examination• Pretreatment recordsPretreatment records• Treatment planningTreatment planning• ConclusionConclusion• BibliographyBibliography

INTRODUCTION:INTRODUCTION:

• Successful complete denture therapy:

Thorough assessment of patients physical and psychological condition.

Determining a treatment plan that will satisfy patient’s expectations.

Above all, treating the patient instead of just constructing complete dentures for them.

DEFINITIONS:DEFINITIONS:

• According to HEART WELL

Diagnosis is

The act or process of deciding the nature of the diseased condition by examination

A careful investigation of facts to determine the nature of a thing

The determination of the nature, location and causes of a disease.

• According to BOUCHER Diagnosis consists of planned observations to determine

and evaluate the existing conditions, which lead to decision making based on the conditions observed.

• In short, DIAGNOSIS can be summarized as:

Recognizing the problem

Formulating the plan

Carrying out the necessary examination

Finally, interpreting the result.

GENERAL INTRODUCTION GENERAL INTRODUCTION TO THE PATIENT:TO THE PATIENT:

• First appointment most important time

Fact finding

Development of mutual trust & understanding

• Familiar with the overall condition of the patient.

• New patients + patients with previous experience complete history taking & thorough examinations in which perceptive abilities of the dentist play an important role.

PRINCIPLES OFPRINCIPLES OF PERCEPTION: PERCEPTION:

• Detection: noticing something• Discrimination: Distinguish that which we have noticed

from something else.• Recognition • Identification• Judgement

DIAGNOSTIC DIAGNOSTIC PROCEDURESPROCEDURES

Preferably carried out in two appointments:

THE FIRST APPOINTMENT:

Acquainted with the patient

Beginning of evaluation of the process involved in diagnosis & treatment plan

Obtain essential information from the patient:

•Radiographic survey •Diagnostic casts

•Thorough history

A thorough history should include:A thorough history should include:

• Personal Data:Personal Data: Name SSN Age Sex Race Occupation Cosmetic index: Class I- High cosmetic index

Class II- Low cosmetic index Personality

• Medical HistoryMedical History General health Pathology

Denture HistoryDenture History Chief complaint Expectation Edentulism Existing or current dentures Pre extraction records

• Clinical EvaluationClinical Evaluation

Square Squaretapering

Tapering Ovoid

Facial form according to House & Loop

Facial profile according to Angle

Class INormal

Class IIIPrognathic

Class IIRetrognathic

Muscle tone according to Muscle tone according to House House Class I : Normal muscle toneClass II: Slightly impaired muscle toneClass III: Greatly impaired muscle tone

Muscle Development according to Muscle Development according to HouseHouseClass I: HeavyClass II: MediumClass III: Light

ComplexionComplexionHair Eye Skin

Lip ExaminationLip Examination

Cracking, fissuring at corner & ulceration: indicative of vitamin B-complex deficiency, candida infection, overclosure of existing denture or neoplasm.

Lip support

Lip thickness

Lip length

Temporomandibular JointTemporomandibular Joint

Clicking, crepitationsPain & tenderness on palpation Temporomandibular arthralgiaImpaired mandibular mobilityIrregularity or deviation on opening & closing of mandibleLocking of mandible.

Neuromuscular EvaluationNeuromuscular Evaluation

Class I: Excellent

Class II: fair

Class III: poor

Arch SizeArch Size

Class I: Large

Class II: Medium

Class III: Small

Determines the amount of basal seat available for denture foundation.

Greater the size, more the support

Greater the contact surface, greater the retention.

Discrepancy in size of the maxilla and mandible can present a problem of stability in the smaller arch.

Arch FormArch Form

Class ISquare

Class IITapering

Class III Ovoid

Ridge Form:Ridge Form:

Class I

Class II

ClassIII

Square

V-shaped

Flat Short Inverted

Flat

Inverted U-shaped

InvertedW

Tall Inverted

Maxillary Mandibular

Inter ridge spaceInter ridge space

Excessive inter ridge space: poor stability and retention because of increased leverage.

Small inter ridge distance: difficulty in setting teeth and maintaining proper freeway space.

Ideal

Insufficient

Excessive

Ridge relationship according to Ridge relationship according to AngleAngle

Parallel Divergent Mandibular

Divergent Maxillary & Mandibular

Ridge Contour:Ridge Contour:

Type I:Type I: High, well rounded bone profileHigh, well rounded bone profile +ve resistance+ve resistance

Type II:Type II: Narrow, knife edge ridgeNarrow, knife edge ridge -ve resistance-ve resistance

Type III:Type III: Rounded but lowered residual ridgeRounded but lowered residual ridge -ve resistance-ve resistance

Type IV:Type IV: Terminal stageTerminal stage -ve resistance-ve resistance

Most ideal is a high ridge with a flat crest and parallel or nearly parallel sides maximum support & stability.

Knife edge ridges or ridges with multiple bony spicules offer the poorest prognosis incapable of with standing much occlusal force.

Best determined by careful palpation.

Class IClass I

Class IIClass II

Class IIIClass III

Lateral Throat Form [mandibular]:Lateral Throat Form [mandibular]: NeilNeil

Palatal sensitivity according toPalatal sensitivity according to House House

Class I: NormalClass I: Normal

Class II: HyposensitiveClass II: Hyposensitive

Class III: Hypersensitive Class III: Hypersensitive

Mucosal Thickness according toMucosal Thickness according to HouseHouse

Class I: Normal uniform density Class I: Normal uniform density (1 mm)(1 mm)

Class II: Thin investing membraneClass II: Thin investing membrane

Class III: Thick investing membraneClass III: Thick investing membrane

Mucosa condition according to Mucosa condition according to HouseHouse

Class I: Healthy

Class II: Irritated

Class III: Pathologic

SalivaSaliva

Class I: Normal

Class II: Excessive

Class III: Xerostomia

Deficient saliva: retention of denture will be affected.

Excess of saliva: complicates impression making.

Thin serous saliva is the best to work with.

Thick saliva makes dentures more difficult to wear.

Colour of Mucosa:Colour of Mucosa:

Ranges healthy pink to angry red.

Redness indicative of inflammation: related to ill fitting denture, underlying infection, systemic disease or chronic smoking.

Pigmented spots or lesions.

White patches keratotic areas caused by denture irritation.

Tongue:Tongue:

If patient has been without teeth for a long time: tongue becomes enlarged & powerful. This will create a problem in impression making & may contribute to denture instability.

A small tongue: may jeopardize lingual seal.

Tongue position is very important to the prognosis of the mandibular denture.

Wright classified tongue positions as follows:Wright classified tongue positions as follows:

Class I: Tongue lies in the floor of the mouth with the tip forward & slightly below the incisal edges of mandibular anterior teeth. Most favourable prognosis.

Class II: Tongue is flattened and broadened but the tip is in the normal position.

Class III: Tongue is retracted & depressed into the floor of the mouth with the tip curled upward, downward or assimilated into the body of the tongue. Least favourable prognosis.

Hard palate:Hard palate:

U-shaped palatal vault; most favourable for retention & lateral stability.

V-shaped vault: less favourable for retention.

Flat palatal vault: also unfavourable.

Soft Palate:Soft Palate:

Classified according to configurations based on the degree of flexure the soft palate makes with the hard palate and the width of the seal area.

Class I: Horizontal & demonstrating little muscular movement. Most favourable condition as it allows for more tissue coverage for posterior palatal seal.

Class II: Turns downward forming a 45o angle to hard palate. Potential tissue coverage is less than for class I.

Class III: Turns downward sharply at 70o angle just posterior to hard palate. Least favourable soft tissue form.

V- shaped vault: associated with Class III soft palate

Flat palatal vault: usually associated with Class I or Class II soft palate.

Gag Reflex:Gag Reflex:

Normal defense mechanism developed by the body to prevent foreign bodies from enetering the trachea.

Can be caused by:

Systemic disorders, Psychological factors, Extraoral & intraoral physiological factors Iatrogenic factors.

Controlled by glossopharyngeal nerve.

Management of gag reflex:Management of gag reflex:

Clinical techniques, pharmacological measures, psychological intervention.

Identify the existence of gag reflex with a thorough conversation with the patient.

Careful handling of impression procedure and constant reassurance of the patient will suffice.

In severe cases, a specialist maybe needed to treat the problem at a psychological level.

Redundant tissue:Redundant tissue:

Excess amount of flabby tissue: cause denture base to shift & move as force is applied, due to instability of denture foundation.

Surgical excision may improve the condition before impression making.

Hyperplastic tissue:Hyperplastic tissue:

When present under ill fitting dentures it may present as an epulis fissuratum, papillary hyperplasia or hyperplastic folds.

Patient should be instructed to rest the tissues by not wearing the existing denture.

Proper oral hygiene and tissue massage.

Existing denture should be refitted with a tissue conditioning or temporary relining material. Occlusion should be improved if possible.

Last resort is surgical correction.

Bony undercut:Bony undercut:

Frequently found on both maxillary & mandibular ridges.

Usually pose no problem in denture insertion.

Rule should be selective relief of denture rather than surgical reduction.

On mandibular ridge, the only undercut that can pose a real problem is a prominent sharp mylohyoid ridge.

Tori:Tori:

Torus palatinus & lingual tori frequently present.

Torus palatinus: range from a small prominence in the midline to one that covers the entire hard palate.

Adequate relief must be planned.

Lingual tori: interfere with denture construction & unless very small should be surgically removed.

Muscle & frenum attachments:Muscle & frenum attachments:

Should be examined for favourable & unfavourable positions in relation to the crest of the ridge.

Attachments most often corrected are maxillary labial and mandibular lingual frena.

Unfavourable frenal attachments may necessitate surgical correction to ensure border seal.

Floor of the Mouth:Floor of the Mouth:

Near the ridge crest or when magnitude of movement is great, retention and stability of the denture

Sublingual gland & mylohyoid areas are concern where floor of the mouth is high cannot be selectively displaced by the denture flange, the prognosis of the mandibular denture will be poor.

Retromylohyoid space maybe partially or totally obliterated by tongue movement.

Since success & failure of treatment depends greatly on mutual confidence & rapport between the dentist & patient, the first appointment is extremely important.

THE SECOND APPOINTMENT

The dentist discusses the

- Proposed treatment plan

- The sequence in which the treatment will be carried out

PATIENT MADE RECENTLY PATIENT MADE RECENTLY EDENTULOUS:EDENTULOUS:

• Completely unaware of difficulties • Assume to continue same eating habits

as with their natural teeth

Patient education is of paramount importance and must begin with the second examination appointment and continue throughout the entire treatment sequence.

• Expect their new teeth to last for a life time not possible as changes occur in the basal seat causing position of dentures to change i.r.t their foundation & to each other.

• “Green Ridge”: - Tooth sockets do not completely fill with new bone- Socket edges not rounded off as desired- Bony spicules remain from extraction site- Bony undercuts with a thin mucosal covering.

• Alveolar ridges recently made edentulous subject to large, rapid changes during the first year.

The dentist must inform the patient of these potential changes before beginning, to avoid problems later on.

PATIENT EDENTULOUS FOR A LONG PATIENT EDENTULOUS FOR A LONG TIME:TIME:

• The problems they present are more difficult to treat especially if they have been previous denture wearers.

• These problems must be recognized before adequate treatment procedures are planned

• Most important among this group are the difficult denture wearers Personality characteristics should be assessed.

THE HOUSE CLASSIFICATIONTHE HOUSE CLASSIFICATION

• Proposed by Dr. Milus M. House• General classification of patient’s mental attitude

They can be classified as:

Philosophic

Exacting

Indifferent

Critical

Skeptical

Hysterical

PHILOSOPHIC:PHILOSOPHIC:

• Willing to accept the dentist’s judgement without question.

• Best mental attitude for denture acceptance.• Motivation is generalized.• Ideal attitude for successful treatment, provided the

biomechanical factors are favourable.

Dr Saransh MalotDept of Prosthodontics

EXACTING:EXACTING:

• All good attributes of philosophic patient.• Require extreme care, effort and patience on the part of

the dentist.• Methodical, precise and accurate and at times make

severe demands.• Like each step of the procedure to be explained.• If intelligent and understanding they are the best

or else extra hours must be spent, prior to treatment, in patient education until an understanding is reached.

HYSTERICAL:HYSTERICAL:

• Emotionally unstable, excitable, apprehensive and hypertensive.

• Prognosis is often unfavorable.• Additional professional help (psychiatric) is required

prior to and during treatment.

Hysterical

DEPT.Of Prosthodontics 56

INDIFFERENT:INDIFFERENT:

• Questionable or unfavorable prognosis.• Little concern for their teeth or oral health.• Seek treatment because of the insistence of family.• Pay no attention to instructions, are uncooperative &

give up easily if problems are encountered with their new teeth.

• Require more time for instruction on value and use of their dentures.

Indifferent

58

OBSERVATION OF THE PATIENT:OBSERVATION OF THE PATIENT:

• Begins when the patient enters the dental clinic.• Aspects to be observed

Motor skills

Facial features

Attitude and adaptive response.

(i) Motor Skills:(i) Motor Skills:

• CVA, Bell’s Palsy, nerve blocks for trigeminal neuralgia hemiplagia and dyskinesia.

• Facial tremors/spasms indicate Parkinson’s disease, nervous habits or possibly drug induced tardive dyskinesia.

• Psychotropic drug therapy may show Uncontrollable chewing movements Licking and smacking of lips Uncoordinated tongue movements

Twitching of the nose

Puffing of cheek

These complications often result in prosthetic failure.

DIAGNOSIS:

• Check fluency and quality of patient’s speech

• Best judged during casual conversation

(ii) Facial features:(ii) Facial features:

• Dentist must note

Length of face

Labial fullness

Apparent support of lips

Observe for hollowness/puffiness in

Philtrum

Nasolabial fold

Labiomental groove

• Texture of skin determines the tone for anterior teeth setup

Rough textured skin deserves a more rugged tooth arrangement than smooth, light coloured skin.

• Size of oral cavity, activity of lips and width of vermilion border directly related to degree of tooth display.

• Profile view indicates position of maxilla to mandible first indication of patient’s occlusal classification.

(iii) Attitude & Level of Expectation:(iii) Attitude & Level of Expectation:

• Factors producing adaptive response to complete dentures: Acceptance of & confidence in dentist Previous favourable experience & capacity to cope

favourably with change Favourable physical conditions Realistic expectation of the patient Good learning capacity Desire to please the doctor

• Factors that produce a maladaptive response to

complete dentures

Lack of trust in the dentist

Poor dentist-patient communication

Negative previous experience

Unrealistic expectations on the part of the patient

Resistance to change

Inadequate tissue tolerance

Muscle in coordination

Chronic dissatisfaction

The wish to fail, since the patient craves for attention from the doctor

Disapproval of the dentures or of the individual with the dentures by people important to them.

HEALTH HISTORY:HEALTH HISTORY:

• Patients today have a more complex health history than ever before.

• More likely to involve the dentist in medicolegal challenge.

• Therefore a complete health history is an extremely important part of the patient’s overall diagnosis and treatment planning.

(i) Systemic Status of the Patient:(i) Systemic Status of the Patient:

• DEBILITATING DISEASESThey must be kept under medical controlEg. Diabetes, Blood Dyscrasias and TB

Require Extra instruction in oral hygiene, eating

habits & tissue rest Physician consultation Frequent recall appointments to check the

status of underlying bone and thus occlusion

• DISEASES OF THE JOINTS

Primary osteoarthritis: Familial disease More common in females “Heberdens nodes” involving

terminal joints of fingers difficult for patient to insert & clean dentures

Osteoarthritis of TMJ:

Painful mandibular movements difficulty in construction of dentures

Special impression trays accommodate reduced mouth opening

Difficulty in recording jaw relations Occlusal corrections have to be made often

• CARDIOVASCULAR DISEASES

Consultation with patients cardiologist is indicated

Surgical procedure of any nature maybe contraindicated

Short appointments with pre- medication

• DISEASES OF SKIN

May have oral manifestations Eg. Pemphigus & lichen planus

Oral mucosa is very painful Medical treatment may or

may not give comfort Constant use of dentures is

contraindicated their use is primarily for mental comfort

NEUROLOGICAL DISORDERS:

Eg. Bells palsy

Parkinson’s disease

Added Problems:

Denture retention

Maxillo-mandibular relation records

Supporting musculature

• ORAL MALIGNANCIES:

Most often detected by the dentist Treatment of choice = eradication of

lesion by surgery or radiotherapy. Prosthodontic treatment therein is

best handled by a maxillofacial prosthodontist.

Radiation therapist must be consulted if tissues lack tonus & have a bronze colour denture construction should be delayed.

Observe for signs of radiation necrosis Dentures should be used on a limited basis

• MENOPAUSE:

Bone changes: generalized osteoporosis Mental disturbances: mild irritability to complete nervous

breakdown Oral symptoms: hot flushes, burning tongue, burning

palate and vague area pains. Tranquilizers and psychotherapy may help. Patient should be made aware of these conditions and

their possible effect during the period of denture adjustment.

RADIOGRAPHIC EXAMINATIONRADIOGRAPHIC EXAMINATION

• The interpretation of the panoramic radiograph should follow a five step analysis:

Screen jaws for defect in structure and bony enlargement, displacement of jaw parts, unerupted teeth or retained root fragments, foreign bodies, radiolucencies as well as radio opacities. TMJ can be screened and findings correlated with history and clinical examination.

Describe the appearance of the lesion as well as any bony changes adjoining the lesion

Correlate the radiographic findings with the clinical, historical and laboratory findings.

Perform a differential diagnosis which includes all the diseases that could explain the findings.

Estimate the growth of the lesion by the appearance of the jaw structures adjoining the lesion.

• Panoramic radiographs also aid in determining the amount of ridge resorption.

• Wical & Swoope advocated measuring the distance from the inferior border of the mandible to the inferior margin of the mental foramen and then multiplying it by 3, the resultant product is a reliable estimate of the original alveolar ridge crest height.

• Class I: Mild resorption, is a loss of upto one third of the orignal vertical height.

• Class II: Moderate resorption, is a loss from one third to two thirds of vertical height.

• Class III: Severe resorption, is a loss of two thirds or more of vertical height.

PRETREATMENTPRETREATMENT RECORDS: RECORDS:

• Diagnostic casts: Helps dentists avoid a potential problem Time consuming Aid in determining the inter ridge space, ridge

relationships, ridge shape and form that cannot be adequately determined by clinical examination alone.

• Pre extraction records: Old diagnostic casts: determining both size, position &

arrangement of teeth. Old radiographs: determining tooth size & bony

change. Photographs: relay information regarding tooth size,

position & display during facial expressions. Forms an effective tool in achieving proper esthetics & patient satisfaction.

TREATMENT TREATMENT PLANNING:PLANNING:

• 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.

• Must have a parallel process of developing a prognosis.• Driven by the diagnosis but must take other factors such

as prognosis, patient health and attitudes into account.

WHY TREATMENT WHY TREATMENT PLAN?PLAN?

Treatment Plans

Addresses patient needs

Lists specific treatment

Specific logical sequence

Informed consent

Treatment

Time

Fees

Enables patient to give

Enables dentist to EstimateOperating timeLaboratory timeCalender timeFees

Dentist delivers & patient recieves

Patient specific care

• Treatment planning determines the patients problems by way of a thorough case history as previously described

Thus making selection of the treatment option that is most ideally indicated for the particular case at hand.

By placing a primer on determining patient problems, it also places a primer on the various treatment options that are best suited for those particular conditions.

PROSTHODONTIC CAREPROSTHODONTIC CARE

Edentulous PatientEdentulous Patient Complete denture

Immediate or conventional

Definite or interim

Tooth, implant or tissue supported.

ADJUNCTIVE CAREADJUNCTIVE CARE

Elimination of infection

Elimination of pathoses

Surgical improvement of denture support & space

Tissue conditioning

Nutritional counselling

• Thus it is seen that diagnosis and treatment planning help Thus it is seen that diagnosis and treatment planning help both the dentist as well as the patient understand the:both the dentist as well as the patient understand the:

Diagnostic procedures Diagnostic results Treatment plan Use of prosthesis Continuing care Fees

BIBLIOGRAPHYBIBLIOGRAPHY• Boucher’s: Prosthodontic treatment for edentulous patients, 11 th edn.• Winkler: Essentials of complete denture prosthdontics, 2nd edn.• J.J. Sharry: Complete denture prosthodontics, 2nd edn.• Bouchers: Prosthodontic Treatment for edentulous patients, 10 th edn.• Rahn & Heartwell: Textbook of complete denture, 5th edn.• The dental clinics of North America, Jan 1996;40(1)• The Dental Clinics of North America, Apr 1977;21(2) • Radiographic examination of edentulous mouths, JPD 1990;64:180-182.• Psychological aspects of prosthodontics, JPD 1973;30:736-744• Wical K.E. & Swoope C.C., Studies pf residual ridge resorption. Part I Use

of panoramic radiographs for evaluation and classification of mandibular resorption, JPD 1974;32:7-12

• Also courtesy to some unknown authors from whome I copied some of slides….!!

THANK YOU

Dr Saransh MalotDept of Prosthodontics