Diagnosis and treatment plan of complete denture

Diagnosis and treatment plan of complete denture
Dr. Dwij Kothari
PG
Darshan Dental College and Hospital
Udaipur

1. 1 Good morning If we wait until we are ready, we will be waiting for the rest of our life

2. DIAGNOSIS AND TREATMENT PLANNING OF COMPLETE DENTURE 2 Presented by – Dwij M. Kothari 1 st year P.G. Darshan Dental College & Hospital

3. CONTENTS: Introduction Definition General introduction to the patient Principles of perception & Diagnostic procedure Oral – Systemic interactions Physical examination Extraoral Intraoral Radiographic examination 3

4. Temporomandibular disorders and orofacial pain Pretreatment records Preprosthetic surgery Treatment planning Conclusion References. 4

5. INTRODUCTION: When people reach middle age they suffer from a variety of infirmities to which younger bodies are not victim. Many of these illnesses were once thought to be inevitable consequences of old age, but now it is known that certain of them, such as nutritional deficiencies and tooth loss, are coincidental rather than incidental to increased age. Aging is a variable process. Elders create a need which must be met by the health professions and many of these patients need complete dentures. 5

6. Successful complete denture therapy begins with a thorough assessment of the patient’s physical and psychological condition and determining a treatment that will deliver a functional complete denture that will satisfy the expectations of the patient. 6

7. DEFINITIONS : 7

8. 8 Prosthodontics is the dental specialty pertaining to the diagnosis, treatment planning , rehabilitation and maintenance of the oral function, comfort, appearance and health of patients with clinical conditions associated with missing or deficient teeth and/or maxillofacial tissues using biocompatible substitutes. According to GPT – 8 TH ED. - PROSTHODONTICS

9. DIAGNOSIS :- 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. 9

10. 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. 10 According to GPT – 8 TH ED. The determination of the nature of a disease.

11. 11 Treatment plan :- According to SHELDON WINKLER Treatment planning means developing a course of action that encompasses the ramifications and sequelae of treatment to serve the patient’s needs. According to GPT- 8 th ed. – The sequence of procedures planned for the treatment of a patient after diagnosis.

12. In short, DIAGNOSIS & TREATMENT PLAN can be summarized as: Recognizing the problem Formulating the plan Carrying out the necessary examination Finally, interpreting the result. 12

13. 13

14. GENERAL INTRODUCTION TO THE PATIENT: First appointment  most important time Fact finding Development of mutual trust & understanding Familiar with the overall condition of the patient. 14

15. New patients + patients with previous experience  complete history taking & thorough examinations in which perceptive abilities of the dentist play an important role. 15

16. PRINCIPLES OF PERCEPTION: Detection: noticing something Discrimination: distinguish which we have noticed from something else. Recognition Identification Judgement 16

17. DIAGNOSTIC PROCEDURES Preferably carried out in two appointments: THE FIRST APPOINTMENT: Acquainted with the patient Beginning of evaluation of the process involved in diagnosis & treatment plan 17

18. Obtain essential information from the patient: 18 Radiographic survey Diagnostic casts Thorough history

19. 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 19

20. A thorough history should include: Personal Data: Name Age Sex Race Occupation Cosmetic index: Class I- High cosmetic index Class II - Moderate cosmetic index Class III- Low cosmetic index Personality (House ). 20

21. Medical History General health Pathology Dental History Chief complaint Expectation Edentulism Previous denture/s. Existing or current dentures Pre extraction records Clinical evaluation 21

22. THE 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 22

23. 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. 23

24. EXACTING: All good attributes of philosophic patient. Require extreme care, effort and patience on the part of the dentist. Immaculate appearance and dress. Methodical, precise and accurate and at times make severe demands. Want written guarantees or remakes at no additional cost. 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. 24

25. HYSTERICAL: Submit to treatment as a last resort, have negative attitude, often poor health, unfounded complaints. Emotionally unstable, excitable, apprehensive and hypertensive. Unrealistic expectations.(demand equals to natural teeth) Prognosis is often unfavorable. Additional professional help (psychiatric) is required prior to and during treatment. 25

26. INDIFFERENT: Questionable or unfavorable prognosis. Little concern for their teeth or oral health. Without dentures or worn out dentures for years. 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. Donot value the efforts or skills of the dentist. Require more time for instruction on value and use of their dentures. 26

27. CRITICAL: Find fault with everything that is done for them. Never happy with their previous dentist. Failure to recognize this category of patients may cause immense problems for the inexperienced dentist. Exercise firm control over these patients Dentist must direct all the treatment & decisions Advise medical consultation. 27

28. SKEPTICAL: Have had bad results with previous treatment. Are doubtful if anyone can help them. Often in poor health. Unfavorable oral conditions. Conduct a thorough examination taking more time than usual, since care and attention to detail at this time will help the patient to develop confidence in the dentist. 28

29. 29 New M.M. HOUSE Classification MM HOUSE MENTAL CLASSIFICATION REVISITED : INTERSECTION OF PARTICULAR PATIENT TYPES & PARTICULAR DENTIST’S NEEDS(J Prosthet Dent 2003;89:297-302.) SIMON GAMER,TUCH,GARCIA

30. 30 O’Shea et al characterized the ideal dental patient as compliant, sophisticated, and responsive. Winkler described 4 traits that characterize the ideal patient’s response: (1) realizes the need for the prosthetic treatment, (2) wants the prosthesis, (3) accepts the prosthesis, and (4) attempts to use the prosthesis. This patient corresponds to House’s philosophical- mind patient. Koper characterized and typed patients who have difficulty in adapting to complete dentures as problem patients, difficult denture patients, or difficult denture birds. Other classifications : (J Prosthet Dent 2003;89:297-302.)

31. PATIENT MADE RECENTLY 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. 31

32. 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. 32

33. 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. 33

34. PATIENT EDENTULOUS FOR A LONG 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. 34

35. OBSERVATION OF THE PATIENT: Begins when the patient enters the dental clinic. Aspects to be observed Motor skills Facial features Attitude and adaptive response. 35 Sheldon Winkler – Essentials of complete denture prosthodontics .

36. 36 ( 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 Sheldon Winkler – Essentials of complete denture prosthodontics .

37. 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 37 Sheldon Winkler – Essentials of complete denture prosthodontics .

38. (ii) Facial features: Dentist must note Length of face Labial fullness Apparent support of lips 38 Sheldon Winkler – Essentials of complete denture prosthodontics .

39. Observe for hollowness/puffiness in Philtrum Nasolabial fold Labiomental groove 39 Sheldon Winkler – Essentials of complete denture prosthodontics .

40. Texture of skin  determines the tone for anterior teeth setup Rough textured skin deserves a more rugged tooth arrangement than smooth, light coloured skin. 40 Sheldon Winkler – Essentials of complete denture prosthodontics .

41. 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. 41 Sheldon Winkler – Essentials of complete denture prosthodontics .

42. (iii) Attitude & Level of Expectation: Factors producing adaptive response to complete dentures: Acceptance of & confidence in dentist Previous favorable experience & capacity to cope favorably with change Favorable physical conditions Realistic expectation of the patient Good learning capacity Desire to please the doctor 42 Sheldon Winkler – Essentials of complete denture prosthodontics .

43. 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 43 Sheldon Winkler – Essentials of complete denture prosthodontics .

44. Medical history 44

45. MEDICAL HISTORY: Patients today have a more complex health history than ever before. More likely to involve the dentist in medicolegal challenge. Therefore a complete medical history is an extremely important part of the patient’s overall diagnosis and treatment planning. 45

46. (i) Systemic Status of the Patient: DEBILITATING DISEASES They must be kept under medical control Eg . 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 46

47. 47 DIABETES MELLITUS Includes heterogenic group of disorders all having in common alteration of glucose tolerance or impaired lipid & carbohydrate metabolism. Type I – IDDM (autoimmune, destruction of b- cells of pancreas , 5- 10 % cases. In adoloscence ) Type II – NIDDM (insulin defeciency , 85-90% cases, genetic cause, lifestyle disease, elderly people, obesity.) Symptoms : Polyuria , Polydipsia , Polyphagia . Oral manifestations : - Hyposalivation , Salivary Gland Dysfunction, Parotid Enlargement, Taste Alterations, Burning Mouth Sensation & Fungal Infections Braz Dent J (1995) 6(2): 131-136 ISSN 0103-6440 . Oral Manifestations of Diabetes Mellitus in Controlled and Uncontrolled Patients.

48. Diagnostic Criteria & Management Management - Diet control Regular exercise Oral hypoglycaemic agents - Sulfonylurea – Tolbutamide , Gliclazide - Biguanides – Metformin - Alphaglucoside inhibitors – Acrabose Insulin therapy 48 Diagnostic criteria – Fasting Blood Sugar Level > / = 140 mg/ dL Post Prandial - >/= 200 mg/ dL Glycosylated Hb – more than 6-8% Dent Clin N Am 50 (2006) 591–606

49. Prosthodontic considerations Blood Sugar Level Shorter appointments preferably in mornings Mucostatic impression technique Avoid adrenaline in LA Liquid supported dentures Use of soft denture liners. 49

50. Tuberculosis 50

51. Tuberculosis Prosthodontic considerations Spread by aerosolized droplets  high risk to dentist Past history of T.B. physician’s consultation  if culture positive  only emergency treatment provided Minimal use of high speed handpieces Operating air should be vented out . Oral lesions may make use of prosthesis difficult 51

52. 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 52

53. 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 53

54. Osteoporosis Osteoporosis is a systemic disease in the elderly. Osteoporosis shows a decrease in the skeletal mass without alteration in the chemical composition of bone. Loss of the spongy spicules of bone that support the weight bearing parts of the skeleton can be seen in radiographs of regions of the skeleton that bear heavy loads, such as the vertebral column, epiphysis of long bones, the mandible and the fingers. 54

55. 55 Osteoporosis is common in aging individuals, especially post menopausal women when the estrogenic blood level is low. In elderly men and women, osteoporosis is caused by a variety of factors such as calcium loss, calcium deficiency, hormonal deficiency, change in protein nutrition and decreased physical activity. Progressive loss of alveolar bone may be a manifestation of osteoporosis

56. CARDIOVASCULAR DISEASES Includes ischemic heart disease(anginas), arterial hypertension, arrhythmias, myocardial infarction & chronic heart failure. Consultation with patients cardiologist is indicated Surgical procedure of any nature maybe contraindicated Short appointments with pre- medication 56

57. 57 Oral manifestation of cardiovascular disease. Not specific. Consequences of pharmacologic treatment, rather type of heart disease. Most frequent cardiovascular drugs & their related manifestations are : ACE inhibitors : - Erythema Multiforme , Xerostomia , Loss Of Taste, Pharyngitis , Burning Sensation & Ulcers. B- blockers : Xerostomia , Paresthesia . Calcium antagonists ( nifedipine ) : Gingival Hyperplasia, Sialorrhea Diuretics : Xerostomia , Parotid Gland Hypertrophy. Nitrates : Alterations Of The Denture Base Materials. These all affects complete denture treatment . For eg . Xerostomia - impairs prosthesis retention. oral mucosa irritation Adhesion of food to prosthetic materials (Dent Clin N Am 50 (2006) 483–491 – ischemic heart diseases & their management. James R. Hupp )

58. 58 Prosthetic Management Communicate with the patient’s physician. Prevent hemorrhage in pt. taking anti-coagulant therapy. Reduce patient’s stress and anxiety. Morning appointment. Short wait in waiting room. Reassurance & peaceful environment.

59. 59 Avoid surgical procedures if possible. If not, perform it under proper antibiotics coverage. Postpone procedures for at least 6 months if not very necessary. Do not treat patient with coronary bypass until at least 2 weeks after operation. Always ready with emergency kit & services for an immediate control.

60. 60 HYPERTENSION Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension. Bruce Bavitz Adult classification: Classification Systolic BP Diastolic BP Normal 120 80 Prehypertension 120–139 or 80–89 Stage I hypertension 140–159 or 90–99 Stage II hypertension 160 or 100

61. 61 Oral side effects of antihypertensive medicines Drug Oral adverse side effects Diuretics Dry mouth, lichenoid reaction Beta blockers Dry mouth, taste changes, lichenoid reaction ACE inhibitors Loss of taste, dry mouth, ulceration, angioedema Calcium channel blockers Gingival enlargement, dry mouth, altered taste Alpha blockers Dry mouth Direct-acting vasodilators Facial flushing, possible increased risk of gingival bleeding and infection Central-acting agents Dry mouth, taste changes, parotid pain Angiotensin 2 antagonists Dry mouth, angioedema , sinusitis, taste loss Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension. Bruce Bavitz

62. 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 . 62

63. 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 63

64. 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 64

65. 65 White patch : - it may be :- Leukoplakia (non scrapable , habit associated) Frictional keratosis – seen only on ridges. Lichen planus – wickham striae . Candidiasis – scrapable

66. Oral submucous fibrosis An insidious chronic disease affecting any part of the oral cavity & sometimes pharynx ,although occasionally preceded by &/or associated with vesicle formation. It is always associated with juxta epithelial inflamatory reaction followed by fibro-elastic changes of lamina propria , with epithelial atrophy leading to stiffness of oral mucosa & causing trismus & inability to eat. 66

67. Etiology Chronic irritation- chillies, tobacco, lime, arecanut Nutritional deficiency Defective iron metabolism Bacterial infections Collagen disorders Immunological disorders Genetic susceptibility Altered salivary composition 67

68. Management Restriction of habit Medicinal therapy – Supportive treatment Steroids – local , systemic Hyaluronidase Vitamine E Oral physiotherapy- Mouth opening, Ballooning of mouth, Forceful mouth opening with mouth gag 68 Surgical treatment Indications – marked trismus , neoplastic change Surgical treatments –conventional, laser, cryosurgery

69. Prosthodontic considerations Difficulty in impression making  due to restricted mouth opening Solution – use of sectional impression trays 69 Journal of Prosthodontics 2010: 19; 299-302

70. Difficulty during border molding d/t restricted movement of tongue Difficulty in insertion & removal of dentures Solution – use of sectional dentures 70 Journal of Prosthodontics 2010: 19; 299-302

71. Vesciculo-bullous lesions Vesciculo-bullous lesions which may have intra oral manifestations are – Pemphigus Pemphigoid Erythema multiformae Management – Topical / systemic steroids Immuno-suppresive therapy 71

72. Prosthodontic consideration – Difficulty in wearing removable prosthesis Increased chances of trauma due to prosthesis 72

73. Candida associated lesion [denture stomatitis ] [chronic atrophic candidiasis ] Site – usually under CD & RPD Appearance patchy distribution often associated with speckled curd like white lesion Symptoms  soreness & dryness of mouth Signs  palatal tissue  bright red, edematous & granular 73

74. Red patches  erythematous or speckled sharply outlined & restricted to the tissue actually in contact with the denture Multiple pinpoint foci of hyperemia involving maxilla 74

75. Treatment Removal of the cause Replacement of denture or relining or applying mycostatin Denture – cleaned thoroughly & regularly & should be left out of the mouth at night in hypochlorite solution Anti-fungal treatment 75

76. Angular chelitis [ perleche,angular cheilosis ] Causes Micro-organisms – mainly candida albicans Mechanical factors – over closure of jaws - edentulous patient - prosthesis with decreased vertical dimension Nutritional deficiency Atopic/ seborrhoic dermatitis Hypersalivation 76

77. Clinical features Dry & burning sensation at corners of mouth Rough triangular area of edema & erythema Wrinkled & maserated epithelium,deep fissures appear ulcerated  do not bleed 77

78. Management Removal of cause Nutritional supplement Antifungal treatment –Miconazole Restore correct vertical dimension 78

79. Herpes Recurrent intra oral herpes Herpes zoster Prosthodontic considerations Use of prosthesis  uncomfortable Care taken to avoid herpetic whitlow 79

80. HIV AIDS Acquired immuno deficiency syndrome Epidemic disease Associated with wide range of oral lesions like Oral candidiasis Oral hairy luekoplakia Kaposis sarcoma NUG & NUP Recurent aphthous ulcerations 80

81. Many of the dental treatments are contraindicated in HIV patients The treatment plan depends on the overall systemic health of the patient Precautions for prevention of transmission 81

82. NEUROLOGICAL DISORDERS : Eg . Bells palsy Parkinson’s disease Added Problems : Denture retention Maxillo-mandibular relation records Supporting musculature 82

83. 83 BELL’S PALSY JPD vol35, Issue 2, February 1976, Pages 192-201.Prosthetic support for unilateral facial paralysis. Larsen & carter Bell's palsy is a disorder of the nerve that controls movement of the muscles in the face. Damage to this nerve causes weakness or paralysis of these muscles. Cause: Not clear. May be due to Herpes zoster infection The face will feel stiff or pulled to one side, and may look different . Other symptoms can include: Difficulty eating and drinking; food falls out of one side of the mouth Drooling due to lack of control over the muscles of the face Drooping of the face, such as the eyelid or corner of the mouth Hard to close one eye

84. 84 Dr. Suresh s. & Dr. Vipul asopa : Prosthodontic management of complete edentulous patients with neuromuscular disorders - Case reports. JADR Jan 2011 : 2(1); 67-72. Symptoms: Problems smiling, grimacing, or making facial expressions Twitching or weakness of the muscles in the face Dry eye or mouth Loss of sense of taste Sound that is louder in one ear ( hyperacusis )

85. 85 Prosthodontics considerations : Proper training on insertion & removal of dentures. Non- anatomic teeth. Heat strength metal reinforced denture bases Upright positions with head supported for making impressions. Repeated JR’s. Record neutral zone Denture hygiene instructions. Regular follow-up. Dr. Suresh s. & Dr. Vipul asopa : Prosthodontic management of complete edentulous patients with neuromuscular disorders - Case reports. JADR Jan 2011 : 2(1); 67-72.

86. 86 Dr. James Parkinson in 1817. Parkinson's disease is a disorder of the brain that leads to shaking (tremors) and difficulty with walking, movement, and coordination. Occurs mostly above 50 yr. of age. Cause – destruction of dopamine producing brain cells which control muscular movement . Parkinson’s disease (shaking palsy) Symptoms Automatic movements (such as blinking) slow or stop Constipation Difficulty swallowing & Drooling Impaired balance and walking Lack of expression in the face (mask-like appearance) Muscle aches and pains Movement problems. Confusions, dementia, hallucinations, memory loss etc.

87. 87 Gen Dent. 2008 May-Jun;56(4):e12-6.Complete denture prosthodontics for a patient with Parkinson's disease using the neutral zone concept: a clinical report. Makzoume JE Prosthodontic management : Neutral zone technique. If xerostomia is also present, then use of salivary substitutes recommended.

88. 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. 88

89. Seasonal attacks  routine dental treatment – when frequency of attacks is lowest Patients on steroids  additional dose may be required to avoid serious reaction to dental stress Avoid inhalation anaesthetics or analgesics 89 Management Dietary calcium Estrogen therapy Regular exercise

90. 90 ADDITIONAL TESTS & MEDICAL CONSULTATION Routine blood test. Blood sugar. Urine sugar. Referral to family physician. Specialist consultation.

91. Physical examination 91

92. Clinical Evaluation 92 Square Square tapering Tapering Ovoid Facial form according to House & Loop

93. Facial profile according to Angle 93 Class I Normal Class III Prognathic Class II Retrognathic

94. Muscle tone according to House Class I :Normal muscle tone(immediate denture pt.) Class II: Slightly impaired muscle tone(following loss of all natural teeth) Class III: Greatly impaired muscle tone & function Muscle Development according to House Class I: Heavy Class II: Medium Class III: Light Complexion (helps in shade selection) Hair Eye (pale anemic look) Skin( underlying disease) Nasolabial fold (normal 110 deg., wrinkles ) 94

95. Cracking, fissuring at corner & ulceration: indicative of vitamin B-complex deficiency, candida infection, overclosure of existing denture or neoplasm. Lip contour - adequately supported or unsupported(collapsed or wrinkled appearance) Lip thickness Lip length- long , medium and short. Lip mobility – normal( classI ) reduced mobility( classII ) paralysis.(class III) Lip examination: 95

96. 96 Lip thickness – thick or thin Thick – gives more freedom in teeth setting. Thin – any change in labiolingual position can alter fullness, support or drape of thin lip. Lip length – long or short . Measured from - base of the nose to vermillion border of lip (ideal = 25 mm). or with index finger tip ,from incisive papilla to upper lip. Long – will hide denture base & most of the tooh (maximum facial expression is required for display of tooth). Short – any expression will expose most of the tooth or even denture base.

97. Lips can be classified into 4 types Competent lips – lips are in slight contact when the musculature is relaxed Incompetent lips – morphologically short lips which do not form a lip seal in a relaxed state Potentially incompetent lips – normal lips , fail to form lip seal Everted lips – hypertrophied lips with weak muscular tonocity 97 S.I. bhalajhi – orthodontics art &science, 3rd edition.

98. Temporomandibular Joint Clicking(disc displacement), crepitations ( osetoarthrosis ) Pain & tenderness on palpation Temporomandibular arthralgia Impaired mandibular mobility Irregularity or deviation on opening & closing of mandible Deflection. Locking of mandible. 98

99. 99 Examination includes : Analysis Of Mandibular Movements Palpation Auscultation Two types of examination :- preauricula r ( 8 – 13 mm ahead of tragus) intraauricular Preauricular is performed at 7o’ clock & 12 o’ clock position Intraauricular is performed only at 12 o‘clock position.

100. Neuromuscular Evaluation Speech- normal or affected. Coordination :- Class I: Excellent Class II: fair Class III: poor Arch Size Class I: Large (best for retention & stability) Class II: Medium (good retention & stability but not ideal) Class III: Small (difficult to achieve good retention and stability) 100

101. 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. 101

102. Arch Form 102 Class I Square Class II Tapering Class III Ovoid

103. 103 B ORDER ATTACHMENTS (HOUSE) :- Class I – Attachements are high in maxilla or low in mandible with relation to ridge crest (0.5 inches or more between level of attachment and crest of ridge) Class II – Attachements height is 0.25 to 0.50 inches. Class III - < 0.25 inches from ridge crest. F RENUM ATTACHMENTS (HOUSE) :- same as border attachements Class I – high in maxilla or low in mandible i.r.t . ridge crest. Class II – medium Class III – freni encroach on the crest of the ridge and may interfere with denture seal. Surgical correction may be required ( frenotomy or frenectomy )

104. Ridge Form: 104 Class I Class II ClassIII Square V-shaped Flat Short Inverted Flat Inverted U-shaped Inverted W Tall Inverted Maxillary Mandibular

105. Ridge Contour: Type I: High, well rounded bone profile + ve resistance Type II: Narrow, knife edge ridge - ve resistance Type III: Rounded but lowered residual ridge - ve resistance Type IV: Terminal stage - ve resistance 105

106. Ridge relationship according to Angle GPT8 - The positional relation of the mandibular ridge & maxillary ridge. 106 Class – I Parallel Class – II Divergent Mandibular Class – III Divergent Maxillary & Mandibular

107. ridge relationship according to smith It can be described as the Anteroposterior position of the mandibular residual ridge relative to the maxillary residual ridge when the jaws are in centric relation . 107

108. Hard palate: U-shaped palatal vault; most favourable for retention & lateral stability. V-shaped vault: less favourable for retention. Flat palatal vault: also unfavourable. 108

109. 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. Forms a 10o angle. 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. 109 Sheldon Winkler – Essentials of complete denture prosthodontics .

110. V- shaped vault: associated with Class III soft palate Flat palatal vault: usually associated with Class I or Class II soft palate. 110 Sheldon Winkler – Essentials of complete denture prosthodontics .

111. 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. 111

112. Palatal throat form: house CLASS – I Large and normal in form Immovable band of resilient tissue 5-12 mm distal to a distal edge of the tuberosities CLASS – II Medium size and normal in form Relatively immovable resilient band of tissue 3-5 mm distal to distal edge of the tuberosities CLASS – III Usually accompanies a small maxilla Curtain of soft tissue turns down abruptly 3-5 mm anterior to distal edge of the tuberosities 112

113. Gag Reflex: Normal defense mechanism developed by the body to prevent foreign bodies from entering the trachea. Can be caused by: Systemic disorders, Psychological factors, Extraoral & intraoral physiological factors Iatrogenic factors. Controlled by glossopharyngeal nerve. 113 Sheldon Winkler – Essentials of complete denture prosthodontics .

114. 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. 114 Sheldon Winkler – Essentials of complete denture prosthodontics .

115. Palatal sensitivity : house Class I: Normal Class II: Subnormal (Hyposensitive) Class III: Supernormal (Hypersensitive) Mucosal Thickness according to House Class I: Normal uniform density (1 mm) Class II: Thin investing membrane Soft tissues have mucous membranes twice the normal thickness. Class III: Thick investing membrane(redundant tissue, tissue treatment) 115

116. Mucosa condition according to House Class I: Healthy Class II: Irritated Class III: Pathologic 116

117. Class I Class II Class III Lateral throat form [ mandibular ] : neil 117 Lateral throat form is classified according to the extent of anterior movement of the retromylohyoid curtain as the tongue is extended anteriorly beyond the vermilion border of the lip.

118. Saliva : Class I: Normal(cohesive & adhesive) Class II: Excessive(mucus) Class III: Xerostomia (remaining mucinous .) Flow – regular or irregular. Quality – thin serous, mucinous , mixed. Quantity – normal, excessive, scanty. Contact – competent & incompetent. Deficient saliva: retention of denture will be affected. Excess of saliva: complicates impression making. 118

119. Thick mucous saliva makes dentures more difficult to wear. It will push out denture by accumulating beneath the denture. Mixture of both Thin serous & Thick mucous saliva is the best to work with. 119

120. 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. 120

121. 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. 121

122. 122 According to House : - Class I – normal in size, development, & function. Class II – teeth have been absent for long time .permits change in form & function. Class III – excessively large tongue.all teeth have been absent for a long time, allowing for abnormal development of the size of the tongue.

123. 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 tensed, 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. 123

124. Examination of existing dentures Mucosa examined for pathological changes As per the study conducted by ostlund in 1953 it was reported that in 77 % of the denture wearing patients there will be presence histological changes even though mucosa appears clinically normal. Evaluation of Denture cleanliness CR & CO premature contacts, sliding Vertical dimension Denture extensions Type of teeth Retention , stability Esthetics phonetics 124

125. Radiographic examination 125

126. RADIOGRAPHIC 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. 126

127. 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. 127

128. 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. 128 . Studies of residual ridge resorption . I. Use of panoramic radiographs for evaluation and classification of mandibular resorption . J Prosthet Dent. 1974 Jul;32(1):7-12 Wical KE, Swoope CC

129. 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. 129

130. 130 Radiographs is useful in the following instances : - Bone pathosis , cysts, tumors. Retained roots or teeth. Bony fractures. Soft tissue thickness. Extent of bone resorption . Thickness of body of mandible. To locate mandibular canal & it’s proximity to ridge crest. To locate maxillary sinuses. To plan surgeries. Remaining bone density and quality. As treatment records. For patient education.

131. TMJ disorder 131

132. Temporomandibular Disorders (TMD) It represents a constellation of painful symptoms in the jaw muscles and TMJs. Patient with TMDs commonly complain of pain in the muscles of mastication, most frequently the masseter and temporal muscles). 132

133. classification Group Disorder Group I Muscle disorders Ia Myofacial pain Ib Myofacial pain with limited opening Group II Disc displacement IIa Disc displacement with reduction IIb Disc displacement with reduction, with limited opening IIc Disc displacement with reduction, without limited opening Group III Arthralgia , arthritis, arthrosis III a Arthralgia III b Osteoarthritis of the TMJ III c Osteoarthrosis of the TMJ 133

134. Jaw disability checklist What activities does your present jaw problem prevent or limit you from doing: Chewing Drinking Exercising Eating hard foods Eating soft foods Smiling/ laughining Cleaning teeth or face Yawning Swallowing Talking Keeping your usual facial appearance 134

135. Clinical considerations for determining the probability of a TMD Considerations High Low Pain Constant ache / tightness Sharp pain with jaw use Sharp, electric, burning, paroxysmal, intermittent, spontaneous pain. Sharp pain with jaw use Muscles Masticatory muscles or TMJ Site not necessarily in muscles or TMJs Jaw use Aggravated by jaw use No definitive change with jaw use Clinical Pain reproduced with palpation Reduced range of mandibular motion Painful clicks or grinding in TMJs Jaw catches or locks Associated ear, neck, tension – type headaches May be associated with paresthesia , dysesthesia or other neurologic signs 135

136. Prosthodontics and TMDs Alteration of TMJ anatomy, including disc displacements and bony degeneration, may influence occlusal stability. Thus, prior to prosthodontic treatment, it is prudent to provide clinical and radiographic evaluation of the TMJs. If clinical examination reveals crepitus and radiographic evidence of bony alterations of the condyle or articular eminence, the following steps may be considered prior to prosthetic treatment: CT scan of temporomandibular joints – it allows accurate assess of the degree of degeneration of affected joints but clinician can not predict whether the degeneration is active. 136

137. Scintigraphy . To assess the extent of active metabolic degeneration, aTc 99m bone scan may be requested. If uptake is identified in TMJs, postpone prosthetic treatment. If treatment proceeds in actively degenerating joints, occlusal stability certainly cannot be predicted and treatment failure may occur. Diagnostic stabilization appliance 137

138. Pre treatment records 138

139. PRETREATMENT 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. 139

140. 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. 140

141. Preprosthetic surgery 141

142. 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. 142

143. 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. 143

144. 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. 144

145. 145 . DEFECTS Exostose or divots. Preprosthetic surgeries may be required

146. 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. 146

147. 147 Classification : - Class I - Tori absent or minimal in size. Donot interfere with denture construction. Class II – Moderate size. Mild difficulties in denture construction and use. Surgery not required. Class III – Large in size. Compromise fabrication & function of dentures. Requires surgical recontouring or removal.

148. 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. 148

149. TREATMENT 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. 149

150. WHY TREATMENT PLAN? 150 Treatment Plans Addresses patient needs Lists specific treatment Specific logical sequence Informed consent Treatment Time Fees Enables dentist to Estimate Operating time Laboratory time Calender time Fees Enables patient to Delivered care Patient specific Patient receive Dentist delivers Enables dentist to

151. 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. 151

152. 152 Steps in t/t planning :- Tissue conditioning (finger massage, soft reline) Pre-prosthetic surgery (if any) Articulator (no, manufacturer, control settings) Tooth selection. Denture base materials. Denture base shade. Characterization.

153. PATIENT EDUCATION Use the treatment plan as an educational tool to raise the patient’s level of understanding. Essential element in patient care and should start with the initial contact with the patient. It is defined as an initial and continuing activity integral to, and supportive of the treatment plan. 153

154. Purposes: Appraise the patient of their dental health & it’s significance. Give the patient understanding of the significance of edentulism. Harmonize the patient’s expectations with reality of treatment potential. Explain the nature and use of prosthesis. Identify alternative treatment & their consequences. 154

155. 155 Occasionally, a patient might not agree to suggested treatment plan, due to various reasons. Surgery. Time. Expense. Demand or requests.(within limits) The alternate treatment plan may be less than ideal, but is often necessary for various reasons. However, we must still try to achieve the best possible result. ALTERNATE TREATMENT PLAN

156. 156 REFUSAL OF TREATMENT It is the duty of the Prosthodontist to respect the patients wishes and include it in treatment plan whenever possible. Sometimes , however, a patient’s demand may be unreasonable or against professional judgement or ethics . In such case, the dentist may refuse treatment or refer him to another dentist for a second opinion

157. 157 Definition - A forecast as to the probable result of a disease or a course of therapy.(GPT 8) After considering all the factors of the case, an experienced dentist should be able to predict the degree of success that can be expected . It includes realization by the patient of what can & cannot be achieved. Ultimately leads to more realistic expectations & less frustration & disappointment Prognosis

158. 158 FEES AND INFORMED CONSENT Diagnosis and treatment planning also helps the dentist decide the fees that is fair to both the dentist and the patient. Once the patient has fully understood and agreed on the treatment (including the fees), he/ she must sign a written consent. A signed consent is essential to prevent later misunderstanding.

159. A Primer on Treatment Options 159

160. ADJUNCTIVE CARE Elimination of infection Elimination of pathoses Surgical improvement of denture support & space Tissue conditioning Nutritional counselling 160

161. PROSTHODONTIC CARE Edentulous Patient Complete denture Immediate or conventional Definite or interim Tooth, implant or tissue supported. 161

162. Thus it is seen that diagnosis and treatment planning help both the dentist as well as the patient understand the: Diagnostic procedures Diagnostic results Treatment plan Use of prosthesis Continuing care Fees 162

163. Conclusion: All the facts must be known before they can be correlated in such a way that decision can be made. Only then can treatment plans be developed to best serve the needs of each individual patient. For the patient to be happier the dentist should not only require the skills of complete denture construction but also the skills to treat a patient’s aspirations & expectations. 163

164. References : William R. Laney: Diagnosis and treatment in prosthodontics , 2 nd edition Boucher’s: Prosthodontic treatment for edentulous patients, 10th &12th edn . Winkler: Essentials of complete denture prosthdontics , 2nd edn . J.J. Sharry : Complete denture prosthodontics , 3rd edn . Rahn & Heartwell : Textbook of complete denture, 5th edn . 164

165. Sheldon Winkler – Essentials of complete denture prosthodontics . Bernard levin – impressions for complete denture. Fenn - Clinical denture prosthetics, 3rd edn . S.I. bhalajhi – orthodontics art &science, 3rd edition. JADR Vol II:Issue I: Jan, 2011.Prosthodontic management of complete edentulous patients with neuromuscular disorders - Case reports. Dr. Suresh s. & Dr. Vipul asopa 165

166. 166 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. Arthur Grieder : Psychological aspects of prosthodontics, JPD 1973;30:736-744 Wical K.E. & Swoope C.C. : Studies of residual ridge resorption. Part I Use of panoramic radiographs for evaluation and classification of mandibular resorption. JPD 1974;32:7-12 James R. Hupp : Ischemic Heart Diseases & Their Management. Dent Clin N Am 2006 : 50 (4); 483–491 Bruce Bavitz : Dental Management Of Patients With Hypertension. Dent Clin N Am 2006 : 50 (4); 547–562