Diagnosis and treatment plane for full denture patient

Diagnosis and Treatment Planning for full denture DR MOHAMED A. IBRAHIM

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.

Diagnosis is the examination of the physical state, evaluation of the mental or psychological makeup, and understanding the needs of each patient to ensure a predictable result.

Treatment planning means developing a course of action that encompasses the ramifications and squealed of treatment to serve the patient’s needs.

GENERAL INTRODUCTION TO THE PATIENT

The first appointment is perhaps the most important time the dentist will spend with a complete denture patient.

In this appointment you can develop the mutual understanding and trust between you and your patient

Getting the general information about the personal, social information.

The patient might have an unique question and they might get an old denture, they want to look like someone in picture or asking about the feel The dentist should avoid immediate answer.

It is important to know if the patient has recently become edentulous, has been edentulous for a long time, or has teeth and is contemplating complete extraction either on his own or at the suggestion of another dentist

The intraoral examination will determine if any further surgical correction will be necessary

The dentist should inform the patient with the treatment plan so the patient will not misunderstand any refitting at a later date

The long time denture wearer knows what the problem might associate with the denture the patient must be informed of any possible changes or resorption of the residual ridges that may have occurred.

Much information can be gained by the dentist before he ever looks into the patient’s mouth. Time spent during the first appointment can lay the groundwork of cooperation so necessary for a successful result.

OBSERVATION OF THE PATIENT

The observation and evaluation of the patient begins when he or she enters the dental office

Motor Skills

Facial Features

Attitude and Adaptive Response

Motor skills

The observation of the patient’s physical abilities and motor skills is an important part of the overall evaluation.

Is the patient able to get out of the waiting room chair, or is there some difficulty or assistance required?

This may be the first indication of a bone, joint, or muscle problem.

Upon rising is the patient steady or was time required to gain equilibrium?

Dizziness may be a side effect of medication or a cerebrovascular accident.

Vertigo

may also be due to orthostatic hypotension or be a signal of low blood pressure, overcorrected high blood pressure, or cerebral ischemia

Is the patient out of breath after arriving at the operatory?

The dentist should suspect asthma, congestive heart problems, or heavy smoking.

After being seated in the dental chair, the patient’s ankles should be observed for swelling?

Ankle edema is often associated with congestive heart failure, poor circulation, or kidney disease.

Facial Features

The dentist should observe the face of the patient. Note the

1. length,

2. fullness,

3. and apparent support of the lips.

4. Observe the philtrum,

5. nasolabial fold,

6. and labiomental groove for hollowness or puffiness.

The texture of the skin will help establish the tone of the anterior setup.

Rough textured skin deserves a more rugged tooth arrangement than smooth light-colored skin.

The size of the oral opening, activity of the lips, and width of the vermilion border are directly related to the degree of tooth display

Attitude and Adaptive Response

Studies have shown that a patient’s attitude and level of expectation can profoundly influence the treatment outcome. Complete denture failures can result from a misunderstanding between the dentist and the patient.

Factors which produce an adaptive response tocomplete dentures

1. The acceptance of the dentist and confidence in the dentist, which could also be described as trust.

2. Previous favorable experience with authority figures.

3. The capacity to cope favorably with change. A positive attitude increases this capacity.

4. Favorable physical conditions: youth and good general health were factors which produce an adaptive response to complete dentures.

5. Realistic expectation of the patient.

6. Good learning capacity.

Factors which produce a maladaptive responseto complete dentures

1. Lack of trust in the dentist.

2. Poor communication between the dentist and his patient.

3. Unrealistic expectations of the denture patient.

4. Resistance to change arising from severe anxiety or depression or hopelessness.

5. Low tolerance for anxiety or pain.

6. A high level of anxiety on the part of the patient.

HEALTH HISTORY

The average complete denture patient has a more complex health history than ever before

The complete health history should include

(1) the name of the patient’s physician, including the date and reason for the last appointment,

(2) a record of the status of all major body systems,

(3) a record of all medications within the last six months,

(4) a record of any hospitalization,

(5) a record of any complication that was a result of previous dental treatment,

(6) a record of the patient’s opinion of his or her general health, and

(7) a space to update the health history when the patient is

CLINICAL EXAMINATION

The clinical examination should proceed in a logical and orderly sequence so that nothing is overlooked.

Extraoral Examination

The patient’s head and neck region should first be examined in general for the presence of any pathologic conditions relating to a non dental or systemic condition.

The face and neck are palpated for any masses or enlarged nodes

Facial examination

Facial form and profile can be useful aids in tooth selection

Although direct correlation has never been shown, there should be harmony between facial size, form, and shape, and the artificial teeth selected

A patient’s profile appears not only as fiat or curved so teeth can be set accordingly, but can be an early indicator of the patient’s jaw classification.

A patient’s occluding vertical face height can easily be seen in profile and a judgment made whether the occlusal vertical dimension of an existing denture is open, closed, or within normal limits.

Lip examination

The lips should be examined for cracking, Assuring at the corners, and ulceration.

from organisms such as Candida albicans,

The lips are then examined for support, fullness, thickness, and length. The lack of proper lip support can lead to a collapsed appearance and wrinkling.

Temporomandibular joint examination

The temporomandibular joint should be evaluated for pain by palpation or mandibular movement. The muscles of mastication should also be palpated to attempt to elicit a pain response

Intraoral Examination

An overview of the oral mucosa should be obtained before a specific examination of the denture-bearing area and contiguous structures is conducted.

The dentist should be looking for abnormalities or pathological lesions. The inside surface of the cheeks and lips, residual ridge, floor of the mouth, hard and soft palate, and the tongue are closely examined.

Color of the mucosa

The color of the mucosa may range from a healthy pink to an angry red.

The redness is indicative of inflammation and can be of varying degrees.

It can be related to an ill-fitting denture, underlying infection, a systemic disease such as diabetes, or chronic smoking.

It is important to determine the cause and remove the irritant because successful impression making is not possible until the inflammation is under control.

Saliva

The amount and consistency of saliva will affect the denture construction process and the quality of the final product itself.

If the mouth is dry, retention of the denture will be affected. In addition, a dry mouth has an increased potential for soreness.

Arch size

The size of the maxilla and mandible ultimately will determine the amount of basal seat available for the denture foundation.

Arch form

The arch may be square, .ovoid, or tap e red and opposing arches may not necessarily have the same form.

The form of the ridge will influence the support of the denture and perhaps the tooth selection.

Ridge contour

Ridge contour can vary widely. The ideal is a high ridge with a flat crest and parallel or nearly parallel sides.

This type of ridge will give a maximum amount of support and stability

In time, as the ridge resorbs, it may become flatter , V-shaped, or knife-edged. Knife-edged ridges or ridges with multiple bony spicules offer the poorest prognosis because they are incapable of withstanding much occlusal force and can easily become sore.

Ridge relation

The maxillary and mandibular ridges should be observed at the appropriate occlusal vertical dimension. The amount of interridgedistance should be noted first

An excessive amount of space due to resorption will result in poor stability and retention because of the increased leverage

A small amount of inter ridge distance will lead to difficulty in setting teeth and maintaining a proper freeway space

Hard palate

The hard palate should be examined and its shape noted. The T-shaped palatal vault is most favorable for retention and lateral stability.

A V-shaped 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

Soft palate

There are three classifications of soft palate configurations

A class I soft palate is rather horizontal and demonstrates little muscular movement

A class II soft palate turns downward at about a 45° angle to the hard palate and the amount of potential tissue coverage for the palatal seal is less than for a class I.

A class III soft palate turns downward sharply at about a 70° angle just posteriorly to the hard palate.

Bony undercuts

Bony undercuts are frequently found on both the maxillary and mandibular ridges.

On the maxilla, the undercuts are usually present on the anterior ridge and lateral to the tuberosities

These usually pose no real problem with denture insertion, and the rule should always be selective relief of the denture rather than surgical reduction

Tori

A torus palatinus and lingual tori are occasionally present.

On the maxilla, the torus can range from a small prominence on the midline to one that covers the entire hard palate.

Generally surgical removal is contraindicated unless the torus is so large as to preclude construction of the denture

Tongue

The tongue size should be noted. If the patient has been without teeth or prostheses for a long time or has worn a maxillary denture against the lower anterior teeth only, the tongue can become enlarged and powerful.

RADIOGRAPHIC EXAMINATION

Radiographic examination is an essential part of diagnosis and treatment planning for all dental patients.

Screen jaws for defects in structure and reactive new bone formation, bone enlargement, and displacement of jaw parts. The screening should also include any unerupted teeth or retained root fragments, foreign bodies, radiolucencies, radiopacities, rarefaction or sclerosis, expansion or bulging, and any welldefined or ill-defined lesions.

The TMJ can be screened, although positive findings should correlate with the history and physical examination.

Describe the appearance of the lesion as well as any bone 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 jaw structures bordering the lesion

THE TREATMENT PLAN

The treatment plan for an edentulous patient is simple; either a complete denture is constructed or it is not.

Assembling all the diagnostic criteria takes time, but it is time well spent to assure a successful result. The treatment and expected level of achievement is carefully explained to the patient. Fees, manner of payment, duration of treatment, any necessary tissue preparation and conditioning, and contemplated surgery are discussed.

The trained professional is acutely aware of these ramifications and educates the patient to this end.