Prostho IV-Slides 2- Assessment of the Edentulous Patient

7/27/2019 Prostho IV-Slides 2- Assessment of the Edentulous Patient

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ASSESSMENT OF THE EDENTULOUS

PATIENT

KHALED Q AL HAMAD BDS Msc MRD RCSEd

Associate ProfessorDepartment of Prosthodontics

4TH YEAR, Dent 445

2ND LECTURE


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Pattern of bone loss in edentulous arches

Information Gathering

The presenting complaints and relevant history

Dental history

Medical history

Social history

Extra-oral assessment

Intra-oral assessment

Assessment of the dentures

Specific investigations


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Dental history

Medical history

Social history






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Diagnosis: examination of of the physical state,

evaluation of the mental or psychological make up,

understanding the needs of each patient to ensure

predictable results. Treatment Planning: develop a course of action that

encompasses the sequelae of treatment to serve the

patient needs


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Dental history

Medical history

Social history






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Patient Observation

Is he able to get out of the waiting room?

This could give an indication of bony, joint, muscleproblem.

Upon rising, is the patient steady or time is neededbefore gaining equilibrium

Dizziness might be an indication of possible side effects ofdrugs, cerebro-vascular accident, low blood pressure.

Observe the patients walk and assess the level ofcoordination and steadiness

Indication of Parkinson or arthritis


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At this stage, concentrate on the chief complaints

Chief complaints: this should be recorded in the patients

won words, but make sure that the meaning of the

information being conveyed is clear.

let the patient speak: he will tell you the diagnosis clearer picture of patients expectations

Create a rapport between the dentist and his patient.

The interview should be structured.


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Dental history

Medical history

Social history






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Previous Dental History

Provides information about:

Oral conditions.

Patients attitude.

Why the teeth were lost: periodontal ? Expect more bone loss

When the teeth were lost (history of edentulism)

Freshly edentulous (green ridge): expect Specules

Undercuts

Thin mucosa

Need for surgical intervention

New denture wearer:

The need to explain to the patient his state of edentulism

Old denture wearer:

Explain to your patient that the ability to refit his old dentures is not always

possible.

Estimate the level of the patient satisfaction of his old dentures.


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Medications:

Obtain a full list from the patient, and if this is not possible contact

the patient physician.

Evaluate the possible side effects: Anti-hypertensive drugs: xerostomia

Diuretics: changes in tissue fluidity

Psychological drugs: uncontrolled tongue and facial movements.

Patient opinion about his state of health could give an image about

the type of patient you are dealing with:

Optimistic patient-despite his sever illness is an indication of a cooperative

and adaptive patient-a positive sign for prosthetic treatment success.

It is the dentist responsibility to obtain the medical history and

update over time.


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Social History

Has the potential to influence the course and outcomeof treatment.

Some patients value the opinion of their relatives or

friends but others want to hide their edentulous state-their wishes for prosthodontic privacy should berespected.

Other aspects include the potential influence of

dentures on the selection of particular foodstuffs.


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Dental history

Medical history

Social history





Extra oral Assessment


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Extra-oral Assessment

General examination of the head and neck for non-

dental pathology

The presence of the following should be noted:

Nodules, nevi, ulcerations Facial coloring and tone,

symmetry, neuro-mascular activity.

The face and neck should be palpated for any massesor enlarged nodules.

Lack of mobility: needs for help to get in and out of

the chair. Deficiencies in hearing or sight.

F i l P fil


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Facial ProfileSkeletal malrelationship might influence teeth positioning

or denture stability


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TMJ assessment

Assessment of the masticatory

system: to see whether a range

of pain free movement is

possible.

Palpation of the skin of the TMJ

Auscultationif indicated- of joint

using a stethoscope

Observation of the patient while

they speak:

Mandibular movement Tooth position


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Excessive occlusal vertical dimension

Careful observation of thepatient while they are

speaking will provideinformation on:

mandibular movement,tooth position in relationto phonetics, verticaldimension.


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Lip examination

Cracking, fissuring at the corners, or ulcerations:

Vitamin B complex deficiency, candidal infection,

lack of VD

Lip support, fullness, thickness, and length. Lack of support of the lips will cause collapse and

wrinkles.

Denture can correct

wrinkling present around the modilous of the mouth,

weak, turned in, and not visible vermilion border


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Labio-nasal, labio-mental, philtrum: hollowness or

puffiness. Skin :

loose wrinkled skin that has lost its youthful tone may be

difficult to correct with the new dentures.

Thin tense skin is easily supported but very sensitive to smallchanges in anterior tooth position

Skin texture:

Rouph textured skin : deserve a more rugged anterior teeth set

up than smooth light colored skin.


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Note the bruising on the bridge of the nose- suggestiveof tissue fragility.


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Angular Cheilitis

Angular cheilitis mayalert to:

Poorly controlledDiabetes or dietary

deficiency Anaemia

Presence of poorly

fitting dentures ordenture inducedstomatitis.

Intra oral Assessment


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Intra-oral Assessment

General overview

Color of the mucosa Ranges from health pink to angry red

Angry red is an indicative of

Ill fitting denture

Underlying infection

Systemic disease: diabetes

Chronic smoking

White patches: keratosis from denture irritation

Other color changes: pigmented spots or lesions ranging from

light to dark brown. Dentist should biopsy any suspected color change and send to

the pathologist

li


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Saliva:

Amount

Dry mouth

Poor retention

Susceptible to injuries

Excessive saliva

Difficult to work with (especially in making impressions)

Consistency Thin

Thick

Ropy

Serous : the commonest in patients and the best to work with

Arch size:


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Arch size:

The greater the size , the more support available for thedentures.

Discrepancies in size between arches is an indicative ofpoor stability for the denture on the smaller jaw- this ispossibly caused by

Early loss of teeth in one jaw

developmental trauma

Sever class II or III malocclusion

arch form:

Square, ovoid, tapered The form can affect support for the denture and perhaps

tooth selection

Ridge contour:


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g The best is high ridge with flat crest and parallel or nearly parallel

sides.

Other forms include: V shaped Knife edge (poor support)

Flat ridge (poor resistance to lateral movement)

ridge with multiple specules (poor support)

Ridge relation

Inter-ridge distance: increase distance will increase leverage on thedentures and decrease stability.

Ridge that are not parallel will cause movement of the bases.

Observe the antero-posterior and the lateral relationships. This is determined by the amount and pattern of bone resorption and will

affect teeth arrangement and possible leverage

Classification (Attwood 1971):


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Classification (Attwood, 1971):

Class I: good ridge before extraction.

Class II: Immediate post extraction

Class III: well-rounded ridge form.

Class IV: Knife edge ridge

Class V: flat ridge

Class VI: negative or concave form.

Redundant tissues


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Redundant tissues

Presence of flabby tissues will cause the denture to shift under force

Combination syndrome ( maxillary complete denture against RPD

replacing kennedy class I) Over-eruption of the mandibular teeth

Bone resorption and hyperplasia of the anterior maxilla

Large redundant maxillary tuberosities (fibrous tissues)

Bone resorption under the RPD

Drop of the occlusal plan posteriorly

Papillary hyperplasia of the palate

Pre-prosthetic surgery and special impression techniques is needed

to overcome these problems


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Areas requiringrelief: tender to

palpation, superficialID in the region of

the mental foramina Enlarges tuberosities

Frenal attachmentclose to the crest ofthe ridge

i i i


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Denture induced stomatitis

Relatively common findingin denture wearers.

Characterized by erythema

o the denture-bearing areas,

and also may be

accompanied by varying

degrees of papillary

hyperplasia


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Retention: resistance of displacement away from thetissues

Stability: resist displacement non vertically

Support: resist displacement towards the tissues


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Hard-Palate


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U-shaped (favorable)

V-shaped palatal vault (un-favorable)

Flat-palatal vault (un-favorable) Soft-palate

Class I: horizontal with little mascular movement (most favorablefor posterior palatal seal)

Class II: turns dawn at 45 to the hard palate( less favorably than

class I) Class III: turns dawn sharply at 70 to the hard palate (least

favorable)

V-shaped palate is usually associated with class III softpalate.

Flat palatal vault is usually associated with class I or II.


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Retained roots. Bony lumps requiring relief

of the master casts

Undercuts dictating denture

extensions or path ofinsertion.

Torus Palatinus and Lingualtorus mandibularis


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Video : examination of maxillary &mandibular edentulous arches


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Dental history

Medical history

Social history





Denture Assessment


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Inside the mouth

Denture extensions: over-extensions/under-extensions

Retention

Stability

Teeth arrangement Relation to underlying ridge

Occlusal relationships VD RCP

Free way space

Aesthetics

Extension


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Extension

Retention


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Retention

Stability/ Support


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Stability/ Support

Relation to the underlying ridge


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Relation to the underlying ridge

Occlusion


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Occlusion

Denture AssessmentOutside the mouth


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Outside the mouth

Hygiene Materials used:

porcelain teeth

Lining materials

Signs of wears Inspection of the

impression surface:

Signs of relief

Tooth size, shape, color,arrangement


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Dental history

Medical history

Social history





Specific Investigations


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p g

Radiological

Haematological

Micorbilogical

Diagnostic appliances Assessing patient tolerance/adaptation

Prostho IV-Slides 2- Assessment of the Edentulous Patient

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