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Engelmeier RL, Phoenix RD.DCNA 1996;40(1)
PATIENT EVALUATION, DIAGNOSIS AND TREATMENT
PLANNING FOR COMPLETE-DENTURE THERAPY
1
IntroductionPatient evaluation
History: The Patient’s Storyo Personal Datao Dental Historyo Medical History
Examination: Dentist’s Observationso Extraoralo Intraoralo Existing Dentureo Radiographico Study Casts
2
Contents
Treatment planningo Preliminary Phaseo Surgical/ Restorative Phaseo Rehabilitation Phaseo Maintenance Phase
3
Contents
All the patients seeking dental services have some degree of experience and understanding which should be recognized by the dentist and address it in the treatment planning.
First visit is very important because explanations given to the patient at this appointment form the implicit agreement between the dentist and the patient:
“Seeds of Success and Failures are Sown”
4
Introduction
The collection of medical and dental histories and their careful analysis, coupled with a thorough orofacial examination are the essential and integral part of the prosthodontic management as these are necessary for the selection of the optimal treatment protocol.
5
Introduction
A health questionnaire is a convenient method of collecting the basic information and personal data which can be sent to the patient before the appointment or administered in the reception, dentist then review and clarify the information provided in the private operatory which is comfortably equipped, tastefully decorated, free of distractions so as to provide the patient with the sense of security and privacy that will allow them to communicate honestly and completely.
6
Introduction
Data collected should be well documented.
A logical method to accomplish this is to use a checklist.
7
NameAgeSexRaceOccupationContact detailsCosmetic IndexPersonality and Mental AttitudeSocio-economic StatusOral hygiene habitsOther habits
8
Personal Data
Conversing with the patient addressing him with his name is a good way of gaining the patients confidence. The patient feels he is dealing with a friend and not a stranger and It is easy to get information concerning his medical and dental histories.
NAME
9
A. Adaptability and physiological Condition of Supporting Structures
Younger: Adapt rapidly and high esthetic requirementsBeyond fifth decade: Doesn’t adapt readily
B. Mental AttitudePostmenopausal women: hysterical or exacting with high
esthetic requirementsMen at this age: Preoccupied with their career – indifferent – concerned only with comfort or function
10
AGE
Females: more concerned with appearanceMales: though young male are concerned with
appearance but they grow indifferent to their appearance and shift focus to comfort and
health.
Lack of Oestrogen in postmenopausal women creates Osteoporosis as oestrogen have anti-
absorptive effect on bone. HRT is given.
11
SEX
The occupation of an individual may demand special consideration in denture construction from the
standpoint of esthetics, phonetics, or function or other special qualities in
dentures.
12
OCCUPATION
Critical factor in the characterization of dentures (i.e., choice of denture base shade, placement of denture base stains, etc.)
13
Race
Classify the patient as class 1: high cosmetic index class 2: average cosmetic index class 3: low cosmetic index Patients with high cosmetic indices, though
often exacting, usually are appreciative and cooperative. Conversely, patients with low cosmetic indices often are indifferent, uncooperative, and place little value on the efforts of the prosthodontist.
14
Cosmetic Index
Dentist should assess it all the way during history taking and examination.
Much of this can be revealed through the discussion of the chief complaint, reason of teeth loss, importance of any remaining teeth and the patient’s experience with the dentistry especially with the previous denture.
15
MENTAL ATTITUDES
Personality difficulties become exaggerated under the influence of ill health, old age, menopause or flair up
because of unfavorable social or business environment or the state of dominating or
being dominated by others.
16
MENTAL ATTITUDES
Danger lurks at both the ends of positive negative spectrum. Overly optimistic may have unrealistic expectations and on the other end the patients who expect nothing more than another failure.
In any case dentist must strive to bring the patient to the reality.
“Complete Denture is not the replacement of teeth but it is the replacement of NO TEETH”
17
MENTAL ATTITUDES
It is an general agreement that the complete denture success or failure is not exclusively determined by the patient’s oral anatomy or the efforts of the dental team but also on the patient’s attitude towards the prosthesis.
18
MENTAL ATTITUDES
Loss of teeth in both the general groups, weather they are morphologically or emotionally maladaptive, is an obstacle they cannot surmount easily despite provision of excellent prosthetic replacements.
So, there are many critical element to be considered in managing all the patients, the two most important are the behavior of the doctor and a thorough patient interview both of which involve the skillful handling of verbal and nonverbal communication
19
MENTAL ATTITUDES
The interview can comprise four parts:i. The recognition and acknowledgement of
the problemii. Its identification and explorationiii. Its interpretation and explanationiv. The offering of a solution to the problem
20
MENTAL ATTITUDES
This iatrosedative interview creates indispensable trusting relationship in the process of determining the factors responsible for the problem and seeks to offer a solution.
Dentists tend to very rapidly become masters in technical skills and adept at providing quick solution to problems, however many clinical challenges require significant commitment to “patience with patients”
21
MENTAL ATTITUDES
There are some who have significant psychological problems the require professional help.
These patient should be referred to the appropriate professionals. Because of sensitive nature of such referrals, it usually is best to start with the patient’s physician.
22
MENTAL ATTITUDES
Philosophical
Exacting
Hysterical
Indifferent
23
CLASSIFICATION OF MENTAL ATTITUDES
Philosophic: Those patients are• easygoing, • congenial, • mentally well-adjusted, • cooperative, and • confident in the dentist
Prognosis is excellent
24
CLASSIFICATION OF MENTAL ATTITUDES
Exacting: These patients are • precise, • above average in intelligence, • immaculate in dress and appearance, • often dissatisfied with past treatment, doubt the
ability of the practitioner to satisfy him or her, and
• often want written guarantees or remakes at no additional charge
Once satisfied, an exacting patient may become the practitioner's greatest supporter
25
CLASSIFICATION OF MENTAL ATTITUDES
Hysterical: These patients • submit to treatment as a last resort, • have a negative attitude, • are often in poor health, • are poorly adjusted, • often appear "exacting" but with unfounded complaints, • have failed at past attempts to wear dentures, and • have unrealistic expectations (hysterical patients often
demand esthetics and function equal to or greater than natural teeth).
Prognosis is poor.
26
CLASSIFICATION OF MENTAL ATTITUDES
Indifferent: These patients are • not concerned with appearance, • often go without dentures for years (or wear
poor or worn-out dentures far beyond serviceability),
• do not persevere, and • do not adapt well. • Such patients have no desire to wear dentures
and do not value the efforts or skills of the dentist.
27
CLASSIFICATION OF MENTAL ATTITUDES
28
Anupama MS, Nair KC. Graphoanalysis: an aid in patient evaluation. KDJ. 2009; 32: 14-9
29
Mental Attitude: Handwriting
Determined by OccupationIncomeEducation
30
Socio-economic Status
Method and frequency of oral hygiene should be asked by the patient.
These factors may affect denture-base contouring (e.g, closed interdental contours versus open interdental contours) and tooth arrangement (e.g., presence or absence of diastemata).
Hygiene should be classified as (1) good, (2) fair, or (3) poor
31
Oral Hygiene Habits
Other potentially unfavorable habits• Tobacco smoking and alcohol consumption• Patient should be informed about their
systemic effects, potential local impacts e.g. detrimental effect on wound healing, soft tissue health, or the durability of tissue conditioners
Parafunctional habits• Like bruxism and clenching• Must be considered and their presence must be
considered while forming a treatment protocol
32
Other habits
Chief ComplaintReason of teeth lossDuration of complete edentulousnessWeather a previous denture wearer
Patients comments on present denturesPresent dentures evaluation
Patient’s expectations with the new dentures
33
Dental History
According to DeVan, "The dentist should meet the mind of the patient before he meets the mouth of the patient."
Hence, the dentist must determine the reason the patient is seeking prosthodontic treatment. The patient should be questioned regarding his or her chief complaint.
34
Chief Complaint
There are several reasons for seeking this information.
First, if this is not done, the chief complaint may be overlooked during therapy.
Second, the response allows the practitioner to assess whether the patient's expectations are "realistic" or "attainable."
And finally, the response provides information regarding the patient's psychological classification (for House's personality classification scheme).
35
Chief Complaint
Provide insight into their appreciation of the dentistry and contribute to the prognosis for prosthodontic success.
Patients who lost their teeth in an accident might be more unhappy about their edentulous state than those who lost teeth as a consequence of decay resulting from neglect.
36
Reasons for Teeth Loss
Expectations for the remaining alveolar bone would be great for the patients with a history of rapid teeth loss from decay than for the patients with the long history of progressive periodontal diseases.
37
Reasons for Teeth Loss
Provide information regarding the resorption pattern.
Large, rapid changes occurs in the alveolar ridge morphology during the first year after extraction.
A “green ridge” may have bony spicules remaining from extraction sites or bony undercuts with a thin mucosal covering.
38
Duration of Complete Edentulousness and order of
teeth loss
The patient should be questioned regarding the number and types of previous dentures.
A patient with a history of several dentures over a short period of time is a poor prosthodontic risk.
If the patient is old denture wearer it is wise to know the weather the patient is satisfied with the old denture and dentist is dealing with the hostile or receptive attitude.
39
Previous dentures
Patient should be questioned about the duration, chewing efficiency, comfort, esthetics, speech related to the present denture.
Comments of the patient should be noted down as
1) Good 2) Fair 3) Poor
40
Patient comments on the present dentures
Teeth shade, mold and materialEsthetic, phonetics, retention, stability,
extensions, contoursCentric relation and vertical dimension of
occlusionOcclusal plane orentationPalatePostdamBase Adaptation
41
Present Denture Evaluation
MidlineBuccal vestibuleCrossbiteCharacterizationWearAttachment and hardwareDenture base extensionArch form
42
Present Denture Evaluation
All the properties should be graded as1) Good, Fair and Poor2) Acceptable and unacceptable3) Adequate and inadequate
43
Present Denture Evaluation
Dentist should be aware of each patient’s general health as they are responsible for their well being
Knowledge of medications that patient is taking is important to avoid any conflict in the therapy.
44
MEDICAL HISTORY
Much can be learned from watching the patient entering the operatory and sitting in the dental chair.
45
MEDICAL HISTORY
Cardiovascular disease Anaemia Respiratory Disorder Bleeding disorders Diabetes Asthma AllergyTuberculosis
46
MEDICAL HISTORY
Rheumatoid Arthritis/Bone disordersJaundice Neurological disorder Radiotherapy Palsy Drug history Epilepsy Skin disorders
47
MEDICAL HISTORY
The patient must have this condition under proper medical control. This is important, for the success of
dentures.
The operator should use an impression technique that will produce maximum physiologic compatibility of the
denture base with the supporting tissues
Careful occlusal corrections should be accomplished to remove all interferences.
The food table should be small and the patient should be given detailed instructions on eating habits and oral
hygiene.
Frequent evaluation of the dentures is necessary.48
MEDICAL HISTORYDIABETES
The limited movement of the mandible during impression making may necessitate special trays
and procedures. It may be difficult to get proper registrations.
Generally, the tactile method is the most satisfactory.
Occlusal corrections must be made often because of arthritic changes in the temporomandibular
joint. 49
MEDICAL HISTORYARTHRITIS
Retention is often hard to achieve, and an adhesive may be necessary.
The patient should be educated for mastication and oral hygiene.
50
MEDICAL HISTORYBELL'S PALSY
Control of the patient during fabrication of the denture can be accomplished with sedatives.
Retention is difficult, and an adhesive may be necessary.
It may be wise to remove dentures when they are not in use. This will add to the comfort of the
patient and eliminate the danger of swallowing them.
51
MEDICAL HISTORYPARKINSON’S DISEASE
If dentures are to be made, it in imperative that no abrasion or irritation be present on the
supporting tissues.An open lesion may be the start of a serious
condition, namely osteoradionecrosis.It is best not to use dentures at all over
irradiated tissues, but if dentures are necessary, they should not be used until at
least two years after radiotherapy.
52
MEDICAL HISTORYRADIATION
Extraoral
Intraoral
Existing Denture
Radiographic
Study Casts
53
CLINICAL EXAMINATION: DENTIST’S OBSERVATIONS
Facial symmetry Facial form (Frontal) Facial form (Profile) Facial features Skin color Lip
• Length• Thickness• Tonicity• Lip contact
Appearance• Cheeks• Lips• skin
54
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Nose• Symmetry• Tip• Nasolabial fold
Philtrum Chin TMJ Neuromuscular Control Speech Lymph Node Examination
55
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACIAL SYMMETRY
SymmetricalAsymmetrical
56
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACE FORM (Frontal)(House and Loop, Frush and Fisher and
Williams)1. Square: in this case the face is about equally
wide in the temporal region, the area of the zygomatic arch and the angles of the jaw.
57
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACE FORM
2. Tapering: A decrease in width is generally found in these types as one progresses from forehead to chin.
58
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACE FORM
3. Square tapering: a combination of the square and tapering forms.
59
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACE FORM
4. Ovoid: the area of the zygomatic arch is widest in this case.
60
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACIAL PROFILE (Angle)
Class 1, Normal: that is the Nasion, Point A, Point B are in the same line.
61
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACIAL PROFILE (Angle)
Class 2, Retrognathic: that is Point B is placed posteriorly compared to Class 1
62
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
FACIAL PROFILE (Angle)
Class 3, Prognathic: that is point B is placed anteriorly compared to Class 1
63
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Rugged
Delicate
Average
64
Facial Appearance:
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
ComplexionHair, eye, and skin color provide useful guides in
shade selection.
65
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
ComplexionSkin color also can reveal underlying
disease and pathology. Patients with significant sun damage warrant referral to a dermatologist.
Pale, anemic-looking patients may have underlying systemic diseases and may
require longer adjustment periods.
66
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
LIPContour• Adequately
supported• Unsupported
67
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
LIPMobilityClass 1: Normalclass 2: Reduced MobilityClass 3: ParalysisPatients with minimal lip mobility show very
little of the anterior teeth.
68
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
LIPMobility
Some stroke victims may have paralysis of half the lip, leading to unilateral mouth droop and facial asymmetry.
Patients must be counselled regarding treatment limitations when dealing with such physical challenges. Otherwise, patients may have unrealistic expectations regarding functional and esthetic results.
69
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
LIPLength Classify lip lengths as long, normal or
medium, and short.A long lip reveals little of the anterior teeth,
whereas a very short lip allows the display of the denture base.
Mold selection and denture characterization can be critical factors in these cases.
70
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Cheeks, Lips, Skin: AppearanceFull/ Thin
71
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
NoseSymmetry: Present/ AbsentTip: Prominent/ DepressedNasolabial Fold: Deepened/ Normal
72
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
PhiltrumNormal/ Obliterated/ Deepened
73
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
CHIN• Prominent/ Not prominent
• Deviated/ Undeviated
74
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Labiomental Sulcus Normal/Obliterated/Deepened
75
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
TMJ • Tenderness/
Discomfort • Crepitus• Deviation of
mandible in movement
76
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Mandibular Movements Normal/Deviated/Restricted
77
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Mouth Opening Normal/Reduced
78
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Neuromuscular CoordinationClass 1: ExcellentClass 2: Fair Class 3: PoorPatients with good neuromuscular
control expected to learn to manipulate dentures relatively quickly
79
Muscular Tone (House)
Class 1: the patient exhibits normal tension, tone, and placement of muscles of mastication and facial expression.
Majority of edentulous patients have experienced some degree of degeneration.
Usually present only in immediate denture patients.
80
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Muscular Tone (House)
Class 2: the patient usually exhibits normal tension but impaired tone
81
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Muscular Tone (House)
Class 3: the patient exhibits greatly impaired tone and tension.
This impairment is usually coupled with poor health, inefficient dentures, and loss of vertical dimension, wrinkles, decreased biting force and drooping commissure.
82
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Muscular Development(House)
Class 1: HeavyClass 2: MediumClass 3: Light
83
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
SpeechNormal / AffectedPatients with speech impediments or
those who cannot articulate optimally with their existing dentures require special attention when the dentist places the anterior teeth and forms the palatal portions of the denture base.
84
CLINICAL EXAMINATION EXTRA ORAL EXAMINATION
Lymph Node Examination
(Submandibular, Submental, Cervical, Preauricular, Mastoid)
-Palpable/Non palpable -Tender/Non tender -Movable/Fixed
85
86
Mucosa Tongue• Mucosa• Size• Position
Residual Ridge• Frenal Attachment• Arch Form• Vestibule
87
CLINICAL EXAMINATION INTRAORAL EXAMINATION
Palate• Incisive Papilla• Ruage• Compressibility• Fovea• Maxillary Tuberosity• Palatal Throat Form• Soft Palate
Floor of mouth• Lateral Throat Form
Mylohyoid Ridge88
CLINICAL EXAMINATION INTRAORAL EXAMINATION
Ridge RelationshipInterarch SpaceSalivaTorus
89
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MUCOSA : COLORFrom healthy pink to angry red. Redness indicate: inflammationIll-fitting denture, underlying infection, a
systemic disease such as diabetes or chronic smoking.
Determine the cause and remove the irritant for success of denture.
90
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MUCOSA : THICKNESSS(House)
Class 1: Normal uniform density of mucosal tissue (approximately 1-mm thick).
Investing membrane is firm but not tense and forms an ideal cushion for the basal seat of a denture.
91
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MUCOSA : THICKNESSS(House)
Class 2: (a) Soft tissues have thin investing
membranes and are highly susceptible to irritation under pressure
(b) Soft tissues have mucous membranes twice the normal thickness.
92
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MUCOSA : THICKNESSS(House)
Class 3: Soft tissues have excessively thick investing membranes filled with redundant tissues.
At the very least, this requires tissue treatment such as surgical correction.
93
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MUCOSA : THICKNESSS(House)
Uneven thickness because of different timings of extraction.
Extremely thin: teeth have been missing for a long time
Normal: Teeth removed recently. Other areas may be excessively thick with localized
regions of redundant tissue.
Such variations make it difficult to equalize pressure under the denture and to avoid soreness.
94
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MUCOSA : CONDITION(House)
Class 1: HealthyClass 2: Irritated
Class3: Pathologic
If class 2 or 3 is present, remove the cause of irritation and pathology.
95
CLINICAL EXAMINATION INTRAORAL EXAMINATION
TONGUE POSITION (Wright)
Normal: The tongue fills the floor of the mouth and is confined by the mandibular teeth.
Lateral surface rest on the occlusal surface of posterior teeth.
Most favourable prognosis. The floor of the mouth will be high enough to
cover the lingual flange of the denture producing a border seal. 96
CLINICAL EXAMINATION INTRAORAL EXAMINATION
TONGUE POSITION (Wright)
Class 1: Retracted: The tongue is retracted.
The floor of the mouth pulled downward. The lateral borders are raised above the
occlusal plane and the apex is pulled down into the floor of the mouth.
97
CLINICAL EXAMINATION INTRAORAL EXAMINATION
TONGUE POSITION (Wright)
Class 2: Retracted: The tongue is very tense and pulled backward and upward.
The apex is pulled back into the body of the tongue and almost disappears.
The lateral borders rest above the mandibular occlusal plane.
The floor of the mouth is raised and tense. 98
CLINICAL EXAMINATION INTRAORAL EXAMINATION
CLINICAL EXAMINATION INTRAORAL EXAMINATION
ARCH FORM ( House)
SQURARETAPERING
OVOID
99
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM Height: RetentionParallel walls: Stability as lateral
movements ate limited by this even if vertical displacement occurs
Also, retention ∝ Surface Area
100
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Maxillary)
Class 1: square to gently roundedIdeal for retention and stability
101
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Maxillary)
Class 2: Tapering and V-shapedResults from bone loss in both width and
height, so poor in both retention and stability
102
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Maxillary)
Class 3: Flat
103
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Mandibular)
Class 1: Inverted "U" shaped(Parallel walls from medium to tall with
broad crest)
104
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Mandibular)
Class 2: Inverted "U" shaped (short with flat crest)
105
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Mandibular)
Inverted “W” short inverted “V” tall, thin inverted “V”
Class3: Unfavorable
106
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM (Mandibular)
Undercut
107
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE FORM Defects: Ridge defects, such as exostoses
or divots, may pose problems for complete-denture patients or may warrant preprosthetic surgery.
108
MUSCLE or BORDER ATTACHMENTS (House)
Class 1: High in the maxilla or low in the mandible with respect to the crest of the ridge. ≥ 0.5 inches
Class 2: Medium. 0.25-0.5 inchesClass 3: ≤ 0.25 inches
109
CLINICAL EXAMINATION INTRAORAL EXAMINATION
FRENUM ATTACHMENTS (House)
Class 1: High in the maxilla or low in the mandible with respect to the crest of the ridge.
Class 2: MediumClass 3: Encroach on the crest of ridge and
may interfere with the denture seal. Surgical correction required.
110
CLINICAL EXAMINATION INTRAORAL EXAMINATION
FRENUM ATTACHMENTS (House)
Especially in case of mandible, if freni are present at both labial and lingual sides of the residual anterior mandibular ridge, surgical reposition of the freni is must because denture will be weaker in these area and fracture may result.
111
CLINICAL EXAMINATION INTRAORAL EXAMINATION
INCISIVE PAPILLA• Normal• Tender• Prominent
112
CLINICAL EXAMINATION INTRAORAL EXAMINATION
PALATAL RUGAE• Normal• Prominent• Faint
113
CLINICAL EXAMINATION INTRAORAL EXAMINATION
PALATAL COMPRESSIBILITY• Median area
o Rigido compressible
• Lateral areao Rigido compressible
114
CLINICAL EXAMINATION INTRAORAL EXAMINATION
FOVEA PALATINI • Prominent • Non prominent
115
CLINICAL EXAMINATION INTRAORAL EXAMINATION
MAXILLARY TUBEROSITY • Bulbous• Pendulous• Undercuts
o Unilateral o Bilateral
116
CLINICAL EXAMINATION INTRAORAL EXAMINATION
CLINICAL EXAMINATION INTRAORAL EXAMINATION
SOFT PALATE Class 1 – soft palate is rather
horizontal and demonstrates little muscular movement. It is the most favourable condition because it allows for more tissue coverage for the palatal seal.
Class 2 – soft palate turns downward at about a 45 angle to the hard palate and the amount of the potential tissue coverage for the palatal seal is less than that of the class1.
117
CLINICAL EXAMINATION INTRAORAL EXAMINATION
SOFT PALATE
Class 3 – A class 3 soft palate turns downward at about a 70 angle just posteriorly to the hard palate. Therefore this is the least favourable form of soft palate.
118
PALATAL THROAT FORMClass 1: Large and normal in form, with a
relatively immovable band of resilient tissue 5 to 12 mm distal to a line drawn across the distal edge of the tuberosities.
119
CLINICAL EXAMINATION INTRAORAL EXAMINATION
PALATAL THROAT FORMClass 2: Medium size and normal in form, with
a relatively immovable resilient band of tissue 3 to 5 mm distal to a line drawn across the distal edge of the tuberosities.
120
CLINICAL EXAMINATION INTRAORAL EXAMINATION
PALATAL THROAT FORMClass 3: Usually accompanies a small maxilla.
The curtain of soft tissue turns down abruptly 3 to 5 mm anterior to a line drawn across the palate at the distal edge of the tuberosities.
121
CLINICAL EXAMINATION INTRAORAL EXAMINATION
PALATAL SENSITIVITY(House)
Class 1: Normal Class 2: Subnormal (hyposensitive) Class 3: Supernormal (hypersensitive)
122
CLINICAL EXAMINATION INTRAORAL EXAMINATION
THROAT FORMLATERAL THROAT FORM Class I Low - 1/2 inch or more from the
mylohyoid ridge to the bottom of the retro-mylohyoid fold, visible when the tongue is in a slightly protruded position. Most favorable.
Class II Medium - Less than 1/2 inch under the same conditions as above.
Class III High - Retro-mylohyoid fold at same level as mylohyoid ridge. Least favorable.
123
CLINICAL EXAMINATION INTRAORAL EXAMINATION
THROAT FORM
124
CLINICAL EXAMINATION INTRAORAL EXAMINATION
Class 1 Class 2
Class 3
MYLOHYOID RIDGE• Normal• Resorbed• Sharp
125
CLINICAL EXAMINATION INTRAORAL EXAMINATION
CLINICAL EXAMINATION INTRAORAL EXAMINATION
INTERMAXILLARY RELATIONSHIP
If both the ridges are large, part the lips gently while the patient maintains a rest position and note if there is sufficient space for teeth.
If the space is limited remember to use very thin denture base over the ridges and use acrylic resin teeth.
126
CLINICAL EXAMINATION INTRAORAL EXAMINATION
INTERMAXILLARY RELATIONSHIP
A large intermaxillary space is also unfavorable because the teeth are present so far above the ridge that undesirable forces may be created on the ridges and also denture will be heavy.
127
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE PARALLELISM Class 1: Both ridges
are parallel to the occlusal plane.
Class 2: The mandibular ridge is divergent from the occlusal plane anteriorly.
Class 3: The maxillary ridge is divergent from the occlusal plane anteriorly or both ridges are divergent anteriorly.
128
CLINICAL EXAMINATION INTRAORAL EXAMINATION
RIDGE RELATIONClass 1, Normal,The lower
ridge crest is very slightly to the inside of the upper ridge crest
Class 2, Retrusive,The lower arch is smaller than the upper and the lower ridge crest is inside the upper ridge crest considerably more than in the normal.
Class 3, Protrusive,The lower arch is larger all around than the upper; hence the upper ridge crest is inside of the lower ridge crest. 129
SALIVAClass 1: Normal quality and quantity of
saliva. Mixed Saliva. Cohesive and adhesive properties of saliva
are ideal.Class 2: Excessive saliva; contains much
mucus.Class 3: Xerostomia; remaining saliva is
mucinous.
130
CLINICAL EXAMINATION INTRAORAL EXAMINATION
SALIVAThin watery saliva may affect retention. Thick ropy saliva complicates impression
making and is annoying to the patient as it clings to the denture.
Abundant saliva is common when the denture is first inserted but usually improves with time.
131
CLINICAL EXAMINATION INTRAORAL EXAMINATION
CLINICAL EXAMINATION INTRAORAL EXAMINATION
TORIClass 1: Tori are absent or
minimal in size. Existing tori do not interfere with denture construction.
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CLINICAL EXAMINATION INTRAORAL EXAMINATION
TORIClass 2: Clinical examination
reveals tori of moderate size. Such tori offer mild difficulties in denture construction and use. Surgery is not required.
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CLINICAL EXAMINATION INTRAORAL EXAMINATION
TORIClass 3: Large tori are
present. These tori compromise the fabrication and function of dentures. Such tori usually require surgical recontouring or removal.
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CLINICAL EXAMINATION INTRAORAL EXAMINATION
TORIDoes not require surgical
intervention unless large and bulbous.
The mucosa over tori is usually thin and unyielding.
Do not use arbitrary relief at the site of the torus. The correct relief can be obtained by a special impression procedure or with pressure indicator paste in the finished denture. 135
CLINICAL EXAMINATION INTRAORAL EXAMINATION
TORIMandibular Tori usually more of
a problem as they interfere with the lingual border seal and restrict the tongue space. If prominent, especially if undercut, surgical correction is indicated.
136
OPG should be advised.Check for:• Root pieces• Foreign bodies• Impacted/Embedded teeth• Rarefaction of bone• TMJ-Findings
137
INVESTIGATION RADIOGRAPHS
TREATMENT PLANTreatment planning is the process of matching
possible treatment options with patient needs and systemically arranging the treatment in order of priority but keeping with logical or technically necessary sequence.
The dentist must resist the natural tendency to include in a treatment plan the treatment that the dentist feels competent to deliver. Treatment plan must have a parallel process of developing a prognosis.
Treatment is driven by the diagnosis must take other factors like prognosis, patient health and attitudes into account
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1. ZARB,PROSTHODONTIC TREATMENT FOR EDENTULOUS PATIENTS 12TH EDITION PAGES 73-99.
2. WINKLER S.,ESSENTIALS OF COMPLETE SENTURE PROSTHDONTICS,2ND EDITION ,Pg39-55.
3. ENGELMEIER R.L.,D.C.N.A.,VOLUME 40;1:18
4. WWW.CPMCNET\CHAPTER 1 PATIENT HISTORY.HTM
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REFERENCES