Prosto Lec 1

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Prosto lec 1

Introduction

Maintaining the best prognosis ever you must go in fewsteps before you start treating the patient you have and

these steps are:

1 proper pre-planning which include initial examination,

diagnosis and treatment plan

2 study these initial steps to come with a plan that u can

discuss with your patient to reach a final decision of whatis the most better for your patient

3 take in consideration points that might affect your

treatment which are (chief complaint, medical history,

clinical examination, financial resources of the patient)

4 if the patient needs any counsel other than dentist we

must refer him to the specialist that can help5 information that we need for the best diagnosis is also

the patient attitude , past and present medical conditions ,

past and present dental condition and intra + extra oral

examination

6 take care as a dentist that you have a difference

between the edentulous patient themselves so hardness

in working vary between one and another

Diagnosis

Now we move to the first step which is the diagnosis

where you as a dentist want to help a patient you need to

work on building trust and let patient tell you his complaint

and treatment expectations by his own word so you can

have 3 things


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1 patient trust in you as dentist 2 patient concerns 3 reach

initial ability of treating a patient

Medical history and present medical conditions

The major importance for knowing the medical history is

that being capable of evaluating the best effect of anything

that abnormal on our treatment.

The following examples are evidence that medical

historyis VIP:

1 patient s with these diseases might be very good ascomplete denture patient but risks of pre-prosthetic

surgery is high (uncontrolled diabetes, CVD, treatment

with blood thinners patients and immune compromised

patients)

2 Parkinson disease patients might face disability in

wearing dentures plus their treatment might be hard

3 history of physiological and cognitive impairment

disease might have unreasonable expectations of the

denture

4 history of head and neck radiation treatment can affect

any pr-prosthetic surgery plus leading to xerostomia that is

not okay with denture wearing people

The question now is why we need to update the medical

history and follow up the patients conditions resemble in:

1 sometimes because the complete patient are old people

so they might take few drugs together due to health issue

it helps in knowing these drugs also communicate with the

dr that prescribed these drugs if there was any concern

about one of them


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2 many times the patient coz of his age may forget things

so eventually a friend or a member of family must be

present and capable of answering questions about the

patient health according to the need of the case

3 noticing the vital baseline which is the blood pressure

and pulse that is important and critical in any future

medical emergency (not normal must be referred to

specialist)

4 xerostomia a very big issue that we might face due to

effects on oral health and ability to wear the denturesuccessfully caused by one of these: 1 antihistamine

drugs 2 medications for depression, anxiety, high blood

pressure, muscle relaxation, urinary incontinence and

Parkinson disease

5 allergy is also important because some patients may be

allergic to metal specially the nickel which is considered in

RPD and any allergy that is found in mouth might be

critical before any surgery we might do

*** So eventually the medical history and medical present

conditions give us all the info that we need to be able to

treat the patient properly and avoid any bad things that

can harm the patient (perfect prognosis)

Dental history

like medical history but now it is our filed we must collect

all the info that we need to reach the best results about

edentulous patient and these info varies from the

beginning of the chief complaint and ending with knowing

the attitude of patients from number of CD ( only by

questions)


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The subject of these questions will be like this:

1 regarding teeth: chief complaint, reason of losing teeth,

any effect on the ridge, time of being edentulous

2 regarding denture: time of wearing, period between

losing teeth and wearing, type of denture, type of teeth in

denture, esthetics result of denture

3 regarding patients: expectations, needs, attitude,

finance, physiological psychological factors

examination:extra oralClinical

For this examination first there is a sheet of things youshould work according to found at book page (49+50) not

required to be memorized you will work on one like it in

the clinic next year.

Second examination of head and neck include observation

and palpation and auscultation of anything we might found

and the most important things we need to take care about:

1 mandibular movement to notice any irregular movement

or deviation and disorder or pain coz it can affect the

accurate interocclusal records

2 muscle of mastication's and facial expression (while

movement + conversation)

3 palpation of any muscle tenderness or dysfunction


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4 TMJ must be palpated and ausculated for any pain

tenderness popping or clicking to avoid also what can

happen in point number1

5 neck must be also palpated for any lumps masses or

enlarged lymph nodes

6 lips and skins examining to avoid any non healing lesion

or angular cheilits

7 lip thickness and curvatures while CD is in the mouth

8 face in general with the midline and the philtrumClinical intraoral examination

This type of examination starts with general examination

of the whole oral mucosa so we can determine one of

these conditions: flabby or bound down, pink healthy or

red edematous ,excessively thick and the thin areas and

the last one is that if there is a lot of keratinized attachedtissue or movable mucosa on the ridge

Problems found at examination:

1 extreme irritation and traumatized tissue, with increase

susceptible to fungal over growth and colonization of the

CD, with inflammatory papillary hyperplasia in the palate

and these are due to patients who dont remove and

clean the dentures for long period

2 epulis fissuratum which is redundant tissue and very

painful found at borders of the denture caused by the

excessive flange length of denture and the treatment

is surgery if it didnt gone after denture removal

3 saliva must be checked for amount and consistency coz

it helps the patient to comfortably wear the denture


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because it work as a lubrication factor and it is also the

interface between denture base and the tissue (for

retention) .

So in patient with xerostomia or excessive saliva with

much mucus will face difficulty in putting the denture while

in normal salivary flow patient will get the best of adhesive

and cohesive finally these patients will not face the

prosthesis poor retention also they will face tenderness in

the mucosa so always check for the opening of thesalivary gland for better salivary flow

4 gag reflex issue which is a serious problem that can

affect the fabrication of the denture u may know about it

from the diagnosis or u may find it while working but

mainly it can best solved by using special techniques but

in case u couldnt treat them refer them to a special

prosthodontists

5 panoramic radiographs for tow things the mandibular

arch and maxillary arch to look mandibular height ,

position of maxillary sinuses , mental foramen, retained

root tips, unerupted teeth, residual cyst, bony pathology

parts and unusual TMJ anatomy

** for impacted teeth and retained root tip u must onlysearch for the pathology and also you must remove them

if they are so near the surface or if they are exposed dont

get to remove teeth deep one of them coz we are looking

for the economy of the bone but after all removal of them

is a shared decision between the dentist and the patient

after clearing the benefits and the risks (dont forget it is


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not easy to do surgery coz most patient are old with poor

health)

** maxillary ridge examined for the shape ,size and the

cross-sectional form coz the bigger one is better than the

small one in retention specially

** residual ridge is either ovoid or tapered and the

importance here is for the opposite arch coz if there was

no relation between ridges of opposite arch then the teeth

setting will be hard

** types of shapes of ridges: U-shaped ,V-shaped , knife

edged and flat , the last types are the worst knife and flat

coz there will be a lost of the foundation for the base of

denture

** The ideal ridge is the U-shaped ridge coz of no

undercuts approximating buccal and palatal walls which

give the max retention stability and support** If there was any exostoses or bilateral post. Undercut

then we might go for pre-prosthetic surgery

** regarding hard palate it is calcified as this high,

average, shallow, V-shaped (U-shaped is the ideal) but for

the V one or the high one it could compromise the seal of

denture

** regarding soft palate it is calcified as class 1 , class 2

and class 3 depending on the movement of the soft palate

or sloping against the hard palate

Class1: soft palate that moves slightly and slopes little

(normal ant.post relation)


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Class2: between class 1 and class 3 (retrognathic ant.post

relation)

Class3: drops abruptly at the junction of the hard and soft

palate (prognathic ant.post relation)

**for both maxillary and mandibular ridge which are

almost similar in examination take in consideration

that we dont want any exostoses or bilateral post

undercuts or any tori coz they will affect our work **

6 maxillary and mandibular ridges examined to see the

border tissue allow for CD fabrication

** If frenula is attachment is near the crest of residual

ridge then denture border will be short which will affect the

retention of the denture

7 muscle attachment specially mylohyoid in

retromandibular area is very important according to crest

coz it might compromise the denture retention

8 occlusal vertical dimension of the residual ridges can be

taken by making the patient bite with a finger position

between the upper and lower ridges but this is hard in

most patient so we wait tell the cast is made the we do it

** the maxillary ridge resorp slower and inward and

upward while the mandibular ridge resorp downward andoutward with 4 times more than the maxillary so this is

took in consideration coz the maxilla is resorp to becomes

narrow and short while mandible become longer and wider

with resorbtion

9 take in consideration both relation of the anterioposterior

relation and the mediolateral relation


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Mental attitude of the patient

The wearing of the denture for the edentulous patient is a

skill that is earned and it is mainly depending on the type

of the patient so dr. house calcify these patients in 4 types

with special characters for each type and they are:

1 philosophical patient: he is optimistic, cooperative,

rational and sensible he is the identical patient and he

want to get better from oral health side

2 exacting patient: he is precise, meticulous, and he may

ask for unreasonable demands from the dentist also he is

a detail loving patient he will ask for each step

3 hysterical patient: excitable, nervous and excessively

hypersensitive and pessimistic he will feel that he won't be

able to wear any denture (more than 1)

4 indifferent patient: lack of motivation and unwilling to

follow instruction and he was forced or told to take care ofhis oral health by a member of his family so he is the

least cooperative one and the worst one

Additional diagnosis information

In here we first depend on the cast that we made from

preliminary impression with irreversible hydrocolloid in

stock trays it should include: 1 retro molar pads 2 borderof tissues 3 pterygomaxillary notch 4 posterior palatal seal

area

Secondary we depend on sthng called the PDI

prosthodontics diagnosis index that at the beginning was

putted to help the dentist and insurance companies to

identify the difficulty of patient condition by these factors:


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1 mandibular bone height 2 maxilomandibulare ridge

relation 3 residual ridge relation

4 muscle attachment 5 systemic considerations 5

psychosocial consideration

6 tongue anatomy 7 TMJ disorders 8 need of surgery

Then with developing it calcified the patient into 4 classes

according to the difficulty of the cases and they are:

Class 1 patient: uncomplicated can be treated by any

dentist even if he wasnt properly trainedClass 2 patient: some moderately complicating factors

such as systemic disease or residual ridges and can be

treated by a dentist that has an experience

Class 3 patient: he is with additional complicating

problems like TMD symptoms, limited or excessive

interact distance with possibility of pre-prosthetic surgeryneed and it can be treated by a dentist that is trained and

did do these treatment before

Class 4 patient: most complicated and depilated patient

here the patient has very poor edentulous arches that

indicate pre-prosthetic surgery but can't be done due to

health problems or finance and this only treated by

prosthodontists

planningTreatment

before we just decide the plan we must collect all info from

lab results and recommendations and results of soft and

hard tissue biopsy after that as a dentist you must discuss

all of that with your patient and clear the period of

treatment and the type of treatment and what is the best


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for him and the sequence also then take the approval of

the patient to start the treatment

Prognosis

we can reach this step after doing everything we talked

about and after diagnosis ,examination, PDI system and

eventually according to these information we can get our

results even before start doing the work and we can tell

the patient about the

Done : ahmad fawzi

Study with pleasure

Prosto Lec 1

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