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Prosthodontics 3 Laboratory o A granular type commonly

Tissue Response, Clinical Examination, involving the central part of the


Preprosthetic Procedures to Complete hard palate and alveolar ridge
Denture o cause by presence of microbial
plaque accumulation
 Management of Denture Stomatitis
Long term wear of dentures lead to changes in  Correction of ill-fitting dentures
the oral tissues o Relined with soft tissue
conditioner
o New denture when mucosa has
SOFT TISSUE REACTIONS FROM healed
DENTURE WEARING:  Efficient plaque control (oral & denture
hygiene)
1. Injury and inflammation
o Remove and clean denture after
a. If tolerance is low
meal
2. Fibrous tissue growth ( flabby
o Clean & massaged mucosa with
hyperplastic tissue)
soft toothbrush
a. if tolerance is high and trauma
o Removedenture at night
tolerable
 Anti-fungal therapy
CAUSES OF MUCOSAL IRRITATION o Local therapy
 Nystatin
1. Mechanical irritation by denture
 amphotericin B
2. Accumulation of microbial plaque on
 miconazole
denture
 clotrimazole
3. Toxic or allergic reaction to constituents
o Systemic therapy
of denture material
 Ketoconazole
Local irritation of mucosa, increase mucosal  fluconazole (Resistance
permeability to allergens or microbial antigen occurs)

DIRECT SEQUELA OF WEARING 2. Angular Cheilitis


DENTURE
Often correlated with candida-associated denture
1. Denture Stomatitis stomatitis
Classification Predisposing Factors
 Type I  overclosure of jaw
o A localized simple  nutritional deficiencies
inflammation or pinpoint  iron deficiency anemia
hyperemia
o Caused by trauma 3. Flabby Ridge
 Type II  Due to replacement of bone by fibrous
o A more diffuse erythema tissue
involving a part or the entire
 Most common in anterior part of maxilla
denture covered mucosa,
when opposed by remaining anterior
o Caused by presence of
teeth in the mandible
microbial plaque accumulation
 Caused by excessive load of residual
 Type III
ridge and unstable occlusal condition
 Management *If not corrected may develop into denture
o Remove surgically -to improve irritation hyperplasia
stability & to minimize alveolar
ridge resorption
6. Burning Mouth Syndrome (Denture
o In extreme atrophy - not totally
Sore Mouth)
removed because vestibule will
be eliminated Signs

4. Denture Irritation Hyperplasia (Epulis  Burning sensation


Fissuratum)  Oral mucosa appears healthy
 >50 yrs old females wearing denture
Causes  Often appears for the first time in
 Chronic injury by unstable denture association with the placement of new
 Thin, overextended denture flange denture
 Feeling of dry mouth with persistent
Signs altered taste perception
 Headache, insomia, decreased libido,
 Maybe single or quite numerous
irritability, depression
 Composed of flaps of hyperplastic
connective tissue Causes
Management  Local
o mechanical
 Adjustment of denture
o irritation
 Replacement of denture o allergy
 Surgical excision o infection
o oral habits
5. Traumatic Ulcers (Sore spots) o myofacial pain
Causes  Systemic
o Vitamin deficiency ( Vit B12,
 Overextended denture flange Folic acid)
 Unbalanced occlusion o Iron deficiency anemia
 Nodules on the impression surface o Xerostomia (radiation therapy)
o Menopause
o Diabetes
Signs  Psychogenic factors
o Anxiety
 Develop within 1 to 2 days after o Depression
placement of new denture o Psychosocial stressors
 Small and painful lesion, covered by a
gray necrotic membrane, surrounded by Management
an inflammatory halo with firm elevated
 Depends on the cause
border
Management 7. Gagging

 Adjustment of denture Caused by the tactile stimulation of soft palate,


posterior part of tongue, fauces
 overextended borders Treatment Planning
o posterior part of maxillary
 The process of matching possible
denture
treatment options with the patient needs
o distolingual part of maxillary
and systematically arranging the
denture
treatment in order of priority but in
 poor retention of maxillary denture
keeping with a logical or technically
 unstable occlusal condition
necessary sequence
 increased vertical dimension at
occlusion Treatment Plan
INDIRECT SEQUELA OF WEARING  An initial, tentative outline of
DENTURE therapeutic measures to be undertaken in
accordance with diagnostic data and
Indirect Sequela
indications
1. Atrophy of masticatory muscle
Prognosis
(masseter and medial pterygoid)
 Probable outcome of the treatment
Cause
DATA COLLECTION AND RECORDING
 Reduced bite force and chewing
efficiency  Questions
 Records
Preventive Measures and Management
 Visual Observation
 use of overdenture  Radiographic Examination
 use of implant supported denture  Palpation
 Measurement
2. Nutritional deficiency  Diagnostic Cast
Causes EXAMINATION
 ill-fitting denture Case History
 salivary gland hypofunction
 altered taste perception  General information, chief complaint,
history of present illness, past history,
Management systems review
 mechanical preparation of food before Clinical Examination
eating
 General appraisal of the patient, detailed
EXAMINATION, DIAGNOSIS AND oral exam, special exam when indicated
TREATMENT PLANNING
Diagnosis
Definition of Terms
 Etiology and significance
Diagnosis  prognosis
 Art of distinguishing one disease from Treatment Plan
the other, determination of the nature of
a case of a disease, a evaluation of an  Ideal
existing condition  Alternative
CASE HISTORY o Medical conditions
o Medications
1. General Information
Medical Conditions Directly affecting the Mouth
 Name (address by name to add a
 Anemia
personal touch)
o soreness of tongue and palate
 Address & telephone number (contact)
may occur
 Birth or age (capacity to withstand
o in severe cases, pallor &
stress, healing, diseases)
breathlessness
 Occupation (value on esthetic and
 Stroke
quality of the denture, type of work,
o may lead to loss of use of
working schedule, financial status)
muscles of the face
 Sex (women on appearance, men on
 Arthritic disease
comfort & function)
o rheumatoid arthritis or
Personal & Social History osteoarthritis may rarely affect
the TMJ
 Marital status o special trays are needed if
o duration, number of children, unable to open mouth wide, jaw
etc relation recording may be
 Habits difficult
o Alcohol, oral habits, tobacco  Diabetes
 Personality o more susceptible to infection
o Moody, sociable, easygoing, o healing maybe slower
complaining ,etc o rate of bone resorption may
 Weight increase
o Recent loss or gain of weight  Epilepsy & Blackouts
o danger of fracture of denture
2. Chief Complaint  Parkinson’s disease
o loss of muscular coordination
 A symptom or symptoms in the patient’s  Allergies
own words relating to the presence of an o hypersensitivity to materials
abnormal condition  Cardiovascular diseases and disorders
o short appointments with
3. History of Present Illness premedications (history of
angina & heart attack)
 A chronological account of the chief o antibiotic prophylaxis
complaint and associated symptoms o increased blood pressure is not
from the time of onset to the time the contraindicated if under
history is taken medication
 Include the date of onset of the chief  Transmissible diseases
complaint, type of onset, character, o diseases can be transmitted from
location, and relation to other activities patient to dentist and laboratory
personnel
4. Past Medical History o tuberculosis, AIDS, hepatitis,
herpes, SARS
 Patient’s general health prior to the  Psychological disorders
onset of the present illness
o anxiety, depression or hysteria Indiffere Unconcern Sent by Fair
might be difficult patients nt ed relatives
Drugs Adversely Affecting CD

 Steroids 5. Past Dental History


o suppress the inflammatory  Etiology of tooth loss
reaction  Previous denture
o retard healing of mucosa after  Existing denture
trauma o degree of wear
o osteoporosis of jaw bones is o cleanliness
likely o type of denture
o dryness of mouth o retention & stability
o confusion o occlusion
o behavioral changes o fit
 Antidepressants
o some supress salivary secretions 6. Family History
 Diuretics
o Dryness of mouth  General health of the family
o Change in the shape of the  History of mental disease
mucosa  Cause of death of parent if deceased
 Immunosuppressants  Diseases in the family
o mucosa is slow to heal
 Anti-hypertensive 7. Systems Review
o dry mouth
o postural hypertension  Head-headache, eyes, ears, nose, throat
 Anticoagulants  Cardiorespiratory-chest pains, rheumatic
o important considerations when fever, dyspnea
preprosthetic surgery or deep  Gastrointestinal-sore tongue, nausea &
scaling is planned. vomiting, diarrhea
 Antiparkinsonism  Genitourinary-polyuria,
o dryness of skin and mucosa edema,menopause
o confusion  Neuromuscular-paresthesia, arthritis,
o behavioral changes paralysis, tremors
Mental Health / Attitude CLINICAL EXAMINATION
House’s Classification of Patients EXTRAORAL EXAMINATION
Type of Attitude Principal Prognos
patient Characteristi is Extraoral Observations
cs
 Appearance
Philosophica Trusting Accepts Good
l advise
 Bearing and manner
 Gait
Exacting / Doubting Gives advise Fair/poo
critical to surgeon r  Facial color, sweating, tics
 Any obvious swelling or disproportion
Hysterical / Demanding Unpleasant Poor
skeptical past of face
experience  Wearing eyeglasses, hearing aids
Frontal Face Form Classification (Outline of the  Firmness
Face)  Painful area
 Thickness
According to House, Frush, Fisher

 Square
 Tapering
 Ovoid
Cheek
 Combinations (square tapering, tapering
ovoid)  Essential for peripheral seal due to
placement of tissues over the buccal
Lateral Face Form Classification
flanges of the denture
According to Angle  Commonly seen lesions
o lichen planus
 Class I – Normal
o Submucosal fibrosis
 Class II – Retrognathic o White lesions
 Class III - Prognathic o Malignancies
Lips Classification Tongue Size
 Lip Length ( long, medium, short)  Class I - Normal
 Lip Thickness (thin or thick)  Class II – edentulism permit change in
 Lip mobility form & function
o Class I normal  Class III - Excessively large tongue
o Class II reduced mobility  make construction difficult
o Class III paralysis
 tongue biting
 Smile or Lip line (High lip line, low lip
 Management
line, normal)
o Occlusal plane lowered
 Lip support (adequate or inadequate) o Use narrower teeth
 Competent or incompetent o Intermolar distance increase
Neuromuscular Coordination Classification o Grind off lingual cusps
o Avoid setting a second molar
Ability to perform various mandibular
movements Tongue Position Classification

 Class I – excellent  Normal


 Class II – fair o fills floor of the mouth
 Class III - poor o lateral borders rest at occlusal
plane while dorsum above it
TMJ o apex rests at or slightly below
incisal edges
 Pain or difficulty in mouth opening
 Class I retracted
 Uncoordinated jerky movements o Floor expose till molar area
 Tenderness, clicking or crepitus o Lateral borders raised above
INTRAORAL EXAMINATION occlusal plane
o Apex pulled down into the floor
Mucous Membrane of the mouth
 Class II retracted
 Color
o Tongue retruded backward and o Poor resistance to lateral forces
upward
Soft Palate Classification
o Lateral borders raised above
occlusal plane  Determines the extent of additional area
o Apex pulled into the body of available for retention as well as the
tongue and almost invisible width of the posterior palatal seal area
o Floor of mouth  Class I – almost horizontal
Frenal Attachment Classification  Class II – slope about 45 degrees from
the hard palate
 Class I – sulcal or low attachment  Class III – slope about 70 degrees from
 Class II – attaches midway between the the hard palate
sulcus and crest of the ridge
 Class III – crestal or near crestal (high) Arch Size & Form Classification
attachment Arch Size
Floor of the Mouth  Class I – Large
 Near or at level of the ridge crest  Class II - Average
 Hyperactive floor  Class III - Small
 Ridge resorption so great that the floor Arch Form
of the mouth in the sublingual gland and
mylohyoid region spill onto the ridge  Class I - Square
 Class II - Tapered
Maxillary Tuberosity  Class III - Ovoid
 Enlarged Arch Relationship Classification
o Back end of occlusal plane may
be placed too low Anterior
o Not enough space to set all
 Class I
molars
 Class II
 Undercut (unilateral or bilateral)
o Denture insertion and removal  Class III
difficult and painful Posterior
Hard Palate Classification  Class I
 Class I  Class II
o U shaped  Class III
o Most favorable for retention & Interarch Space
stability
 Class II  Class I - Normal
o V shaped  Class II - Excessive
o Not very favorable o Associated with highly resorbed
o Slight movement will break seal ridge
and cause loss of retention  Class III - Insufficient
o Associated with tapered arch o Setting difficult, each tooth
 Class III might be ground to fit space
o Flat or Shallow vault o Associated with large ridge
o Not very favorable
Residual Ridge Classification  Class II - Excessive (makes construction
difficult & messy)
 Class I
 Class III – Reduced/ Xerostomia
o Residual bone height of >21mm
(reduced retention, increase tissue
measured at the least vertical
soreness)
height of the mandible
o Class I maxillomandibular DIAGNOSIS AND TREATMENT PLAN
relationship
Diagnosis
 Class II
o Residual bone height of 16-  Etiology and significance
20mm Class I  Prognosis – good, fair, poor
maxillomandibular relationship
 Class III Treatment Plan
o Residual bone height of 11-
 Ideal
15mm
 Alternative
o Class I, II, III
maxillomandibular relationship Fees and Signed Consent
 Class IV
o Residual bone height of <10mm  Fees fair to both dentist and the patient
o Class I,II, III maxillomandibular  Signed consent essential to prevent later
relationship misunderstanding

Undercuts SURGICAL AND NON-SURGICAL MOUTH


PREPARATION FOR COMPLETE
 Unilateral or bilateral DENTURES
 Labial or lingual / anterior or posterior
NON-SURGICAL METHODS
 Mild, moderate or severe
 1. Rest for the Denture Supporting Tissues
 Isolated anterior undercut poses no
problem  Removal of denture for extended period
 Relieved inside portion of the denture  Use of temporary soft liner (for several
 Unilateral posterior undercut, change days)
path of insertion  Regular finger or toothbrush of denture
 Bilateral undercut, relieve or surgically bearing mucosa, especially the
removed one edematous and enlarged
Saliva
2. Occlusal Correction of the Old
Consistency Prosthesis

 Thin serous (favorable for denture  To restore vertical dimension using


retention) interim resilient lining material
 Thick mucus (tends to displace denture)  Correction of the extent of the tissue
 Mixed (contains both) coverage
Amount Good Nutrition
 Class I - Normal (ideal for denture  Eat a variety of food
retention)
 Build diet around complex o move to the right, relax
carbohydrates: fruits, vegetables, whole o move forward, relax
grains and cereals
*To be done 4x each, 4 sessions a day
 Eat at least five servings of fruits and
vegetables daily SURGICAL METHODS (PRE-PROSTHETIC
 Select fish, poultry, lean meat, or dried SURGERY)
peas and beans every day
Definition
 Obtain adequate calcium
 Limit intake of bakery products high in  Surgical procedures designed to
fat and simple sugars facilitate fabrication or to improve the
 Limit intake of process foods high in prognosis of prosthodontic care
sodium and fat Classification:
 Consume 8 glasses of water daily
 Related to the development of a
retentive denture
Oral Signs of Nutrient Deficiencies  Related to the provision of a stable
denture
Nutrients Oral Symptoms  Those which will allow the
Proteins Decreased salivary flow
establishment of a correct vertical
Enlarged parotid glands dimension
Vitamin B Complex, iron, Lips Surgical procedures included are
protein
 Cheilosis  Improve the bony foundation
 Angular
stomatities  Improve the soft tissue foundation
 Angular scars  Improve ridge relationship

Tongue
Inflammation
 Implant procedure

 Edema 1. Procedures to Improve Bony Foundation


 Magenta tongue
 Atrophy of
filiform papillae  Unerupted teeth or retained roots
 Burning sensation
 Soreness  Removal of cysts or tumors
 Pale, bald  Removal of alveolar excess
Vitamin C Edematous oral mucosa
Gingiva
o Alveoloplasty, tuberosity
reduction, sharp and irregular
 tender, red and ridges, genial tubercle reduction
spongy
Spontaneous bleeding or reattachment, removal of
torus and exostoses and alveolar
repositioning
Conditioning of Patient’s Musculature  Techniques to deal with excessive
resorption
 Use of jaw exercises can permit o Overlay dentures, ridge
relaxation of the muscles of augmentation, vestibuloplasty,
mastication and strengthen their lowering the mental foramen
coordination
 Eg. Stretch relax exercises Torus mandibularies
o open wide, relax  Prevent proper extension of the denture
o move to the left, relax base
 Border seal cannot be made o Hydroxyappatite crystals
 Soreness can occur due to thin tissues o (nonresorbable &
 Fracture of the denture base nonosteogenic)
o Tricalcium phosphate
Torus Palatinus o (resorbable & osteogenic)
 Affect denture stability o Visor or vertical osteotomy
o horizontal or sandwich
 May cause sore spot
osteotomy
 Interfere with tongue function
 Affects post-damming
2. Procedures to Improve Soft Tissue
 May fracture denture Foundation
Indications for Removal of Torus
 Excision or sclerosing hypermobile
 Extremely large torus that prevents the tissue
formation of an adequately extended and  Epulis fissuratum
stable denture  Papillary palatal hyperplasia using
 Traps food debris due to undercuts electrosurgery or microbrasion
causing chronic inflammatory  Hyperplastic maxillary tuberosity
conditions  Frenectomy
 Torus that extends past the junction of  Benign soft tissue lesions, such as
the hard and soft palate (prevents papilloma, mucocele fibroma, etc
formation of posterior palatal seal)
 Patient concern (cancerophobia) Hyperplastic ridge

Bony Exostosis  Interferes with optimal seating of the


denture
 Creates discomfort  Affects denture stability
Genial tubercle Epulis fissuratum
 Creates discomfort causing  Interfere with optimal seating of the
displacement denture
Pressure in mental foramen Papillomatosis
 Present in extreme mandibular  Harbors microorgaisms
resorption, causing pain
 Removal using electrosurgery or
Vestibuloplasty microbrasion

 Increases the vertical extension of the Frenular Attachment (Close to the Ridge Crest)
denture flanges
 Difficult to obtain ideal extension
 Reposition muscle attachment from
 Affects peripheral seal
crest of the ridge
Pendulous fibrous maxillary tuberosities
Ridge Augmentation
 Encroachment or obliteration of
 Increase bulk of the ridge
interarch space
 Eg.
o Onlay grafts from iliac, ribs
o Particulate bone and marrow
3. Procedures to Improve Ridge
Relationship

 Maxillary advancement procedures


 Maxillary retrusion procedures
 Mandibular advancement procedures
 Mandibular retrusion procedures
Discrepancies in jaw size

 Places considerable stress and


unfavorable leverages on the basal seat

4. Dental Implants

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