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Textbook of Complete Dentures Plummer - Ebook download as PDF File . pdf), Text File .txt) or read book online. CONMPLETE DENTURE. PROSTHODONTICS. A STUDY AND PROCEDURE GUIDE by. Brien R. Lang, D. D. S., M. S.. Professor and Chairman. Department of . Presents various aspects of the basic principles of complete denture prosthodontics. This book relates the basic sciences of anatomy, physiology, pathology.
Dental stone is poured into the impression and vibrated to remove air bubbles and allow the stone to cover all impression surfaces. Arthur O. Soft Tissue Examination: If not. Consults should be written to appropriate physicians to evaluate any questionable medical conditions.
Pre-clinical complete denture prosthodontics. Essentials of complete denture service. The significance of the fovea palatini in complete denture prosthodontics. The ala-tragus line in complete denture prosthodontics. Clinical applications of concepts of functional anatomy and speech science to complete denture prosthodontics. The future of complete prosthodontics. Facebow transfer does not achieve better clinical results than simpler approaches in complete denture prosthodontics.
BOOK REVIEWS and encourages the logical progression to an initial differential diagnosis based on radiographic evidence, followed by a more definitive diagnosis using the additional evidence provided.
Also included in the presentation of each case are two or three relevant questions, often slanted to test the knowledge of the reader on points such as alternative views or other investigations which may be indicated. Not unnaturally one is tempted to turn rather too rapidly to the Answers towards the end of the book and this must be resisted.
The answers are extensive and in many cases include a fairly comprehensive discussion on points of differential diagnosis. In a book of this nature and in which a large number of radiographs are reproduced it is inevitable that one or two at first sight fail to demonstrate a point clearly.
By Toronto: Please verify that you are not a robot. Would you also like to submit a review for this item? You already recently rated this item. Your rating has been recorded. Write a review Rate this item: Preview this item Preview this item. Textbook of complete dentures Author: Shelton, Conn. People's Medical Pub. House ; London: Ref electronic medical library. Ref An electronic book accessible through the World Wide Web; click for information online.
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Complete dentures. User lists with this item 1 dental items by bzou updated Linked Data More info about Linked Data. Primary Entity http: CreativeWork , schema: MediaObject , schema: Intangible ;. House " ;. Ref Online service " ;. Ivanhoe " ;. Plummer " ;. Mandibular Ridge Fonm: Pattern of tooth wear: Ability to adjust to previous dentures: Diagnosis and Treatment Planning Form Patient: Facial Appearance: Occlusal plane height: Patient expectations of new denture: Chief complaint patient's own words: Compare your observations witli the patient's comments: Base extension: Evidence of self-adjustment: Evaluation of Present Dentures: Maxillary Ridge Form: B-L tooth position: Date of last visit to dentist: Denture hygiene: Patient reaction to previous treatment: Soft Palate Form: CI I normal.
Figure Angular chelltis. Tuberosities R L Parallelism Ridge relationship: Hard Palate Form: Medio-lateral c. Patients Mental Attitude: Inter-ridge spaee: An te ropos te ri or b. CI II retro. Patients Adaptive Potential: Figure Complete denture examination. CI III prog normal.
Floor of mouth: Note the condition of the mucosa—specifically whether it is fiabby or bound down. Excessively thick or ihin areas of oral mucosa should also be noted. For example. The mueosa should be evaluated as it relates to the ridge.
Diagnosis andTreatment Planning 51 Intraorai Examination Tlie intraorai exam should begin first with a general evaluation of the patient's oral mucosa Figure Some complete denture patients refuse to remove or clean their prostheses for prolonged periods Figure and as a result might have extremely initated and Figure Hyperkeratotic lesion in cheek oral mueosa Figure Denture of patient who failed to remove and dean denture.
The saliva should be evaluated both in amount and consistency. A normal amount and thickness of saliva is paramount in the ability of most patients to comfortably wear dentures. A patient with xerostomia or excessive saliva containing much mucous can have difficulty obtaining an adequate seal Figure Inflammatory papillary hyperplasia.
These areas should also be noted and appointed for surgical excision if the condition does not resolve following the removal of the overextended denture border. The saliva acts as a lubricant and also serves as the interface between the denture base and tbe tissue allowing for denture retention.
These patients are much more susceptible to fungal overgrovvth and colonization of the prosiheses and subsequent inflammatoi-y papillary hyperpUisia—especially in Uie palate Figure Note the highly inflamed tissues of a patient who rarely removed the maxillary complete denture. This condition must be addressed prior to fabrication of a new denture. Usually caused by an overextended denture flange. Retained root tips and impacted teeth should be evaluated for any pathology' and whether they are completely retained in bone.
Conditions to especially note are the mandibular bone height. Ideally tbe saliva would be ofa thin. In every case the patient shotild be informed of the risk and benefit of the removal of the impacted teeth and root tips. Ridges are generally U-shaped. Generally speaking. A hypersensitive gag reflex can complicate successful fabrication of a complete denture. Most of these patients can be successfully treated by the dentist using proper impression techniques.
Teeth and root tips that are only covered by soft tissue or are exposed to the oral cavity should be considered for removal. Patients with diy mouth not only have poor prostliesis retention but also a greater tendency for oral mucosa tenderness.
During the oral exam. Next cross-sectional form should be noted. The shape is probably most important as it relates to the opposing arch because mismatched arch shapes can make tooth arrangement challenging. Diagnosis andTreatment Planning 53 Figure Epulls fissuratum. The residual ridge shape is cla. A cuiTent panoramic radiograph reflecting the patient's present condition must be evaluated. The worst type of ridge is a knife edged or Oat ridge.
Often patients will volunteer their gagging problems while discus. During the course of the examination it is helpful to note whether the patient has a problem with gagging. Similar to the maxillary ridge. Class II. An average U-shaped palate is ideal. The hard palate is tisually classified as a high. The form of the hard palate should be determined.
These ridges provide maximum retention. Must be removed if it is so large that it will interfere with space for the tongue. Genei"ally the more severe the angular change from the hard to the soft palate. Bulbous tuberosities can result in bilateral posterior undercuts and insufficient interocclusal space.
In these situations. The ridge should be evaluated for any tori Figiu e Maxillary and mandibular ridges should be evaluated for how much space the border tissues allow for complete denture fabrication. Diagnostic casts are often necessary to adequately evaluate the residual ridges.
A Cla. A V-shaped palate or high vault can compromise the seal of tlie denture. Any pedimculated torus Figure 4—8 or a torus that extends into tlie posterior palatal seal atea should be removed if possible.
One that drops abnipdy at the junction of the hard and soft palate is considered a Class III palate. Tlie ridge should also be evaluated for any exostoses or bilateral posterior undercut. A denture cannot extend onto the movable soft palate without signiftcantly increasing the possibility of loss of denture retention and causing tissue irritation and discomibrt to the patient. The most ideal ridge would be a U-shaped ridge—almost Hat at the crest of the ridge witli tall non-undercut approximating buccal and palatal walls.
A larger ridge can provide more surface area for stability. As with the maxilla. The soft palate is classified as Class I. If frenula attachments are close to the crest of the residual ridge then denture borders must necessarily be short. In observing the anterior posterior position of the ridges. In some patients this is almost impossible and diese notations must be made after casts are mounted on an articulator at the appropriate occluding vertical dimension.
As the lips and cheeks are simulating muscle movement. The anterior-posterior relationship of tlie residual ridges of the complete denture patient can be misleading. Diagnosis and Treatment Planning 55 Figure Mandibular tori. As the residual ridge resorbs. Is the anterior lingual flange ofthe mandibular denture going to be compromised becatise the genial tubercles are near tlie crest of tlie ridge? A patient with sh irt lingtial flanges because of high lingual attachments often referred to as high floor of the mouth can have compromised lateral stability ofthe denture.
Palpate the mylohyoid ridge. As the patient touches his lips with tlie tongue is the retromylohyoid space obliterated or is tiiere space that could be occupied by the lingual flanges of the denture base? How do the opposing residual ridges relate to each other?
The occluding vertical dimension can be approximated in most patients by having them Ughtiy close on a finger placed between the anterior ridges. Is it extremely large or sharp? Evaluate the reuomylohyoid aiea. Must generally be removed. Essentially the maxilla is getting more narrow and shorter. It is especially impoitant to note the muscle attachments on the lingual side of the mandibular ridge. Many patients will exhibit significant bone loss in this area.
The crest ofthe anterior mandibular ridge resorbs four times more than the anterior crest of the maxilla in the first seven years after teeth are extracted. Severe Class II patients should he considered for referral to a prosthodontist. Is the patient's antero-posterior relationship prognatliic Ciiass III. Tuberosities should also be evaluated at the estimated OVT.
Figure An irregular bony resorptive pattern may make complete dentures unstable. Evaluation ofthe patient's inter-ridge space at the estimated OVD is necessaiy.
An enlarged or oversized tongue can greatly compromise a patient's ability to successfully wear a complete denture. The tongue size and position should be noted. If so. Excessive inter-ridge space or too little inter-ridge space can greatly compromise proper denture fabrication.
Learning to use such dentures may present a significant challenge for the patient. Additionally he felt that the ideal position of the tongue was with Uie apex jf the tongue slightiy below the incisai edges of the mandihular incisors and with the dorsmn of the tongue visible above the teeth in all parts of the mouth.
The control or coordination of the tongue should also be noted. The medio-lateral relationship of the opposing ridges should also be evaluated. Ridges that are not parallel at the proper occluding vertical dimension can make the completed dentures quite unstable during function.
According to Dr. Is there any neuromuscular condition that affects the patient's speech. A mouth mirror. Do the arches coordinate? Will teeth have to be set in a crossbite relationship? Are the ridges generally parallel at the proper occluding vertical dimension? Ridges tend to be parallel at the proper occluding vertical dimension unless there has heen some t 'pe of irregular resorptive pattern Figure Some have suggested that dentists are fully justified in charging increased fees to this patient because of the extra treatment time required.
Many times diis patient is seeking treatment not because of concern for his or her dental health but because a spouse or family member has encouraged them to care about oral health.
House has classified complete denture patients into four mental attitude categories— philosophical. Diagnosis andTreatment Planning 57 Figure Example of a very large tongue.
The indifferent patient is likely to lack motiv-adon and might be unwilling to follow instructions regarding bis or her oral health. This tvpe of patient often questions even minute details of the denture. The exacting patient is precise. Mental Attitude of Patient Successfully wearing a complete denture is a learned skill for most patients and especially for new denture patients.
These patients can often require excessive amounts of the practitioner's time to satisfy their demands. The philosophical patient exliibits an attitude that is optimistic. This patienl might dread dentistry and feel that he or she may never be able to wear the new dentures.
This is the ideal patient type. The hysterical patient is often excitable. These patients can be far less than ideal. Patients in this categorv' are less likely to persevere and learn to function witii their complele dentures. These patients can be the most difficult categor ' of patient to treat because of their lack of motivation.
This patient may require professional psychological counseling in order to be treated successfully. Good diagnostic casts should include the retromolar pads and border tissues as well as tlie pterygomaxillary notch and the posterior palatal seal area Figure This system is said to help better identify difficult denture patients and help Figure Examples of nicely made preliminary impressions Figure Examples of excellent diagnostic casts.
Another tool to help the dentist identify' the complexity of their denture patient is called the Prosthodontic Diagnostic Index PDI. The system also idendfies several other criteria and diagnostic modifiers that can be expected to increase complete denture difficulty. A Class I patient is uncomplicated and should be able to be treated by a general dentist vsith limited complete denture experience. A Class III patient has additional complicating prohlems. The PD! This classification system uses four general diagnostic assessment criteria: For the experienced general dentist or prosthodontist.
The prognosis for tliis patient should be good to excellent. These modifiers include systemic considerations.
Once all information has been obtained. Lab test results and referral recommendations as well as results of any soft or hard tissue biopsies should be reviewed before a final diagnosis and treatment plan are fonnalized.
At the final end of the spectrtim is the Class IV patient. This patient is best treated by a surgical specialist and a prosthodontist.
An estimate of cost for the treatment should also be disctissed and approved by the patient. This patient might be characterized by ver ' poor edentulous arches that are indicated for pre-prosthetic surgery but this may not be possible because of the patient's health.
Treatment Planning The proper treatment planning for a patient requires that all information gathered on a patient be considered when determining the treatment to be completed and the sequence of this treatment. The prognosis for this patient would be poor if being tieated by an experienced general dentist and only guarded for the prosthodontist. This would inchide how treatment will be sequenced as well as an estimate of the length of time to complete the treatment. Generallya patient should be free of dental pain to include TMD pain before definitive prostheses are fabricated.
If the patient has existing dentures, these will need to be modified after the surger and managed during the healing period with soft reline material.
If preprosthetic surgery will render the patient edentulous, immediate dentures may need to be fabricated. Depending on the number of teeth being removed, this might require that two sets of complete dentures be fabricated—an immediate set and afier healing a definitive set.
Ifa patient has TMD pain, every effort should be made to have the patient pain free before fabricating definitive prostheses. This might be as simple as modifying the existing worn prostheses with acrylic resin to a more a appropriate vertical dimension of occlusion or fabricating an acrylic TMD splint that fits over the existing prosthesis.
If this does not resolve the problem then it might be necessary to refer the patient to an oral and facial pain specialist before definitive prostheses are fabricated. Once the patient is pain free and appropriate healing has taken place, only then is the patient readv to have definitive prostheses fahricated. After lhe prostlieses are fabricated and initially foUowed-up to ensure proper fit, function, and homecare.
Many times the greatest predictor of success for complete denture patients is whether they have successfully worn complete dentures in the past. References Appleby, R. Ludwig T. Patient evaluation for complete denture therapy. CJiaytor, D. Prostliodondc treatment for edentulous padenis. Louis, MO: Mosby; Textbook of Complete Dentures Heartwell, C. J Prosthet Dent ; 1: House, M. The relationship of oral examination lo dental diagnosis. Treating the modern denture patient: MacEiitee, M.
Tlie complete denture a clinical pathway. Carol Stream, IL: Quintessence Publishing Co. Classification system for complete edentulism. J Prosth ; 1: Ivanhoe, ]. R,, Rahn, A.
Clinical Guide for Complete Dentures. Medical College of Georgia School of Dentistix Ryhn, A. Textbook of complete dentures. Dih ed. W'inkler, S.: Essentials of complete denture prosthodontics.
Littleton, MA: A study of the tongue and its relation todenturestability. J Am Dent Assoc. Zarh, G. The edentulous milieu. Name four classes, or categories, of medications that cause xerostomia. What types of examination techniques should be utilized when performing a head and neck exam?
What type of soft palate, as classified by House, turns down abruptly as related to tlie hard palate and requires tlie most precision when determining the location of the vibrating line? Name four anatomic structures that, when present, complicate the fabrication of a complete denture?
Wniich cross-sectional ridge form is the least desirable? According to Tallgren, at what rate does the mandible resorb cotnpared to the maxilla during the seven-yeai" period following extraction of all remaining teeth? Which anteio-posterior ridge relationship is the easiest, or most ideal, for tlie fabrication of complete dentiues?
Too litde or excessive interarch space can complicate the construction of complete denture? True or False. According to Wright, what percentage of the population has a retracted tongue? Hysterical, exacting, indifferent, and philosophical. High blood pressure medication, antihistamines, muscle relaxants, and many drugs used to treat anxiety and depression. Observation, auscultation, and palpation look, listen, and feel.
Class III 5. Knife edged or flat. Mandible four times greater than the maxilla. Class 1 9. True With these goals in mind, we can then work backward, with a concept of the final result, sequencing the ueaunent s that will realize these goals. These goals can he reached through the achievement of specific objectives, which include creating a broad ridge form, providing an adequate amount of fixed tissue over the denture bearing areas, establishing adequate vestibular depth for prosthetic flange extension, establishing proper inter-arch relationships and spacing, supporting arch integrity, providing adequate palatal vault form, and when required, to provide proper ridge dimensions for implant placement.
Patient Evaluation anil Expectations Prior to the performance of any procedure, several key steps must be performed. The physical examination includes thorough evaluation of the oral hard and soft tissues and radiographs.
This examination will reveal the difticult ' of performing the desired preprosthetic surgical procedures or even whether they are possible. For instance, the refening dentist may desire that the patient receive a reduction of the tuberosities but radiographie evaluation by the surgeon may reveal that tbis procedure is not possible because of the position of the maxillary sinus.
Radiographically, the panoramic radiograph is the workhorse image for preprosthetic surgeiy. With this radiograph one can visualize many of the important anatotnic and structural relationships necessary to accurately create a treatment plan for preprosthetic procedures.
For the mandible and maxilla in general, pathologic lesions, retained roots, impacted teetii, and overall ridge morphology can be seen. For Uie mandible, relationships between the inferior alveolar canal and the ridge crest, and position of the mental foramina to the ridge crest can be obsei-ved. Additionally, the hard tissue contribution versus soft tissue component of hv-perplasic tuberosities can be determined.
Other radiographie images may be required when specific anatomic relationships need to be observed. For preprosthcdc procedures and treatment plans, which may include implant placement, more sophisticated, radiographie studies may be required.
Tomograpbic studies and computerized tomography CT scans may be used. The CT scan can provide cross-sectional detail of the maxilla in both the axial and coronal views. This provides excellent information regarding such important planning factors as alveolar height and width, facial, lingual, and palatal alveolar contours, relationships between the maxillary crests and the sinus fioor and nasal fioor, and the mandibular inferior alveolar canal and mental foramina to the crestal bone.
Treatment Pianning With the desired preproslhetic surgery identified, and the physical evaluation and radiographie examinations completed, a problem list is made. Treatment planning now becomes the next critical step.
No procedures should be performed without a treatment plan designed to sequence and address the patient's problem list. Based on state of health, complexity of treatment plan, and level of anxiety, referral may be made to place the patient in an ennronment where all of these important factors can be safely addressed.
Goals for treatment should address the following factors: With these goals in mind we can sequence the treatment s that will achieve these goals. Review of Fiaps Access to and exposure of the surgical site is critical. The clinician's tool for adequate exposure is the full thickness mucoperiosteal fiap. This aggressive surgical approach with its greater visibility, protection of adjacent tissues, time efficiency, and more routine postoperative course is far more valuable and less traumatic to the patient than other less effective techniques.
Diagnostic casts are excellent aids in outiining areas of surgical focus and for flap design. For most ofthe procedures a midline crestal incision is recommended. This tissue is stronger, more resistant to tears, and holds sutures well. WTien teeth are present. The reflection should be subperiosteal and deliberate. When working around teeth, the papillae should be gendy reflected, then tlie remaining attached tissues in a uniform plane before attempting to teflcct more apically.
Being deliberate, precise, and having patience vAW reward tlie clinician with a clean subperiosteal dissection. The dissection should proceed apically as far as needed to visualize the area of concern. Dissection antero-posteriorly should be made as necessary to allow for elevation of the flap and appropriate exposure without placing tension on the flap.
Althottgh envelope flaps are usually adequate for most procedures, if access is a problem, both anterior and posterior releasing incisions are recommended. The base of the flap niitst be wider than the crestal aspect so tiiat blood supply to the flap will not be compromised.
When the procedure is completed and the flap is repositioned. Then the flap is reelevated and copiously irrigated along the entire length of the flap to remove all debris. Once the flap is anatomically repositioned, a suture is used to secure the Haps p , sition.
Sutures are placed to approximate and not strangulate the tissues. Soft tissue procedures might include maxillary tuberosity soft tissue reduction, maxillary labial frenectomy, mandibular lingual frenectomy, and excision of redtmdant tissue. If more than finger compression is needed, a full thickness flap should be elevated to a point apical to the area in need of recotitotiring. Depending on the amount of recontouring needed, a bone flle may be sufficient to produce tlie desired contours.
For greater recontouring, a side cutting rongeur or handpiece and acrylic resin bur can be used Figure WTien using these burs, always use copious irrigation to avoid overheating the bone and subsequent bony necrosis. Irrigation also cleans tiie flutes of the btir and carries away debris. After bulk recontouring, a bone file is uses to "fme tune" tiie recontouring.
Bone files or rasps give the clitiician a great tactile sense and good control. Wiien finished, the flap is repositioned, contours palpated to verify that a desired endpoint has been reached, and is approximated primarily Figure Wiien soft tissue recontouring is needed, reposition the flap; observe where the adjustments are needed, and tLse a sharp.
Figure Bone rongeur used to accomplish bone reduction during a ridge alveoplasty along with extractions.
It is usually more prudent to sequentially remove small amounts of tissue than to remove too much at one time. Consideration must also be given to maintenance of vestibular deptb and form when trimming and approximating the flap.
Intraseptal Alveoloplasty When the ridge has acceptable contour and height but presents an unacceptable undercut, which extends to the base of the labial vestibule, the intraseptal alveoloplasty might be considered.
This procedure is best accomplished at tlie time of extraction or early in the postoperative healing period,. Using a small rongeur or handpiece and bur, the inti'aseptal bone is removed to the depth of the socket.
A full thickness flap is designed and implemented to fully expose the targeted areas. After adequate removal of bone.
Periosteum and soft tissue should not be violated. If significant resistance is encountered. Digital palpation with tlie flap in place is done until the desired endpoint is achieved. Edentulous Ridge Alueoloplasty For routine eliminadon of sharp knife-edged ridges and removal of undesirable contours. Figure A bone file can be used to smooth rougbened edges.
When tlie mandibular or maxillary edenttilous ridges require multifocal. The crestal soft tissue can now be approximated and closed witb interrupted or continuous sutures. Finger pressure should be applied to the area of the vertical bone cut to achieve mobility of the segment and guide its repositioning. The edentulous ridge alveoloplasty begins with idendfication of the areas of concern. The site is irrigated and close primarily with an interrupted or continuous suture technique.
In this way. A full thickness flap is elevated to completely expose the involved area Figure When an envelope fiap will not provide the necessary exposure without placing tension on the flap.
For gaining assess to a palatal exostosis. A crestal incision is made to extend beyond the margins of the areas reqtiiring recontouring Figure Pre-prosthetic Surgical Considerations 71 Figure Marking Uie midline crestal incision to be used for access to remove buccal exostosis on the mandibular ridge.
Buccal Exostosis This approach can be used on either arch and for irregularities on the palatal aspect of tbe maxillaiy alveolus. Because of the greater palatine and incisive branch anastomosis.
It is important to remember that maxillary sinuses may pneiunatize into the tuberosity areas. Occasionally tori can be large enough to interfere with tongtie mobility and speech. Once the iiTegularity is exposed.
Maxiiiary Tuberosity Reductions Maxillary hyperplasic tuberosities present real problems for gaining appropriate interarch distance posteriorly. The area is palpated throtigh the flap to confirm adequate reduction or recontouring.
If tlie maxillar. If a great deal of bone needs to be removed. When completed. In the edenLulous arch. To identift. A crestal incision is made from a poiiu anterior to where the recontouring will start. Note retractor providing exposure of operating site and protecting adjacent soft tissue.
Tissue must be elevated on both the buccal and palatal aspects to fully expose the tuberosity Figure Mandibuiar Tori In the dentate arch. The tuberosit ' can be recontoured with bone file. After making sure that all soft tissue is protected. Figure Tissue flap is elevated to expose bony undercut arrow that requires recontouring. Figure Arrow indicates recontoured buccal bone with the undercut eliminated. Pre-prosthetic Surgical Considerations 73 Figure Arrow indicates a bony undercut on the lateral surface of the maxillary tuberosity.
A full thickness lingual mucosal flap is slowly elevated. For smaller tori. A midline crestal incision is made to extend about 1. Because the tori may be pedimculated. If an osteotome slips.
The A indicates the reflected tissue flap and the arrow B indicates the bony projection to be removed with the osteotome. Figure Removal cf a mandibular tori. Hematoma formation in the palate under the fiap is a great concern. The tori may be especially problematic when it is positioned more posteriorly.