docSecrets of Successful Dent 1
download 
Report Transcription
Secrets of Successful Dent 1
Secrets of Successful Dentures Course Objectives Identify patients who can be successfully rehabilitated Dr. Bob Loney, DMD, MS Five-step method to diagnose & treat problems Dr. Mark Vallee, DDS, MSc, FRCDC Select & use indicating media correctly Minimize problems with relines Denture esthetics & occlusion Implant overdentures & Locator attachments All Content Online Google: Google: Removable Prosthodontics Dalhousie Welcome Select: ‘CD’ CD’ Menu - Click on ‘Secrets of ...Denture’ ...Denture’ Successful Treatment Selecting cases that can be successful ! Pick Your Patient! • Avoid: Pick Your Patient! • Avoid: No ridge Cheek or frena attach to top of ridge Ridge mucosa moves when tongue/cheek active Vestibuloplasty (relative) Floor of mouth above mand. ridge LOOK during Function! LOOK during Function! 1 Pick Your Patient! • Pick Your Patient! Caution: No saliva • Caution: Poor nutrition Severe wear, loss OVD Many sets in several years Severe undercuts/tori & don’ don’t want surgery Spend time Talking • Pick Your Patient! When Not to Treat Partially Dentate! Patient doesn’ doesn’t want treatment • Caution: No dentures for many years Patient who doesn’ doesn’t want dentures Comfortable Happy with appearance Function not a problem Inform of consequences, costs, options Don’ Don’ t talk patient into treatment Shortened Dental Arch (SDA) Patient who doesn’ doesn’t need dentures Treatment Option: No Replacement Shortened Dental Arch (SDA) Patients can function with as few as 20 occluding teeth No significant difference in No Replacement Shortened Dental Arch (SDA) Require Anterior teeth + 4-6 occlusal units Opposing PM’ PM’s = 1 occlusal unit Opposing M’s = 2 occlusal units chewing Symmetric loss need 4 units discomfort Assymetric loss need 6 units JCDA Sept 07, 73:593-4 2 Patient Satisfaction Patient Satisfaction • Difficult to quantify, unpredictable More than good anatomy More than well constructed denture Includes expectations Satisfaction With various prosthesis • Not directly correlated with quality • Small percentage never satisfied • Low quality results in lower satisfaction • Patients more satisfied with dentures than eyeglasses and hearing aids Patient Characteristics •Not correlated with satisfaction: • Personality • Age • Attitude toward aging •Reduced salivary flow & reduced ridge negatively correlated Percentage of patients satisfied with prosthesis Smedley TC, Friedrichsen SW, Cho MH: A comparison of self-assessed satisfaction among wearers of dentures, hearing aids, and eyeglasses. J Prosthet Dent. 1989; 62: 654-661. Fabrication Variables • Related to satisfaction: • clinical remounts • accurate impressions & occlusal records • patient involvement in denture esthetics Patient Expectations • High expectations if currently dissatisfied • Unrealistic expectations negatively correlate with satisfaction • Pre-treatment interview can help determine expectations 3 Matching Expectations Iatrosedative Interview • 1. Recognize & acknowledge problem • Critical for success • 2. Explore & identify problem • If patient & dentist don’t expect the same result - failure • 3. Interpret & explain problem • Helps determine need for referral • 4. Offer a solution Iatrosedative Interview Iatrosedative Interview • 1. Recognize & acknowledge problem • 2. Explore & identify problem •Patient: “My problem is .... I’d like.... They’re too...” •Dentist: •History - “You say the dentures loosen only when you are chewing on the left side?” •Dentist: “So your dentures feel..., I can see they are... That must be difficult ...” •Exam - Visual intraoral check. Look for variations from normal in denture & tissue. Use indicating media. Have patient demonstrate the problem. Palpate. Iatrosedative Interview Iatrosedative Interview • 4. Offer a solution • 3. Interpret & explain problem •“It appears that the denture teeth may be too far away from your bone. There is not much bone to support them. Look here in the mirror... “ •“The denture will always be looser than normal unless...” • Dentist: • “So to review, you have 3 things you want changed.. • You don’t want these 2 things changed... • I can change/improve ... but not....because... • Do you understand...Do you have any questions • What would you like to do? “ 4 Conclusions 5 Step Denture Troubleshooting • Small percentage never satisfied, even with highest quality 1. Differential Diagnosis • Comprehensive interview can help identify patients with high expectations 3. Patient Demonstrates Problem • Low clinical quality related to reduced patient satisfaction 5. Patient Rates Improvement Principal 1 Establish a Differential Diagnosis • • • • 2. Look for Normal 4. Never Adjust without Indicating Media ** Principle 1: Differential Diagnosis • Form a list of possible causes • Try to prove problem is not caused by “X” by eliminating possible causes Prioritize from common to rare Eliminate common etiologies first, because: Common things occur commonly Rare entities occur rarely Expect resolution within 10-14 days If no resolution, eliminate something else Differential Diagnosis: CD or RPD Pain Occlusion Denture Base Vertical Dimension Infection Systemic Disease Allergy Remount, Articulating Paper, Adjust PIP, Adjust Time to Adapt, Reset Teeth Tests, Referrals, Medications Patch Tests, Referrals, Change Materials Principles of Diagnosis Attempt to eliminate problem. Re-evaluate results in 10-14 days • Don’ Don’ t limit list too early in diagnosis • Keep an open mind • Revisit possible causes 5 Information Gathering • Chief Complaint History of C.C. – • • Gathering Information History – Medical – Dental Often inadequately investigated Spend more time talking to narrow possibilities Where? • • “How does that feel?” feel?” • Not • “Does that feel better?” better?” • Clinical Exam History of Chief Complaint • Ask open ended questions: • Have patient point to problem Partially ignore patient’ patient’s position Dentist locate with stick, instrument or paste History of Chief Complaint Details • • History of Chief Complaint When? • • • Chewing only - Occlusion Gets worse throughout day - Occlusion When first insert dentures Denture Base Principle 2: Identify Variations from Normal: Tissues & Dentures How long? • ...does it last? • ...since it began? Anything make it better/worse? 6 Identify Variations from Normal Loose Denture: Prominent Midline Fissure, Soft Palate Dealing with Variations From Normal Principle 3: Patient Demonstrates Problem Eliminate cause - resolve in 10-14 days If denture alone is not normal correct the denture If anatomy/patient not normal vary method to address variation Principle 4: Always Use Indicating Media Principle 5: Rate Improvement 100% Perfect Now 75% Feels a lot better Never adjust without locating exact position of the problem After adjustment • Use paste, indelible stick, or articulating paper • • 50% Better, but still not right Ask patient to rate improvement • 0%-100% • 0% Still Same, Can’ Can’ t Tell 7 5 Step Denture Troubleshooting Use of Indicating Media Loney & Knechtel,J Prosthet Dent 2009;101:137-141 1. Differential Diagnosis 2. Look for Normal 3. Patient Demonstrates Problem 4. Never Adjust without Indicating Media ** 5. Patient Rates Improvement Applying Pressure Indicating Paste More the colour of indicating medium than denture Dry denture Thin coat with stiff brush Leave streaks Correct Amount with Streaks Insufficient Amount Too Much w/o Streaks Prior to Placement Seat Denture Firmly Ensure damp mucosa Avoid lips/ridge when inserting Spray surface of PIP with air/water Pressure over first molars (not palate) Remove from oral cavity by breaking seal - finger pushing height of vestibule 8 Read the Paste Reading PIP Burn-through (No paste left) No Contact - Excessive pressure that should be relieved Streaks remaining - Burn through Normal Contact No tissue contact Other areas need to be relieved Paste remaining with no streaks - Acceptable contact Non-retentive Denture Denture Base Adjustment What’ What’s Wrong? Relieve pressure spots - large acrylic burs Take care with undercuts • No palatal contact • Short Flange in 1st quad Use Care in Retentive Areas Looks like burn-through May not require adjustment Watch for Bony Impingements Hamular Notch Tuberosity Undercuts Relieve 9 Check for Retention Pull outward & upward on lingual of canines Repeat Until Denture Fully Seats Relatively uniform contact Minimal streaks No gross burn-through Visually Check Peripheries Peripheries Border mold Adjust Check again Seat denture & border mold Adjust high spots or facets Flanges should fill vestibule but not be dislodged by manipulation If denture dislodges, use PIP to adjust Special Attention to Frenal Areas Special Attention to Frenal Areas 10 Use to Check Contours Alter Phonetics Root prominences Thick peripheries More Info see: Website ‘Resources’ Resources’ Paste Removal Gauze, cotton rolls, toothbrushes Secrets of Impressions • Polyvinyl Siloxanes Alcohol for stubborn areas Dimensional Stability Cheap steamer Detail Cement, debris Secrets of Impressions Use for all procedures Final Impressions Load quickly - viscosity Material brought over periphery • Everything Dry 11 Secrets of Impressions Two Mirror Technique - everything visible Secrets of Impressions Flange thickness Secrets of Impressions Seat anterior of tray first Cotton swabs on tray - remove excess posterior Secrets of Impressions Tray not overextended Secrets of Impressions Why remake? Relines This denture needs a reline! 12 Materials Tissue Conditioners PVS Light Body Self/Light Cure? undercuts distortion porosity Clean the Denture Inspect when dry! Position the Denture OVD & Occlusion Improperly Placed! Longer Teeth! Lousy Occlusion! Relieve Denture Relieve Denture Remove undercuts Shorten flanges Create space for material Vent holes for relief of hydraulic pressure 13 Remove Excess Material Cotton Swabs on tray Better Contours Posterior Palatal Seal Needed for retention Secrets of Jaw Relation Records Mark Contacts Prior to/After Reline Red/Blue Should be close If not, don’ don’t proceed Secrets of Jaw Relation Records Record Bases stable & retentive Perfectly flat contact between rims Secrets of Jaw Relation Records Ensure: Record bases don’ don’t contact anything Casts don’ don’t contact anything Wax Rim Adjustment Video Only wax rim to wax rim contact 14 Secrets of Jaw Relation Records Centric Record with PVS Consider polyvinyl siloxane records Aluwax the most variable Video Clip Elastomers least errors • Mullick et al. J Prosthet Dent 1981;46:304 • Ockert-Eriksson et al, Int J Prosthodont 2000 • Millstein & Hsu, J Prosthet Dent 1994 • Breeding et al, J Prosthet Dent 1994 Partially Dentate Casts If stable contacts (no rocking) Most accurate mounting - no medium Secrets of Jaw Relation Records Elastomers are extremely accurate Remove occlusal blebs from dentate casts Won’ Won’t fit into interproximals on some casts If cast doesn’ doesn’t fit into record, may need to adjust Secrets of Jaw Relation Records Stabilize casts when mounting Secrets of Denture Occlusion All posteriors contact simultaneously Mean occlusal discrepancy of 1.6mm when hand held 0.25 mm sticks & sticky wax • • (Gunderson & Siegel, J Prosthodont 2002) 15 Secrets of Denture Occlusion Secrets of Denture Occlusion • No contacts on inclines • Contacts buccal to the ridge destabilize - even monoplane Browning, JPD 1986 Removable partial dentures M B C B caused unseating Central loading better than distal loading Secrets of Denture Occlusion Excessive overbite will destabilize Secrets of Denture Occlusion No best occlusal scheme - use easiest possible monoplane, lingualized, fully balanced L D Secrets of Denture Occlusion Light rapid taps sound loud, mark widely Video Clip Secrets of Denture Contours No sharp contours Mildly convex lingual and buccal contours Use finger to feel for sharp contours 16 Secrets of Denture Delivery • Step 1 • Check Denture base with PIP • Moisten with air water syringe • No peripheries Secrets of Denture Delivery • Step 2 • Denture peripheries with PIP • One side at a time Avoid cheeks • Laboratory Prescription Secrets of Denture Delivery Fabricate: • Step 3 Remount index • Occlusal Adjustment Remount casts • Remount with help Record Centric Relation Small amount of bite registration material Remount maxillary denture Secrets of Denture Delivery • Step 3 • Remount with help • Assistant remounts denture using centric record • Stabilize casts Just cuspal indentations 17 Adjust Occlusion Secrets of Denture Delivery Extraoral adjustment more efficient Eliminates continual removal & replacement of dentures Secrets of Denture Delivery Step 5 • Check Esthetics & Phonetics • If large change, warn a head of time Step 4 • Chewing Test • • • Avoids reflex avoidance • • Cotton roll No discomfort If discomfort now, worse after use Secrets of Denture Delivery • Step 6 • Polish • Brasseler Denture Polishers 6 Step Delivery Step 1 Adjust Denture base with PIP Step 2 Denture peripheries with PIP Step 3 Occlusal Adjustment Step 4 Chewing Test Step 5 Check Esthetics & Phonetics Step 6 Polish 18
