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Removable Prosthodontics at a Glance. James Field
Читать онлайн.Название Removable Prosthodontics at a Glance
Год выпуска 0
isbn 9781119510697
Автор произведения James Field
Жанр Медицина
Издательство John Wiley & Sons Limited
The clinical process
Communication aside, the process of making removable prostheses is more manageable than it may seem at first. There are often simple approaches that can yield excellent results, without expensive materials or equipment. In the main, technical success is about attention to detail and knowing which materials work best in your hands.
The aim of this at-a-glance guide is to provide advice on how to achieve optimal outcomes at each clinical stage of the process. Our opinions are based on decades of combined experience teaching at undergraduate and postgraduate level, and routinely treating a wide range of cases. We have provided recommended reading for each chapter in case you wish to read more about the technical stages, or to understand better the theory and evidence base that underpins the fabrication of removable prostheses.
Educationally, we use the term ‘bricolage’ (tinkering) when we are teaching our students about new materials in the clinics. If it has been a while since you have used some of the materials in this book, then get hold of some of them, and have a play!
2 The function of removable prostheses
Function
It is often assumed that the function of a prosthesis relates only to ‘mastication’ – but there are many other functions that removable prostheses can serve. As clinicians, we are often good at recognising technical reasons why dentures should be constructed – but often the social aspects from the patient's perspective are overlooked.
Be mindful that the prosthesis must serve a function as perceived by the patient. If we are constructing a prosthesis that has a clear clinical rationale, but the reasons are less obvious to the patient, then we must spend time explaining how we intend the prosthesis to help. Unless the patient understands and believes the rationale for their construction, they are unlikely to wear them regularly.
That said, it is remarkable what patients will tolerate in order to achieve a desired outcome. For example, a patient might wear their prostheses whilst they are out of the house in order to facilitate a more normal social life – even if it is painful – but it is likely that they will take them out once they enter the house again – especially if they live alone. This is probably not dissimilar to us kicking off a pair of shoes that have been rubbing – but made us look good. Many patients living alone also take their dentures out in order to eat – so do not always think that the primary function of your lovingly constructed dentures is to help your patient to chew!
It is important to remember that replacement of all of the patient's missing teeth is often unnecessary. That said, it is still critically important that denture bases are extended into the full denture-bearing area in order to maximise stability and retention – and this will be discussed further in the following chapters.
Removable prostheses are indicated primarily for the following clinical reasons (Figure 2.1):
Restoring masticatory function
Restoring appearance
Restoring speech
Restoring soft tissue bulk and providing soft tissue support
Acclimatisation during the transition to becoming edentulous
Removable prostheses are often indicated for the following technical reasons:
Restoring long edentulous saddles
Restoring multiple short edentulous saddles
Providing posterior stability and improving occlusal load distribution
Preventing undesirable tooth movements
Rehabilitating to an increased vertical dimension
Facilitating functional anterior guidance
In order to prescribe diastemata between prosthetic teeth
To avoid preparing abutment teeth for fixed prostheses
To avoid cantilevering from root-treated teeth
To aid planning and diagnosis, especially prior to implant placement
Finally, but by no means least, our patients may well request removable prostheses in order to:
Improve aesthetics
Restore social confidence
Improve their eating experience
Restoring vs improving
Notice that most of the clinical rationale is based around restoring or rehabilitating, whilst patient requests often centre around improving. This important subtlety can easily be lost when negotiating informed consent. Correcting technical deficiencies and restoring clinical function does not necessarily result in a patient-perceived improvement. Again, moderating patient expectations is critical at each stage of treatment.
Quality of life
One of the most profound moments as an undergraduate was when Professor Janice Ellis (Newcastle) asked us whether we would rather lose a leg, and have a prosthetic replacement, or lose all of our teeth and wear a denture? At the time this seemed like a ridiculous comparison to make – but actually as clinicians we do become desensitised to seeing edentulous patients or partially dentate patients. The bottom line is whether we really sympathise with our patients or not. By working on a daily basis with edentulous patients who are struggling to cope, it is relatively easy to sympathise with the condition – even if we are unable to fully empathise. However, if we converse with denture-wearers less frequently, then there is a chance that we forget about what Professor Ellis termed the ‘edentulous plight’. This reiterates why it is important that we take the time to listen to what our patients want, and that they feel comfortable enough to tell us.
Risks of removable prostheses
One of the most significantly overlooked aspects of denture provision is the potential negative impact on the hard and soft tissues. Primarily this relates more to the provision of partial prostheses – and patients should be made aware as part of the planning process (through informed consent) of the risks and benefits of receiving dentures. Do not assume that because your patient is already wearing dentures that there is no need to reiterate the potential risks.
Whilst the jury is probably out in terms of the impact on periodontal disease, there is clear evidence of an increased risk of plaque accumulation, gingivitis and root caries for patients wearing partial prostheses. Many well-conducted studies show that the key to minimising soft and hard tissue damage whilst wearing dentures is to maintain an optimal level of oral hygiene, and to attend regular review and maintenance appointments; this is very much a shared responsibility between clinician