Removable Prosthodontics at a Glance - James Field

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also see the sample Complete Denture Assessment Proforma in Appendix 1.

      The patient and the rationale for treatment

       Why does the patient want new or improved dentures?

       Is there any difficulty chewing or speaking?

       Do the dentures cause pain or nausea?

       Do the dentures cause gagging, and if so, is it immediate?

       Are the dentures of a satisfactory appearance?

       Have any of these problems got worse recently?

      Prosthodontic history

       What type of denture is the patient currently wearing?

       How old is the prosthesis and where was it/they made?

       For how many years has the patient been edentulous?

       How many prostheses has the patient received before?

       Is the patient willing to attend for the necessary appointments, including review appointments?

      Clinical examination

      Before considering removable complete prostheses, it is important to carry out a full and comprehensive extra- and intraoral assessment. The following aspects can then be considered (Figure 4.1).

       Intraoral access – Can the full denture-bearing anatomy be palpated easily, and can the existing prostheses be easily inserted and removed from the mouth?

       Tongue – Does this occupy a normal space, or does it exhibit lateral spread? Is there a habit of using the tongue to retain the upper denture posteriorly?

       Gag reflex – Can the full denture-bearing area be palpated without eliciting a gag reflex? If not, where are the trigger zones? These are most often the dorsum of the tongue, or the posterior palate.

       Ulceration – Are there any existing signs of ulceration, and do they correspond to the extensions of a prosthesis?

       Temporomandibular disorder (TMD) – Are there currently any signs of muscle pain or temporomandibular joint (TMJ) derangement?

       Candidosis and angular cheilitis – How old are the prostheses and what is the patient's current hygiene regime? Does the patient seem to be over-closed? Is there a high carbohydrate intake throughout the day, nutritional deficiency or a dry mouth?

       Dry mouth – Does the patient complain of a dry mouth? Is this medication-induced? You can grade a dry mouth using the Challacombe scale (see recommended reading).

       Tori or significantly undercut ridges – If present will these interfere with the denture extensions or path of insertion?

       Retained roots – Could these be retained as overdenture abutments?

       Any suspicious lesions, particularly for at-risk patients, that should be investigated or monitored alongside treatment?

      Ridge assessment

      Manual palpation is very important in order to assess the ridges adequately. This includes the ridge form (Figure 4.1) (well-formed, atrophic, rounded, flat, knife-edge, fibrous, undercut) and the proximity of the frenal attachments to the crest of the ridges.

      Assessment of existing prostheses

      The stability (resistance to horizontal or rotational displacement when fully seated) and retention (resistance to vertical displacement) of each prosthesis should be assessed in turn. It is easier to do this individually rather than having both prostheses in at the same time. The upper should be seated from in front of the patient, and whilst holding the molar units, should be rotated in a horizontal plane. It can then be displaced vertically, ensuring that the patient is not holding the denture in place with their tongue, to assess retention. The lower should also be seated from in front of the patient, ideally with the patient in a seated position. Stability can be assessed as above, but also in an antero-posterior direction by pinching the lower incisors between thumb and forefinger and moving the denture lingually and labially.

      The denture extensions should then be considered – labial, buccal and posterior aspects – but also coverage of the tuberosities on the upper and disto-lingual extension on the lower. The anatomy of the denture-bearing area is considered in Chapter 10. It is important to assess the extensions systematically to look for under- or overextension. Direct vision is possible for the lower but it can be more challenging on the upper. Retracting the sulcus with your index finger parallel to the arch means that as you seat the denture, you can feel whether the sulcus is ‘pulled in’ towards the prosthesis. If this is the case, the denture is overextended in this area. It is also possible to take a wash impression in silicone or alginate to assess the denture extensions at this stage.

      In terms of aesthetics – lip support, incisal plane and buccal space should be noted. These are considered further in Chapter 20.

      Finally, in relation to the occlusion, it is important to note whether the intercuspal position is stable and whether there are any heavy contacts. Is the intercuspal position coincident with the retruded arc of closure – and if not, what are the characteristics of the slide? Finally, assessment should be made of the freeway space between the dentures – although at this stage an estimate can be made by listening to the ‘speaking space’ available – sibilant sounds will sound sharp and whistle-like if the freeway space is restricted, and hollow or absent, if it is excessive.

      At this point, a diagnosis can be made with a suitable prognosis (and justification), and your patient's expectations can be discussed in an informed way. A treatment plan can be devised relating to the fitting surface, the occlusal surface and aesthetics (polished surfaces).

The figure shows a range of edentulous ridge presentations.

      Upper edentulous ridges

      Photograph 1

      Intraoral access here is good and the full denture-bearing area (DBA) can be palpated without any pain or gagging. The mucosa looks moist and there are no signs clinically of a dry mouth. The ridge is well formed with high and rounded ridges – and this would be classified as Class III (Cawood and Howell). A retained root has recently been extracted from the UL5 and this presents as a crestal defect. The prominent incisive papilla is erythematous and this is a sign that it may need a degree of relief in order to prevent recurrent trauma. There is a slight buccal defect to the ridge on the left-hand side and the muscle attachment here inserts into the base of the sulcus. Paradoxically it can be easier to account for high muscle insertions than lower ones – and so this area would receive particular attention during the working impression. It is possible to see the posterior extent of the existing denture, which is short of the fovea palatini by at least 10 mm. It is also possible to see the limited degree to which the denture base wraps around

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