3. History and Exam

John Beumer III, DDS, MSand

Robert Duell, DDSDivision of Advanced Prosthodontics, Biomaterials and Hospital Dentistry

UCLA School of Dentistry

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• Medical and dental history• Orofacial exam• Prosthodontic assessment• Prognosis• Preliminary impressions• Tissue conditioning

History and Clinical Exam

Medical HistoryPotential medical emergenciesEffects on denture supporting

tissuesEffects on oral neuromuscular

control

Effects of Smoking

Predisposition to oral cancer

Predisposition to periodontal disease

Success – failure rates of osseointegrated implants

Oral Facial Exam:

Oral cancer screening exam

Exam for other pathology Local

Systemic

Prosthodontic assessment

Intraoral and Extraoral Exam

Checking for:• Clicking• Popping or crepitus

Palpate the temporomandibular joint

Conduct a thorough oral cancer screening exam

• Lips and cheeks•Lateral border of the tongue•Floor of the mouth•Tonsillar region and the soft palate•Base of the tongue •Oropharynx•Neck

Intraoral and Extra Oral Exam

Extraoral Exam

LymphaticsThe first sign of oral cancer is often a palpable lymph node

Lips and cheek

Examination of the Lips and Cheeks

Visual inspection Palpation

Bidigital

You are palpating for:• Lumps and bumps, indurations etc.

Examine the denture bearing surfaces, the soft palate, tonsillar region, the vestibules and the buccal mucosa.

Hamular notch

Intraoral Exam

Examine the lateral borders of the tongue

Examine the ventral surface of the tongue and the floor of the mouth.

Intraoral Exam

Oral Lesions and Disease Factors

Diabetes (long term insulin dependent) Epithelium is thinner and less keratinized.

Result: Compromised, support and impaired tolerance of complete dentures.

Impact on Complete Dentures

Oral Lichen Planus – Erosive lesions and subsequent scarring in the buccal shelf area limit denture extension in this region and make it difficult for some patients to tolerate their dentures.

Result – Compromised support and tolerance of the mandibular denture.

Disease FactorsWickham’s striae

Pemphigoid – Chronic ulceration with subsequent scarring of the oral mucosa.

Result – Limited denture extensions compromising support, stability, retention and tolerance of complete dentures.

Disease Factors

Low saliva flow rates leads to increased numbers of fungal organisms leading to a high incidence of chronic Candidiasis.

MildCandidiasis

SevereCandidiasis

Angular cheilitissecondary to chronicCandidiasis.

Chronic Candidiasis

Clinical Manifestations

Burning and irritation of the denture bearing mucosa, making tolerance of complete dentures difficult. In addition the fungus is keratolytic, further compromising support and tolerance.

Treatment

Topical antifungal therapy followed by relining of the dentures (Nystatin is the drug of choice. It can be dispensed as a cream, a powder or an oral lozenge).

Begins as a traumatic ulcer secondary to an overextended denture flange.

Common Oral Lesions

Inflammatory fibrous hyperplasia

Continued denture wear and irritation leads to inflammatory fibrous hyperplasia (epulis fissuratum).

Therapy – Surgical excision

Common Oral Lesions

Inflammatory fibrous hyperplasia

Common oral lesions

Secondary to ill fitting maxillary dentures. Usually complicated by chronic candidiasis.

Inflammatory papillary hyperplasia

Therapy: Antifungal medications applied topically. In extreme cases,surgical excision.

Therapeutic Approaches – Palatal Papillary Hyperplasia**with Associated Candida Albicans

Antifungal therapy*a) Reline or remake dentureb) Nystatin powder (100,000 units per gram) Apply to undersurface of denture

three times per day for 3-4 weeksc) Nystatin cream – Best used for lesions associated with the corners of the

mouthd) Reline denture with temporary reline material

Surgical excision with electrosurgery (when antifungal therapy has reached an end point)

*Nystatin rinse is generally ineffective. Nystatin oral or vaginal suppositories used as an oral lozenge are reserved for fungal infestations that extend beyond the denture bearing surfaces.

**Is this a premalignant lesion? No!!!!

Other Oral Lesions of Importance

Premalignant Lesions

Both these lesions can transform into Squamous Cell CarcinomasLeukoplakia Erythroplakia

Other Oral Lesions of Importance

Squamous cell carcinomas

Unless detected early most patients with squamous carcinoma have a survival of less than 50%. Early detection dramatically improves survival.

Squamous Cell Carcinoma•A thorough oral cancer screening exam must be performed on all patientsconsidered for complete dentures.

•Early oral cancers (A) are difficult todetect and may be confused with otherphenomenon, but the cure rates are high.

•Advanced oral cancers (B,) are easy to detect, but cure rates are very low.

•Our challenge is to detect oral cancerswhen they are small, localized, andtreatable.

A

B

Other Oral Lesions of Importance

Oral Exam

Clinical Factors Influencing Stability, Retention, and Support of

Complete Dentures

Definitions – Removable Prosthodontics

Retention – Resistance to vertical displacement of the denture away from the denture bearing surface during.

Stability – Resistance to lateral displacement of the denture during function.

Support – Resistance to vertical forces of occlusion. Factors of the bearing surface that resist or absorb occlusal loads during function.

What factors associated with the denture bearing tissues influence the quality of retention, stability, and support provided the complete denture?

Quality of Bearing Surface Mucosa Affects Support.

The more keratinized attached mucosa available, particularly in the mandible, the better the support.

Stratum corneum

Stratum granulosum

Stratumspinosum

Basal layer

Lamina propriaKeratinized Less keratinized

a) Degree of keratinizationb) Amount of attached mucosa vs unattached mucosa

Keratinized Attached mucosa is the Remnant of Attached Gingiva.

Attached Gingiva Keratinized attached mucosa

Mucogingival junction

The more available on the denture bearing surfaces, the better the support.

Maxilla – Abundance of keratinized attached mucosa. Covers entire palate and alveolar ridges.

Mandible – Narrow zone of keratinized attached mucosa. Confined to the alveolar ridges.

Note the amalgam tattoo

Maxilla vs Mandible

Loss of Keratinized Attached Mucosa Result:(a) Reduced support.(b) Reduced tolerance to occlusal load.

Zone of keratinized mucosa

What is the impact of bone resorption on retention, stability,

and support?

All three are negatively impacted.

Ridge Resorption

Pattern of Ridge Resorption*

The rate of resorption is much higher in the mandible than in the maxilla.

*Talgren, 1964

Resorption patterns in the edentulous patients*

Ridge Resorption

*From Zarb et al, 1983

Ridge Resorption

Note the sharp mylohyoid ridge (arrow)

Mandible – Prime Support Areas

*Of the above, the alveolar process is most affected by the process of bone resorption

Retromolar pad Buccal shelf Alveolar process

The pad contains glandular tissue, loose areolar connective tissue,the lower margin of the pterygomandibular raphe, fibers of the buccinator, and superior constrictor and fibers of the temporal tendon. The bone beneath does not resorb secondary to the pressure associated with denture use. It is one of the primary support areas.

Retromolar PadOne constant, relatively unchanging structure on the mandibular denture bearing surface is the retromolar pad (dotted line).

Buccal Shelf

Boundaries of the buccal shelf: The external oblique line and the crest of the alveolar ridge (area within the dotted lines).

The buccal shelf is a prime support area because it is parallel to the occlusal plane and the bone is very dense. It is relatively resistant to resorption.

Masseter groove area

Buccinator limits the extension in this area

Buccal Shelf

Buccal shelf area (area within the dotted lines). The greater the access to the buccal shelf the more support there is available for the denture. Access is determined by the attachment of the buccinator.

B

Mandible – initially buccal lingual dimension of the alveolar ridge is narrowed, compromising support (A, B, C).

A

Patterns of Resorption - Mandible

C

But thereafter, the height is affected compromising support,stability, and retention (D,E).

D

Patterns of Resorption - Mandible

E

Continued calcification of the attachment of the mylohyoid muscle leads to the development of a sharp bony projection on the lingual surface. The mucosa overlying this region is poorly keratinized and prone to perforation secondary to trauma from complete dentures.

Mylohyoid ridge

Patterns of Resorption - Mandible

Following extraction, resorption is from buccal-labial towards the lingual.

Labial plate

Result: Some compromise of stability and support.

Pattern of Resorption - Maxilla

Continued resorption leads to loss of vertical height of the alveolus.

Result:a. Significant compromise of stability of the denture.b. Pseudo-class III jaw relation.c. Secondary affect – compromised retention because ofcompromised stability. Peripheral seal of the denture is more easily broken because there is little resistance to lateral displacement of the denture during function.

Patterns of Resorption - Maxilla

Note steep anterior guidance. There are no contacts in working, balancing or protrusive when the patient goes through the chewing cycle.

As a result, during the chewing cycle , the denture tips anteriorly, compressing the mucoperiosteum of the premaxilla, leading to resorption of the bone of the premaxillary area.

Combination Syndrome It produces a very specific pattern of resorption of the maxilla.

It is caused by edentulous maxilla opposing dentate mandible where anterior dentition has been retained and where the denture has not been properly balanced.

Result:(a) Resorption of premaxilla(b) Hypertrophy (fibrous

hyperplasia) of maxillary tuberosity.(c) Occlusal plane problems.

Occlusal plane

Hypertrophic maxillary tuberosities

Resorbed premaxilla

Combination Syndrome

Mandible – Similar Phenomenon Observed

Resorption can be so severe as to require augmentation with bone grafts in order to prevent pathologic fracture of the mandible.

Measures to Prevent or Slow Resorption.1. Well adapted and properly extended dentures with properly designed and executed occlusion.2. Retention of residual tooth roots in key locations.

3. Use of osseointegrated implants

Retained roots and osseointegrated implants are useful because they absorb much of the occlusal load locally, thereby preventing compression of the periosteum and in turn preventing resorption of the adjacent bone.

Retained root tips (A) andOsseointegrated implants (B, C)

A

B

C

The denture rests on the implants or root tips. Compression of the mucoperiosteum is minimized, preventing resorption of the underlying bone.

Preventive Measures

Note tissue bar connected to the implants

Bar facilitates retention, stability and provides support in the anterior region.

Preventive Measures

Frenum – Folds of mucus membrane containing fibrous connective tissue (A) (arrows).

A

Frenum are of little consequence. However, they may limit denture extensions (B) (arrows) or make seal difficult to maintain, and occasionally affect the retention of the maxillary denture.

B

Other Factors – Frenum Attachments

Other factors – Frenum attachments Mandibular frenum.

If they are prominent they may affect denture extensions, particularly the lingual frenum

Buccal frenum

Lingual frenum

Floor of mouth posture and tongue position (depth of retromylohyoid space) affect stability and retention.

Favorable anatomy as seen here (A, B,) permits development of a longer lingual flange.

A

B

Result: Improved stability and retention of the mandibular denture

Floor of Mouth Posture and Tongue Position

Impressions and dentures made for patients with favorable floor of mouth posture and favorable (anterior) tongue position. Note length of lingual flange. Stability and retention are enhanced.

Favorable Floor of Mouth Posture

Patients with unfavorable floor of mouth posture and tongue position (A, B). The tip of the tongue has lost its definition and is retruded and the floor of the mouth is elevated.

Result: Length of lingual flange of the denture will be limited, compromising stability, retention and the ability of the patient to control the lower denture.

A B

Unfavorable Floor of Mouth Posture and Retruded Tongue Position

Carefully examine the retromylohyoid space to determine the floor of mouth

Determining Floor of Mouth Posture

Result:a. Improved retention. Note denture snaps onto retention bar.b. Improved stability (from the implants and the tissue bar).c. Improved support (anteriorly).d. Better control of the bolus (tongue no longer must position denture and control the bolus simultaneously).

Solutions - Retruded Tongue Position and Unfavorable Floor of Mouth Contour.

1. Dentures retained with osseointegrated implants

This surgical procedure has been used to overcome problems caused by a retruded tongue position, unfavorable floor of mouth posture and a narrow residual zone of keratinized attached tissue.

Muscle attachments in the floor of the mouth are lowered and the zone of attached keratinized tissue is widened with the skin graft.

a.Result: Improved stability and retention of the denture because the lingual flange is lengthened.

b.Result: Improved support, because the zone of attached keratinized tissue is dramatically widened.

2. Skin graft vestibuloplasty

Skin grafted areas

Solutions - Retruded Tongue Position and Unfavorable Floor of Mouth Contour.

Residual keratinizedattached mucosa

Impact of Saliva and Salivary Glands

Palatal glands

Glandular tissue

Posterior palatal seal area

The presence of these glands permit compression of the tissues helping to overcome poor adaptation of the denture in this area secondary to shrinkage of the acrylic resin during processing. Peripheral seal of the denture is thereby maintained.

Posterior Palatine Salivary Glands

When making impressions this area of tissue is compressed, allowing us to compensate for shrinkage of the acrylic resin during polymerization and movement of the denture base during function.

Result: Tissue adaptation of the denture is maintained and therefore peripheral seal and retention of the maxillary complete denture is maintained.

When these glands atrophy, the tissue become less compressible making it more difficult to obtain and maintain peripheral seal.

Posterior Palatine Salivary Glands

Shrinkage of acrylic resin is also accounted for by scoring the cast in the postdam area (arrow).

Posterior Palatal Seal Area

Salivary Flow and Retention

Low flow rates• Difficult to achieve and maintain peripheral seal of the maxillary denture• Compromised adhesion and cohesion.

Saliva as a Lubricant

Low flow rates• Primarily affects the mandibular denture

bearing surfaces.• Results in more friction at the mucosa-

denture interface as the mandibular denture slips and slides over the denture bearing surface during function.

Neuromuscular Control

• Some patients have the ability to manipulate their lower denture and control the bolus simultaneously, regardless of the quality of the design and construction of the denture. • Many patients with good neuromuscular control can overcome unfavorable bearing surface contours and anatomy and chew efficiently with their complete dentures and the converse is also true.

Tissue Factors Affecting Support

Mandible:• Retromolar pad• Alveolar ridge contours (the broader the more support)• Amount of attached keratinized mucosa (the more present the better the support)• Buccal shelf area (the more access and the greater the surface area the better the support

Maxilla:• Amount of keratinized mucosa• Alveolar ridge contours• Palatal shelf area and contour

Tissue Factors Affecting Stability

Mandible:• Alveolar ridge height• Floor of mouth contour (favorable vs. unfavorable)• Tongue position (anterior vs. retruded)• Neuromuscular control• Presence of flabby, moveable denture bearing surface tissues.

Maxilla:

• Alveolar ridge height• Presence of well formed maxillary, moveable denture bearing surface tissues tuberosities• Presence of flabby

Tissue Factors Affecting Retention

Mandible:

Primary Factors:• Tongue position• Floor of mouth posture• Neuromuscular control

Secondary Factors• Peripheral seal• Adhesion• Cohesion

Maxilla:• Shape of the palatal vault (peripheral seal)• Drape of the soft palate - House classification (peripheral seal)• Quality and quantity of saliva (peripheral seal)• Compressibility of posterior palatal seal area (peripheral seal)• Presence of well shaped tuberosities• Height of alveolar ridge (resistance to lateral displacement)

Clinical exam - Prosthodontic Assessment

Assessment of existing dentures• Retention• Stability• Vertical dimension of occlusion• Centric relation• Esthetics

Prosthodontic Assessment

Posterior teeth• Tooth forms• Materials• Wear

Prosthodontic Assessment

Retention - Maxilla

Apply a tipping force to the incisors in an attempt to break seal

Prosthodontic Assessment

Stability - Maxilla

Prosthodontic Assessment

Stability and Retention - Mandible

Prognosis based upon:

• Bearing surface anatomy, tongue position and floor of mouth posture

• Neuromuscular control• Denture history

• Psychological classification

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