By:
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY2020-2021
Department of Prosthodontics
Department of: HERE
Welcome to the Fifth Class
Lecture of today
Dentist Ethics & Dentist – Patient relation ship Diagnosis & treatment plane
Dr. Monia MN Kandil
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Department of: HEREDentist Ethics & Dentist – Patient relation ship Introduction
The word ethics comes from the Greek word ethos character Latin word mores customs or habits. Together these two terms character, and moral acts.Dentist duties and obligations “Ethics”
Dentist should ensure proficiency, knowledge, hygiene roles, mutual trust with the patient, good examination and perfect treatment plane.Before undertaking any treatment, a dentist must inform his patient of his conditions and the treatment's cost, as well as should be informed if there is any complication occurring during the treatment.
If the patient asks for information, the dentist must be objective and honest.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYDentist Ethics & Dentist – Patient relation ship
Dentist must be fully committed to his professional civil liability.
Dentist must ignore any intervention, which may influence the performance of his duties.
We should keep secrecy of Patient’s confidential information, unless if ordered by law, or in case to prevent an act of violence (suicide, death and serious bodily injury). §7. Accessibility and correction of patients’ records : Must be performed continuously, and if the patient requested for a copy, the dentist should forward a free of charge copy of his information.Dentist must charge fairly and reasonably, according to: The time of the service, the complexity, the exceptional competence or speed, and the amount of patient’s disbursements (treatment’s coast). Also should notify his patient of a approximate cost before beginning, but if there is any change in the plane, the patient must informed without delay, for the additional fees.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Dentist Ethics & Dentist – Patient relation ship The positive relationship between dentists and their patients That should be friendliness, being calm, giving moral support, and working quickly.The method of communication affected by:
A patient’s age, race/ethnicity, education, psychological classification*: Class 1= Philosophical patients: that accepts dentist's judgment and instructions, best prognosis. Class 2= Exacting patients: which are methodical and demanding, asks a lot of questions, good prognosis. Class 3= Hysterical: that are emotionally unfit, never happy, worst prognosis. Class 4= Indifferent: patients are doesn't care about dental treatment and gives up easily.
*House's classification (Psychological)
020-2021
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYDiagnosis & treatment plane
Diagnosis & Pretreatment Communication with the Patient
The first visit interview is important; Patients will describe their thoughts and attitudes about treatment, and they must be allowed to offer their comments.During the history taking, the dentist has an opportunity to understand the patient’s physical and emotional background. Diagnosis include:
Medical history
Oral examination
Health information
020-2021
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYDiagnosis & treatment plane
Medical history
The patient should be questioned about the following items: Cardiovascular problem & Arteriosclerosis Renal diseases
Diabetes Endocrine imbalances
Gastrointestinal complaints Allergies, asthma, or other similar disturbances Immuno deficiencies
Severe migraine headaches Diseases of the central nervous system Insomnia, depression & psychological problems
Malnutritional effectsSexually transmitted diseasesSmokingNeoplasm’s treatmentMenopausal and post menopausal manifestation
020-2021
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Diagnosis & treatment plane
Health information
Anatomical abnormalities Age
Systemic illness Physical limitation Occupation, Financial & educational condition Sex
Oral examination
Radiograph
Visual and digital examination Impressions
Inter-occlusal space &Vertical dimension of occlusion Occlusal planes Esthetic profile Lip support & lip line
Previous treatment
So the examination should include the process of observing both normal and abnormal conditions. Extra-oral (visual appraisal) & Intra-oral hygiene, teeth, periodontal condition, ect.
020-2021
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYDiagnosis & treatment plane
TREATMENT PLANNING
For fabricating dental prostheses that meet patients' demands and have good longevity and function, appropriate treatment planning and decision-making are required.
This done by:
Patient documentation Review of clinical findings Research treatment options Review treatment options with patient Review financial status for treatment(s)
TYPES OF PROSTHETIC OR TREATMENT
Treatment may take the form of an interim, temporary intervention (immediate prosthesis), or a definitive prosthesis. Removable, fixed, or hybrid fixed-removable prosthesis. Tooth or implant abutment, or even tissue supported appliances.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Diagnosis & treatment plane
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Diagnosis & treatment planeImmediate Denture
Begins with … It is a denture, inserted and replaced immediately after extraction of the teeth. Indicated mainly to improve & preserve esthetic , functional demands for the patient, as well as alveolar bone health and wound healing. Not indicated for patient received radiation or chemotherapy, or patient at surgical risk.
For Conventional Immediate Complete Dentures:
The concept include: Maxillary six anteriors are still. Remove all posterior teeth about 1-3 months before making immediate denture. After healing, it is relined with acrylic resin.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Single dentureThe single denture is a complex prosthesis that requires a complete understanding of the basics of denture occlusion. The basic principles of retention, stability, and support should be taken in mined, and steps must be completed so that all components are working in harmony for success of the denture. So preparing the oral environment & correct occlusal plane for example is important, before denture fabrication to ensure better success.
Single Denture Success Depends on:
Occlusal adjustments for remaining teeth by the help of “occlusal template”.Achieving bilateral balance occlusion & articulations.If single denture is against natural teeth, it’s better to supported by implants (overlay denture), the number & position of implants depend on the alveolar bone quality, type, shape of the jaw, costs & such factors. Occlusal Template
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Diagnosis & treatment planeOver denture (Overlay Denture)
Define as: Any removable dental prosthesis that completely or partially covers and rests on one or more remaining natural teeth, the roots of natural teeth, and/or dental implants. It indicates if few remaining teeth or teeth with an unfavourable distribution in the arch which make the treatment with a RPD is difficult. If severe loss of periodontal attachment in a patient who cannot afford a fixed partial denture. With congenital absence of teeth i.e. Partial anodontia.
If significant tooth loss due to attrition was seen, and if aesthetic conditions due to tooth migration which make restoration with a removable or fixed partial denture is difficult.Overdenture types, can categorized to: Immediate, transitional & definitive overdenture. May be tooth (root) supported or implant supported overdenture. Can be partial or complete overdenture.If it’s supported by teeth, it may be still vital or with RCF, with capping or not, with Dum-shape, short, medium or with long preparation.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Diagnosis & treatment plane
Types of attachmentes retained overdenture.
a) stud attachment
b) bar attachment
c) magnet attachment
d) telescopic attachment
1) Intracoronal
2) Extracoronal
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
ATTACHMENT SELECTION (in general):Criteria for selection:LocationAvailable spaceFunction/type of retention –rigid or resilient- Cost Diagnosis & treatment plane
Magnet attach.
Stud extracoronal attach.
Stud intracoronal attach.
Telescopic attach.
Bar attach.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Dental implants
Removable denture supported by implants
Fixed denture supported by implants
Diagnosis & treatment plane
Dental Implant:Define as: a perimucosal device which is biocompatible and biofunctional and is placed within mucosa or, on or within the bone associated with the oral cavity to provide support & retention for fixed or removable prosthetics.Implant preserve the residual bone from excessive resorption. They’re excellent in aesthetics, retention & support demands.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Dental Implant Treatment PlanningDiagnosis & treatment plane
Depends on: How many teeth are missing? What is the degree of bone loss? Are the remaining teeth in a good position and do they have a long-term prognosis? What does the patient expect for an end result? What treatment will result in the best cosmetic outcome? What is the patient's budget?
So, the clinical factors that must be considered during designing using the implants:
Quality, quantity, and shape of supporting alveolar bone. The cantilever design can be avoided if the implants are placed posterior to the foramen. A fixed option could be utilized but will display less teeth, while a removable option will provide increased tooth display. A patient who has the bone quality to support a fixed prosthesis could also be a candidate for an implant overdenture supported by fewer implants.
020-2021
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYRemovable Partial Denture (RPD)
The basic principles of removable partial denture design, depend on:
Kennedy classification. The primary abutments, number & positions. The guiding planes direction, that affect the anterior - posterior (AP) tilting of the cast.AP tilt
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Classification of partially edentulous archesKennedy method of classification is the most widely accepted classification of partially edentulous arches.
A
B
C
D
E
F
G
H
A Class I. B Class II.C Class III. D Class IV. E Class I, modification 1. F Class II, modification 2. G Class III, modification 1. H Class III, modification 2. Components of a typical removable partial denture are:
1. Major connectors 2. Minor connectors 3. Rests 4. Direct retainers 5. Stabilizing or reciprocal components (as parts of a direct retainer assembly) 6. Indirect retainers (if the prosthesis has one or more distal extension bases) 7. One or more bases, each supporting one to several replacement teeth
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
MAJOR CONNECTORSUpper Major Connector
Lower Major Connector
Components of Typical rPd
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Upper Major ConnectorA, Single palatal bar. B, Single palatal strap-type. C, U-shaped. D, Anterior-posterior palatal bars. E, Anterior-posterior palatal strap-type. F, Palatal plate-type major connector
A
B
C
D
E
F
Components of Typical rPd
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Lower Major ConnectorA, Lingual bar. B, Sublingual bar. C, Lingual bar with continuous bar (cingulum bar). D, Cingulum bar. E, Linguoplate. F, Labial bar
A
B
C
D
E
F
Components of Typical rPd
020-2021
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYThe hinge for this continuous labial bar connector is located at the buccal aspect of left second premolar. Latching mechanism can be seen on buccal flange of the denture, between the right canine and first premolar.
The 4 mm
Gingival Protection Space
Components of Typical rPd
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Components of Typical rPdDepartment of: HERE
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRYComponents of Typical rPd
Clasp Design
Department of: HERE
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Components of Typical rPd
Clasp Design
In addition there are a couple of specific theories which include the clasp design:
RPI: mesial rest, distolingual guide plate, I-bar The RPI design was made for clasping a bilateral free end extension. These clasps are unique because they have to take into account extra torque force due to being tissue borne (and not tooth borne) at the posterior. Described by Kratochvil in 1963 and modified by Krol in 1973 Kratochvil designed the abutment tooth with a long rest (from the mesial marginal ridge to the distal pit), long guide plane, and a regular I-bar clasp. Krol modified this design with a short occlusal rest, short guide plane (touching only from occlusal to middle third), and a mesial-shifted I-bar. The theory behind Krol's decision was to allow for movement of the partial denture without placing too much torque on the abutment tooth. RPA: mesial rest, distolingual guide plate, Akers' clasp-style retentive arm. RPC: mesial rest, distolingual guide plate, other type of cast circumferential clasp.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Framework components: 1, major connector; 2a, minor connector by which the acrylic resin denture base will be attached; 2b, minor connector, proximal plate, which is part of clasp assembly; 2c, minor connector used to connect rests to major connectors; 3, occlusal rests; 4, direct retainer arm, which is part of the total clasp assembly; 5, two minor connectors and two rests gives reciprocal stabilzation & support; and 6, an indirect retainer .Finish lines
Notice
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
ExercisesExercise (1): What are the possible treatment plans: for patient with lower edentulous resorbed ridge, and complete set of upper teeth, that his medical history revealed, he just finished his radiation therapy; so he has signs of xerostomia?
Hints for answer : Talk about:* occlusal modification (occlusal stent).* lower removable single denture, with possibility using of "split denture", or artificial saliva such substitute .*using impression material and technique…registed the fine details & most retained , stable denture….can use neutral zone technique.*for future (after 6 months or more) using implants & over denture for maximum retention; (may need ridge augmentation). Exercise (2): What are the possible treatment plans: for old patient complaining from chronic periodontitis for all his teeth, intra-oral examination and X-rays revealed that's no chance for such teeth to be in function anymore?
Hints for answer : Talk about: * extraction sequence as preparation to immediate denture. * how to conserve V.D. & centric relations and patient's profile. *how to choose, arrange the teeth in manner suitable for the patient. *for future making a definitive complete removable denture or using implants & over denture for maximum retention.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
ExercisesExercise (3): What are the possible treatment plans: for patient has completely edentulous lower arch and the remaining teeth in the upper arch were only the four premolars (which are extruded in position), his medical history revealed that he was finish his radiation therapy before two weeks only, and he has signs xerostomia?
Hints for answer : Talk about:
Exercise (4): Patient about 38 years old, with Class III Angle’s skeletal classification. Lost his all lower teeth but still have his upper dentition in a functionally condition, his upper 1st premolars were super-erupted in their positions above the occlusal plan in about 4 mm, and from adjacent teeth in about 2mm. He is poor economically and need urgent moth rehabilitation that he had engagement meeting in about 3 weeks later. Hints for answer : Talk about: At first start in adjustment of the occlusal plane, by carful grinding of the irregular upper teeth. The upper 1st premolars need more reduction that may combined with root canal filling & cast preparation then covered by crowns for protection. Then make a single lower denture with maximum coverage of the foundation areas, & minimum bucco-lingual with & number of artificial teeth.
*occlusal modification before making upper RPD whatever it's metal base (with drawing its design); or overdenture.* lower removable single denture, with possibility using of "split denture", or artificial saliva such substitute.*using impression material and technique…registed the fine details & most retained , stable denture….can use neutral zone technique.*for future using implants & overdenture for maximum retention; (may need ridge augmentation).
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
Exercises
Exercise (5): Patient about 52 years old, he has just finish his radio and chemotherapy, lost his all upper teeth and the posterior lower teeth from long time ago. He had an upper single denture but it’s loose, no retention, stability or support was seen with occlusal plane disorientation. This lead to developing of special sever resorption pattern in the premaxilla, with a development of fibrous hyperplasia in the maxillary tuborosity; the lower canines are slightly over erupted. Hints for answer : Talk about: After extensive mouth care and using conditioning materials. Make a new upper single denture, this done after correction of the occlusal plane by adjusting & carful grinding of canines to produce bilateral balance occlusion.
Exercise (6): Patient about 45 years old that lost his all upper teeth during the previous 5 years, as a result of bad oral hygiene. The upper alveolar ridge generally with good contour, except sever undercuts buccally to the maxillary tuborosities. He had a complete set of lower teeth with some restorations in a good condition, the patient refuse to do implant operations because some economic issues.
Hints for answer : Talk about: At first step a surgical correction of the maxillary tuborosities was done, we prepared before an immediate upper denture with conditioning materials, followed by correction of the occlusal plane as mandatory step. After 3-4 months of wearing the immediate prosthesis start to make a definitive upper single denture with bilateral balance occlusion.
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY
ExercisesExercise (7): Old edentulous patient with Cl II Angle’s skeletal classification, need a removable complete denture as soon as possible, his alveolar ridge is low round in shape, salivation is less than normal (has slight xerostomia), what do you suggest to gain most stable removable complete denture? Hints for answer : Talk about:*Because he had a weak lower ridge small with low height so we planned to but the occlusal plane as low as possible toward the weak ridge with acrylic non-anatomic teeth, so to decrease the harmful effect of horizontal lateral forces, and the leverage action on the lower ridge. Acrylic teeth is more suitable for weak low height ridge, than ceramic teeth.*Because he had slight xerostomia so during impression, choose a material not be hydrophilic such as “plaster of Paris”, but we can us ZOE or Rupper base imp. Mat. If there is alveolar undercuts, advice patient to wash his mouth before imp. Taking and as much as he can to decrease damage for soft tissues and improve retention of denture in future as well as using some of saliva subistitutes or artificial saliva.*Occlusion theories can followed in such condition: Linqualized occlusion if upper teeth is semi-anatomic in nature, or monoplane theory with posterior rump if upper teeth are non-anatomic.*When ever any steps of treatment is done, the patient need saliva substitute and wetting his mouth, and when wear the denture may need conditioning materials if some mucosal sourness will seen. *Can you add any thing else? Thank you for listening
THE END
UNIVERSITY OF MOSUL COLLEGE OF DENTISTRY2020-2021