Geriatric and Prosthetic

  Arthritis 

Dental considerations
Difficulty in denture care procedure. TMJ may show difficulty in performing different movements during steps of denture construction.

Avoid prolonged procedure to avoid patient fatigue.

Cardiac problems:

Neurological disorders: Parkinson's disease

The movements and spasmodic head positioning associated with the disease may compromise the dentist’s ability to carry out restorative care. These patients’ involuntary movements can make the use of sharp and rotating instruments hazardous.

Osteoporosis.

May be caused by hormones or drugs as steroids and anticonvulsants Antiepileptic drugs
This is not a disease entity but may be a manifestation of a diverse group of diseases ,it is characterized by a reduction in the mass of bone / unit volume.

Osteoporosis can be caused by certain hormonal disturbances as:

Hyperparathyroidism Hypothyroidism DM Adrenal insufficiency Menopause in females

Dental considerations for Osteoporosis:

Fragility Fractures resulting from minimal trauma can result in significant morbidity and mortality in older adults who are functionally independent.


Diabetes Mellitus (DM)
Hypoglycemia
Dental Considerations for DM
Short appointments at morning. Treatments sh. be with minimum trauma & stress . Maintains good oral hygiene regarding using topical agents , such: chlorhexidine. Using Prophylactics & fluoride gel found to be effective Management of related xerostomia & other endocrines signs. Dentist sh. Learn about diagnosis & treatment of Hypoglycemia shock.

Nutritional deficiency

a) 1ry: which is due to lack of nutrients in diet b) 2ry: due to failure to absorb ,utilize or increase nutrients due to illness or excessive exertion.

Vit.B12  angular chelitis Vit.B2 pellagra

Vit.C  General weakness, retarded wound healing, petechial patches due fragility of capillary walls, gingival bleeding and marked bone resorption.

The geriatric prosthetic patient

Geriatric patients (as well as all dental patients) should not be promised too much. Patients tend to remember every claim the dentist has made and will hold him to it. Esthetics is important in fabricating dentures for the aged. An esthetic denture may be the turning point in patient acceptance.

Replacement options

Conventional options:
Temporary RPD
Complete dentures
Permanent RPD

RPD for Geriatrics

The design should be as simple as possible So as to decrease the trapping areas predisposing to increase the caries susceptibility
Design should consider future addition of questionable teeth. The design should consider deleting rests from compromised teeth to avoid overloading.

Complete dentures

considerations
benefits
Contributes further bone loss Tissue support sore spots Nerve exposure pain On going expenses to maintain by relining, denture adhesives &cleansers. Loose fitting diff. in eating and speaking. Palatal coverage interferes with normal sensation of food.
Least costly approach fast

Implant as a prosthetic option

Over denture supported with implants
Benefits: Next least costly approach Better fixation of denture Improve chewing ability


Benefits: Best fit mostly like natural teethNo dietary limitationsMaximize nutritional intakeNo interference with taste due to minimal coveragePreserve bone Implant retained fixed bridge
Considerations: Cost Longer treatment time Multiple visits

Masticatory Performance

All Natural teeth 100% Implant retained bridge 90% Implant with over denture 60% Conventional complete denture 10% No teeth or denture 0%

What is the best choice?

Several factors are considered to choose the best treatment modality: Amount of bone available Quality of bone Patient systemic conditions Amount of force applied Patient financial conditions

:Implants for irradiated patients

Problems of irradiated bone: Decrease number of osteoblasts and osteocytes Fatty degeneration in marrow spaces Blood vessels undergo progressive degeneration, hyalinization and fibrosis, resulting in regional ischemia.

Recommendations for using irradiated bone for implant insertion:

Minimal one year elapsing before implant insertion. Using hyperbaric oxygen

Complete denture construction

Prior to making edentulous impressions for geriatric patients, the denture-bearing tissues must be carefully examined. If ill-fitting dentures have abused them, the use of tissue conditioner is a necessity until their return to normal physiologic color and tone.

The final steps of impressions are made according to the condition of residual alveolar ridge
Impressions:

Flat ridge

Muco-compressive impression technique
Called closed mouth technique, it requires; A well fitting record base. An accurate occluding rims An acceptable vertical dimension Final impression made using zinc oxide impression paste or viscous elastomeric material while the patient closing on the occlusal rims

Selective pressure impression techniques

Dynamic impression technique (Functional impressions)
These techniques may be used where problems of stability exist : Three materials are commonly used for functional impressions. Alginate materials Elastomeric materials Tissue conditioning materials Used to record the range of muscle action, spaces into which the dentures can extend without displacement.

Final impression making

Butterfly impression technique :
Indicated with advanced ridge resorption with projecting sublingual gland and with presence large mandibular tori
Projecting sublingual gland
Mandibular tori

Flabby Tissue

A selective pressure impression technique
Sufficient relief and escape hole drilled in special tray opposite to flabby tissue to ensure relief of pressure over this area and proper load distribution.

A sectional impression technique (Two part impression technique)

Vertical dimension:
Certain acts must be taken into consideration during determining the vertical dimension. The interocclusal distance increases with age. Excessive restoration of the vertical dimension to achieve a more youthful appearance is contraindicated. Properly constructed bite blocks support the lips and improve the facial appearance are necessary.

In severe cases of over closure of patient’s old dentures it must be done over a period of time gradual elevations. The vertical dimension should be opened no more than 5 mm at any one time. After a period of a few years, the dentures can be remade and the interocclusal distance increases another 3 to 4 mm. An interocclusal distance of 5 to 10 mm may be indicated because of physiologic changes in the facial musculature, alveolar bone, skin, and sensory perception.


Centric relation: The determination of centric relation must be precise and accurate and not left to chance

Posterior tooth selection: The arrangement of posterior teeth plays a significant part in the retention and stability of the dentures. Many Prosthodontist recommend zero degree posterior teeth according to zones be as follows: More adaptable for class II and III More easily for width variation of jaws Eliminate the horizontal forces Less time consuming technique and offer greater comfort and efficiency for a longer period. If anatomic teeth are used for an aged person, balanced occlusion is necessary to ensure no interference with jaw movements.

Selection and setting up of teeth: 

Cross-linked cusp-less acrylic teeth to decrease lateral force to increase stability Set up the teeth in neutral zone to increase denture stability. Non anatomic or cross linked zero degree teeth with curves or ramps. Zero degree teeth with reverse lateral curve (curve of Pleasure)


Adjustment The insertion usually followed by irritation and trauma in varying degrees. The geriatric patient should be seen the day after insertion or at least the second day, depending upon the condition the patient can remove one or both dentures during the day if their mouth feels tired after adjustment period. Home care of complete denture should be stressed throughout the adjustment period.