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2. INTRODUCTION
DIAGNOSIS: the determination of
the nature of the disease.
TREATMENT PLAN: the sequence
of procedures planned for the
treatment of a patient after
diagnosis.
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3. FIRST VISIT
De Van stated, “ meet the
mind of the patient before
meeting the mouth of the
patient”
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4. FIRST VISIT
Develop mutual understanding and trust
Treatment plan should be based on realism rather
than hope otherwise it may result in disappointment
and frustration
Much information can be gained by the dentist before
he ever looks into the patient’s mouth
Time spent during the first appointment can lay the
groundwork of co-operation so necessary for a
successful result
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5. PRINCIPLES OF PERCEPTION
Visual perception is the primary mode of data gathering in
the examination
Simplest of it is seeing with eyes and interpreting with
the brain
Tasks identified in this process are:
Detection
Discrimination
Recognition
Identification
Judgment
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11. Dr M.M. House (1950) classified patients as
Philosophical
Exacting
Indifferent
Hysterical
This is the most widely used classification.
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12. Philosophical Patient
The philosophical type is the best mental attitude
for denture acceptance
Patient is rational, sensible, calm and composed in
difficult situations
Overcomes conflicts and organizes his time and
habits in an orderly manner
Eliminates frustrations and learns to adjust rapidly
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13. Exacting Patient
May have all of the good attributes of the
philosophical patient
However he may require extreme care, effort and
patience on Prosthodontist’s part
Patient is very methodical, precise and accurate and
makes several demands
Patient is comfortable when each procedure is
explained and discussed with them in detail.
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14. Indifferent Patient
Presents a questionable or unfavorable prognosis
These patients are identified by their lack of concern
and motivation and apathetic attitudes.
Pays no attention to instructions, will not cooperate and
is prone to blame the dentist for poor dental health.
An education program in dental conditions and dental
treatment is the recommended treatment plan before
denture construction.
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15. Hysterical Patient
Emotionally unstable, excitable, excessively
apprehensive and hypertensive
Prognosis is often unfavorable and additional
professional help (psychiatric) is required prior to
and during treatment
Patient must be made aware that his/her problem is
primarily systemic and that many of his symptoms
are not result of dentures
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17. Facial expression
This provides information about the mental attitude
and presence of any disorders.
Absence of any expression indicates loss of muscle
tone, trigeminal neuralgia, plastic surgery or
disorders of central nervous system.
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18. Complexion
Used to select the colour of the teeth.
It may also be indicative of the following conditions:
• Pale—anaemia, lack of nourishment.
• Ruddy—polycythaemia, chronic alcoholic.
• Bronze—radiation therapy, Addison disease.
• Bluish-purple—vitamin deficiency, cyanosis.
• Lemon-yellow—jaundice.
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19. Speech
The fluency and quality of the speech should be noted, as it will
help in arranging artificial teeth.
If speech is altered due to poor denture construction, it should
be rectified.
Speech can also be altered due to the following pathologies:
• Hypernasality—paralysis of palatal musculature.
• Hoarseness—paralysis of both vocal cords, excessive smoking.
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20. Breathing pattern
Abnormal breathing patterns may indicate the following:
Heavy sighing—emotionally disturbed
Wheezing—asthma
Shortness of breath—lung disease, heart failure
Shallow breathing at rapid rate—pulmonary fibrosis
Erratic breathing—continuous hyperventilation
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23. NAME
Documentation
Confidence and psychological security
Makes them comfortable
Idea about the patient’s family and
community
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24. AGE
Important to predict the outcome of the treatment
Refers to the physiologic age and provides information about the
patient’s expectations and care for the dentures.
Used to rule out certain systemic conditions apart from
determining the prognosis.
4th decade of life- good healing abilities
Greater than 6th decade- compromised healing
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25. GENDER
Generally, appearance is a higher priority for women than for
men.
Though younger men often are concerned with esthetics,
males often grow indifferent to their own appearances as
they age. During this process, men shift their concerns to
the comfort and function of dentures.
Women facing the physiologic and psychological problems of
menopause often present as exacting or hysterical patients
who are very concerned with esthetics.
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26. draaryas
OCCUPATION
Executives in high stress jobs may exhibit bruxism.
For professionals, appearance and retention may be more important than
efficiency.
Public speakers and singers may need greater attention to palatal shape and
thickness and perfect retention.
Wind instrument players may require special positioning of anterior teeth.
Patients in high socioeconomic groups may be more demanding and critical,
while those of low economic status may show disinterest and poor hygiene
maintenance.
27. LOCATION
Fluorosis endemic areas,-may need characterization
HABITS
Pan chewing, smoking, chronic alcoholism
Pencil biting and nail biting
Parafunctional habits like clenching and bruxism
28. NUTRITIONAL HISTORY
It is important to obtain a record of food intake of the
patient over a 3–5 days period. This helps in evaluating the
nutritional status of the patient.
The ability of the oral tissues to withstand the stress of
dentures is greater in a well-nourished patient. Dietary
counselling is necessary in malnourished patients.
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30. Successful treatment requires
An Understanding Of
Patient’s general health
Dental history
Thorough appreciation of the status of
Oral and perioral tissues
Any existing prostheses, be they successful or
unsatisfactory
31. Health Questionnaire
Convenient method of collecting basic information and
personal data
Can be sent to the patient before the appointment or
administered in the reception area if facilities permit its
confidential completion
Dentist can then review and clarify the information as
necessary in the private operatory as part of the clinical
examination
32. MEDICAL HISTORY
Debilitating diseases: Diabetes mellitus, candidiasis,
blood dyscrasias, tuberculosis
Diseases of the joints: Rheumatoid arthritis and
Osteoarthritis
Cardiovascular diseases
Diseases of the skin: Pemphigus
Neurological disorders: Bell’s Palsy, Parkinson’s disease
34. DENTAL HISTORY
Chief complaint
The chief complaint is recorded in patient’s own words.
It should be determined if the complaint is justified and realistic.
It gives ideas about the patient’s psychology.
Patient’s desires and expectations
It is important to find out what the patient expects from the
treatment.
The patient should be asked about his/her expectations.
Unrealistic expectations will be detrimental to success of treatment.
Patient education regarding what is possible is very important in such
cases.
35. PAST DENTAL HISTORY
The following information should be elicited:
1.Reason for tooth loss:
If periodontal disease was the reason, more bone loss is
anticipated. It also helps in prognosis.
2. Period and sequence of edentulousness:
Longer the period, more will be the bone loss. By understanding the
sequence, bone resorption pattern can be identified.
36. 3. Previous dental and denture experience:
Traumatic experiences will affect the attitude of the
patient towards dental treatment
They will require more counselling and education.
Patient’s experience with previous dentures will give
an insight into their attitude, desire and
expectations.
37. Existing or Current Dentures:
The patient should be questioned about the length of
time he or she has worn the current dentures.
Responses should be compared with clinical
observations.
Careful observation may provide valuable information
about denture experience, denture care, dental
knowledge, parafunctional habits, etc.
38. Denture Success
Patient should be asked about the esthetics and function
of existing maxillary and mandibular dentures. Responses
may indicate the patient's ability to wear or adjust to
complete dentures.
Denture success for each arch should be rated
"favorable" or "unfavorable."
39. PRE-TREATMENT RECORDS:
The pre-treatment record is a very valuable information.
Pre-treatment records include information about the previous
denture, current denture, pre-extraction records and diagnostic
casts.
Pre-extraction photographs, radiographs, casts, and facial
measurements may prove helpful in denture therapy.
These adjuncts may be used to recreate anterior esthetics and
facial support, as well as to aid in the evaluation of vertical
dimension of occlusion.
41. EXTRA ORAL EXAMINATION
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Concerned principally with
Facial contours and
symmetries
Appearance of the teeth and
their relationships with the
lips in repose
Palpation of the
temporomandibular joints
and of the submandibular
and cervical lymph nodes
Masticatory and facial
muscles
FACIAL EXAMINATION
MUSCLE TONE AND DEVELOPMENT
LIP EXAMINATION
TMJ EXAMINATION
NEUROMUSCULAR EXAMINATION
53. COMPLEXION
Hair, eye, and skin color provide useful guides in shade selection.
Skin color also can reveal underlying disease and pathology.
Patients with significant sun damage need referral to a dermatologist.
Pale, anemic-looking patients may have underlying systemic diseases
and may require longer adjustment periods.
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54. NASO-LABIAL ANGLE
Naso-labial angle for a normal individual varies from
90-110 degrees which is decreased in an edentulous
patient as the upper lip loses support from the
maxillary incisors.
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56. LIP LENGTH
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Upper lip length- measured from base of nose to
inferior part of upper lip.
MALES- 22 to 26 mm
FEMALES- 20 to 22mm
- affect how much teeth would be exposed
- short lip tend to reveal more of tooth structure
and denture base
59. LIP FULLNESS
Apparent fullness of the lip is directly related to the
support provided by the teeth and alveolar bone or
denture base
Lip fullness should not be confused with lip thickness,
which involves the intrinsic structure of the lip.
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60. INADEQUATE LIP SUPPORT
If anterior maxillary denture teeth are set
excessively palatally to reduce the overjet can lead
to a lack of lip support
Producing vertical wrinkles in the face
Results in the teeth appearing to be “too short”—a
problem usually best corrected not by lowering the
occlusal plane but by increasing lip support
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61. EXCESSIVE LIP SUPPORT
Prominence of the residual alveolar ridge or excessive
thickness of labial flange can result in excessive lip
support
Make the lip appear to be too full rather than
displaced
Also can make the lip appear thick or short
An obliterated philtrum or mentolabial fold suggests
excessive support
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62. CORRECTION OF LIP SUPPORT
Problem with lip fullness is in the patient’s reaction to
changes
If the existing dentures have the teeth set too far palatally,
the patient may feel that the new and corrected tooth
arrangement makes the lip too full
Extra time will be needed at the try-in of the wax dentures
to ensure that the patient is comfortable with the agreed
design
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63. THIN & THICK LIPS
Patients with thin lips present special problems
Any slight change in the labiolingual tooth position makes an evident
change in the lip contour
critical that even overlapping of teeth may distort the surface of the lip
Both the arch form and the individual tooth positions can have effect on
lip contour
Thick lips give the dentist a little more opportunity for variations in the
arch form and individual tooth arrangement before the changes are
obvious in the lip contour
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66. TMJS & MASTICATORY MUSCLES
EXAMINATION
TMJ plays a major role in the fabrication of a CD.
The joint should be examined for range of movements,
pain, muscles of mastication, joint sounds upon opening
and closing.
Severe pain in the TMJ indicates increased or
decreased VD.
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• Class I: Co-ordinated
• Class II: Jerky
• Class III: Restricted
67. NEUROMUSCULAR EVALUATION
Patients gait, coordination of movements, ease with
which he moves noted
Uncontrolled tremors of mandible and tongue may
lead to prosthesis instability.
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SPEECH
COORDINATION
68. SPEECH
Should have a basic knowledge of speech, particularly its articulatory
component
Articulation is the modification of speech sounds by structures of the
throat, mouth, and nose
Fortunately, the neuromuscular activity that produces speech can adapt
to, or accommodate, a certain amount of structural change
Relationship of the positions of the teeth, lips, and tongue in the
articulation of speech are very important
Assessment should be made during the diagnosis appointment to identify
existing problems and determine the potential for improvement
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69. COORDINATION
• Patients with good neuromuscular coordination can be expected to
learn to manipulate dentures relatively quickly and likewise adapt
readily to new dentures.
• Patients with poor coordination or a neurologic deficit (such as
from a stroke) may never adapt to a denture completely.
Classify neuromuscular coordination as follows:
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Class 1: Excellent
Class 2: Fair
Class 3: Poor
77. ARCH SIZE
CLASS I LARGE BEST FOR RETENTION AND STABILITY
CLASS II MEDIUM GOOD RETENTION AND STABILITY BUT
NOT IDEAL
CLASS III SMALL DIFFICULT TO ACHIEVE GOOD RETENTION
AND STABILITY
• Arch size = amount of basal seat available
• Increased Arch Size → More Stability & Retention
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78. ARCH FORM
CLASS I SQUARE Best form
to prevent
rotational
movement
CLASS II TAPERED Offers
resistance to
movement but
to a lesser
degree
CLASS III OVOID -------
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79. CLASS I NORMAL Anterior segment of
mandibular ridge directly below
or slightly posterior to the
maxillary anterior ridge
CLASS II RETROGNATHIC Anterior segment of mandibular
ridge retruded beyond the
normal position
CLASS III PROGNATHIC Anterior segment of mandibular
ridge protruded beyond the
normal position
RIDGE RELATIONSHIP
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80. RIDGE FORMS
CLASS I SQUARE
CLASS II TAPERING
CLASS III FLAT
CLASS I INVERTED U SHAPED- TALL
TO MEDIUM WITH BROAD
CREST
CLASS II INVERTED U SHAPED-SHORT
WITH FLAT CREST
CLASS III UNFAVOURABLE
• TALL THIN INVERTED V
• SHORT THIN INVERTED V
• INVERTED W
• UNDERCUT
MAXILLA MANDIBLE
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87. INTER RIDGE DISTANCE
CLASS I Ideal inter-arch space to
accommodate the artificial
teeth
CLASS II Excessive inter-arch space
CLASS III Insufficient inter-arch space
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88. RIDGE PARALLELISM
Class I Both ridges are
parallel to the
occlusal plane
Class II Mandibular ridge is
divergent from
occlusal plane
anteriorly
Class III Maxillary ridge is
divergent from the
occlusal plane
anteriorly and/or
both ridges are
divergent anteriorly
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94. PALATAL SENSITIVITY
Evaluated by running a mouth mirror over the soft palate
Gagging controlled by:
Careful handling of impression procedure
Constant reassurance
Diverting the patient attention from the procedure
○ Class I: Normal
○ Class II: Hyposensitive
○ Class III: Hypersensitive
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95. LATERAL THROAT FORM
Distance between the floor of the
mouth and the middle of the
retromolar pad when the patient
protrudes the tongue ¼ inch beyond
the edge of the lower lip
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98. BORDER ATTACHMENTS
Class I: Attachments are high in
maxilla and low in mandible
with relation to ridge crest
0.5 inches or greater
Class II: 0.25 to 0.5 inches
Class III: < 0.25 inches
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99. FRENAL ATTACHMENTS
CLASS I ATTACHMENTS IN
MAXILLA → HIGH
MANDIBLE → LOW
CLASS II MEDIUM
CLASS III ENCROACHING CREST OF THE
RIDGE MAY INTERFERE WITH
THE DENTURE SEAL
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100. SALIVA
Quality and quantity of saliva are crucial factors in a
patient’s ability to tolerate dentures
Both the flow rate and the viscosity are important to
denture success.
Normal resting salivary flow is about 1 ml/min.
A flow of medium viscosity at this rate lubricates the
mucosa and assists retention of complete dentures
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101. SALIVA
Quantity
If dry- decreased retention, potential for
soreness
If excess- complicates denture
construction, especially impression making.
Quality
Thin, watery type
Thick, ropy - denture wearing more difficult
(scanty, thin saliva interferes with seal of
complete dentures)
To check consistency of saliva, string test
Class 1: Normal quality and quantity
of saliva. Cohesive and adhesive
properties of saliva are ideal.
Class 2: Excessive saliva; contains
much mucus.
Class 3: Xerostomia
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107. TORI
TORUS PALATINUS
• Found at midline of hard palate
• Small ones may be accommodated by
relief of denture base
• Surgical excision if fills palate to
occlusal level, or extends beyond
vibrating line
• Treatment deferred for 2-6 months
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108. MANDIBULAR TORI
• Lingual premolar region
• Difficult to provide relief without
breaking border seal of denture
• Surgical removal is necessary for
successful denture construction
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109. RIDGE DEFECTS AND
REDUNDANT TISSUES
It is common to find flabby tissue covering the
crest of the residual ridges.
These movable tissues tend to cause movement
of the denture when forces are applied.
This leads to loss of retention.
Ridge defects include exostosis that may pose
a problem while fabricating a complete
denture.
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111. EPULIS FISSURATUM
Border tissues may be chronically
traumatized by flanges that were originally
overextended or have become so as a result
of lost ridge support, producing a reactive
hyperplasia
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112. PAPILLARY HYPERPLASIA
Cauliflower-like in appearance and tends to
occur on the anterior region of the palate in
long term denture wearers.
Often this tissue is inflamed when it is
referred to as inflammatory papillary
hyperplasia
Deep crevices of papillary hyperplasia are
prone to infection, frequently with C.
Albicans.
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113. INFECTION
Oral fungal infections are common in
edentulous patients, particularly in
maxillary denture-related stomatitis
Concomitant inflammation of the
corners of the mouth—angular
cheilitis—should raise suspicions of
candida albicans infection
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116. INTERPRETATION OF OPG
Defects in structure /
reactive new bone formation
Bone expansion
Unerupted teeth / retained roots
Foreign bodies
Radiolucencies and radiopacities
Maxillary sinus checked for
inflammation, cysts, polyps,
tumors
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117. RIDGE RESORPTION
Class I Mild resorption – Loss of 1/3 of
original height
Class II Moderate – loss of 1/3rd to 2/3rd
Class III Severe – Loss of 2/3rd or more
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118. PHOTOGRAPHIC IMAGES
Preextraction photographs can be useful for
determining teeth selection and arrangement
Observations on face form and jaw relations
also can be made
Circumoral support and smile lines may be
usually gleaned from a series of old pictures
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119. DIAGNOSTIC/STUDY CASTS
3D analogue of available denture-
bearing areas
Provide accurate information on
tooth size and arrangement
When articulated, reveal jaw
relationships, interarch tooth
relationships
Under-cuts can be observed
directly or determined precisely
with the aid of a dental surveyor
Assist in making decisions on
preprosthetic surgery
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120. Classification for the Completely
Edentulous Patient
(ACP-1999)
Class I
Class II
Class III
Class IV
Ideal or minimally
compromised
Moderately
compromised
Substantially
compromised
Severely
compromised
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121. Potential Benefits Of The System
Better patient care
Improved professional communication
Better screening tool to assist dental school
admission clinics
Standardized criteria for outcomes
assessment
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124. DEVELOPMENT OF
THE TREATMENT PLAN
After all the intraoral and general physical and
dental conditions have been recorded and
radiographs, casts, and other visual aids are in hand,
they can be interpreted and the treatment plan
developed
Details of the specific observations determine the
details of the treatment required
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125. A PRIMER ON
TREATMENT OPTIONS
1. Adjunctive care
2. Prosthodontic care
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126. ADJUNCTIVE CARE
Elimination of infection
Elimination of pathoses
Surgical improvement of
denture support and space
Tissue conditioning
Nutritional counselling
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127. PROSTHODONTIC CARE
For a patient destined to become
edentulous
For an edentulous patient
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128. Removable partial denture
Conventional
Interim
Hybrid complete denture/removable
partial denture
Transitional
Complete denture
Immediate or conventional
Definitive or interim
Tooth, implant, or soft tissue supported
FOR A PATIENT DESTINED TO
BECOME EDENTULOUS
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130. Clinical Conditions That Suggest
Need for Teeth Extractions
Advanced periodontal disease with severe
bone loss around the teeth
Severely broken-down crowns with subgingival
residual tooth tissue that cannot be
adequately restored
Fractured roots
Periapical or periodontal abscesses that
cannot be successfully treated
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131. Treatment plan decisions
Tissue conditioning / finger massage
• Type of treatment material, frequency
Preprosthetic surgery
• Procedures proposed and staging
Impression procedure
• Primary / final, material
Jaw relation and articulator
• Face bow transfer, articulator & its control settings
Tooth selection
• Shade, mold, material and number
Denture base material
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133. FINANCIAL IMPLICATIONS
Must consider the financial implications of any
selected treatment plan
Optimal treatment plan is useless if the patient
cannot afford it
Prioritize the need for different treatments based on
the significance of the identified problems
Treatment plan should balance the patient’s needs
and ability to pay
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134. SUMMARY FOR THE TREATMENT PLAN
Requires a broad knowledge of treatment possibilities and detailed
knowledge of patient needs determined by a careful diagnosis
Treatment beyond the competency of the treatment planner should
be referred to more experienced
Treatment planning must have a parallel process of developing a
prognosis
Treatment planning is the process of matching
possible treatment options with patients’ needs
and systematically arranging the treatment in
order of priority but in keeping with a logical
or technically necessary sequence.
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139. Stay Home Stay Safe..
Thanks for watching…
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Notas del editor
Any patient’s decision to seek prosthodontic care may be influenced by past dental treatment experiences, as well as current systemic and oral health concerns.
The collection of medical and dental histories and their careful analysis, coupled with a thorough orofacial examination, are an essential and integral part of prosthodontic management and cannot be overemphasized.
They are necessary to ensure the selection of an optimal treatment protocol with an associated favorable clinical outcome
In addition to lymph node palpation, the dentist may need to explore other structures such as the.
an elementary book for teaching children to read
.
Treatment planning is the process of matching possible
treatment options with patients’ needs and systematically
arranging the treatment in order of priority but in keeping
with a logical or technically necessary sequence