INSERTION OF PROSTHESES
Prosthetic insertion is a fundamental appointment in the treatment of total edentulism where technical and clinical checks of the polymerized prostheses are carried out before the patient wears the new prostheses.
This is the last sequence of a carefully established construction. It includes:
– Insertion of the prosthesis in the mouth.
– patient care based on their complaints (patient adaptation)
– The advice.
– The controls.
Upon returning from the laboratory, technical checks of the prostheses must be carried out in the absence of the patient, then, in the presence of the patient, again, numerous clinical checks are carried out.
INSERTION OF PROSTHESES
I/Technical checks of prostheses
Upon return from the laboratory, the prostheses must be delivered by the laboratory in a waterproof plastic bag, previously moistened inside.
1) Verification of the correct coaptation of the prosthetic bases on their plaster supports.
2) The extrados of the prosthesis must be carefully polished.
3) The intrados of the prosthesis and other support surfaces must be polished, free of roughness or bubbles and must not have sharp edges.
4) The edges of the prosthesis must be rounded, not sharp and must be relieved at the level of the muscle insertions, flanges and frenulums.
5) The position of the teeth must be observed in order to detect any changes that may have occurred during the flaring process.
6) Search for a stable contact position between the two prosthetic arches (the secondary models are detached from the articulator). This position must be found on the articulator. This bodes well for the existence of a stable position of the prostheses in the mouth.
II/Clinical checks of prostheses with the patient
1/ Prosthetic stability checks : This is the first parameter to check
For patient comfort, prostheses should always be moistened before insertion into the mouth.
The mandibular prosthesis is inserted first: it contains the spread of the tongue and better prepares the patient for the new prosthetic volume.
The prostheses are inserted into the mouth obliquely, spreading the lip and cheeks to one side and then the other using a mirror. They are centered in relation to the median sagittal plane. Sufficient pressure is exerted by the fingers on the occlusal surfaces of the teeth and on the support surfaces in order to expel the air from under the prostheses.
2/Checks of the mucoprosthetic interface
Second key element of the insertion, it is necessary to control the absence or presence of painful areas, generated by “defects” of the mucoprosthetic interface.
Verification of the limits of the edges of the prosthesis in relation to the bottom of the vestibule, to the muscular insertions, to the frenulums and to the flanges, to the specific maxillary and mandibular anatomical zones (excessive polishing of the prosthesis during its finishing can cause a loss of precision of the limits).
Verification of the filling of passive spaces by the surfaces of the prosthesis.
Checking static stability: in a semi-open mouth, manual mobilization of the muscles, frenulums and flanges must not cause movement of the prosthesis.
3/Brake checks and muscle insertions
Third element to check, the free play of the muscular insertions and the brakes present at the limits of the prostheses
4/Checks of the stabilizing polished surfaces
Any error in finishing the extrados and in particular in excess thickness of the polished stabilizing surfaces results in a defect in the stability of the prosthesis. These errors can be simply highlighted by means of silicone materials which, deposited on the extrados, are locally removed by the movements of the lips, the tongue
CONCLUSION: At this stage, some corrections can be made: removal of irritating thorns polishing of rough or retouched surfaces unloading of the edges of the prosthesis if there is interference with the muscles, frenulums or bridles.
INSERTION OF PROSTHESES
5. INTERMAXILLARY RELATIONSHIP and IMMEDIATE EQUILIBRATION :
For the majority of authors, occlusal corrections should always be performed before the patient wears the prosthesis, on the day of prosthesis insertion. These corrections aim to eliminate clinical and technical errors.
In the first step, on the day of insertion, corrections only concern the centric relation position, with the principle of not overloading the support surface. Eccentric corrections are carried out later.
The patient clenches his teeth on two rolls of salivary cotton placed opposite the molars (one on each side) for a few minutes.
The practitioner removes the two rolls of salivary cotton and positions himself at 11 o’clock in relation to the patient. He mobilizes and guides the mandible in centric relation, taking care to hold the maxillary prosthesis with the fingers in order to better locate the first contact that is established between the prosthetic arches and to perceive a possible tilting of the prosthetic bases. The patient closes in this position and clenches the teeth for a few minutes. This operation is repeated several times.
The practitioner places a piece of articulating paper on each side at the level of the molar and premolar sectors and asks the patient to click the teeth several times. This makes it possible to highlight the premature contact between the prosthetic bases and to ensure equal pressure on each side.
The contacts obtained in the mouth and those observed on the articulator can be compared by using articulating paper of a different color.
METHOD OF OCCLUSAL CORRECTIONS BY GRINDING : see occlusal balancing course
III. ADVICE FOR PROSTHESIS WEARERS
EXPLAIN TO BETTER PREVENT….
1. Hygiene advice
- For what?
The total removable prosthesis is made of resin: it is a porous material on which the microorganisms of the oral cavity can reside, take shelter and develop.
Over time, old resins become more and more permeable. With the friction of the prosthesis on the mucous membranes, we will see a histological modification of the supporting gum and a reduction in the tissues’ ability to defend themselves.
- How?
- After each meal: Remove your prosthesis, rinse it and rinse your mouth.
- Once a day: brush your prosthesis with a specific brush and toothpaste, without forgetting the intrados. Rinse it well.
- Soak your prosthesis for 15 minutes in a Chlorhexidine-based mouthwash (e.g. ELUDRIL, HEXTRIL)
- Regularly brush the mucous surfaces on which the prosthesis rests (palate, gingival ridges) with a soft brush.
- If you do not wear your prosthesis at night, leave it submerged in water.
2. Dietary advice
-Get into the habit of chewing on both sides from the start.
-Avoid hard and sticky foods. Favor a soft but consistent diet. Chewing should be slow and controlled.
3. Speech problems
Speech disorders are almost mandatory. Warn the patient that they are temporary and will only last a few days.
4. Taste disturbance
It is necessary to explain to the patient that the responsibility for tasting should be attributed mainly to the tongue and not to the palate.
However, resin bases can release monomer for a few days after they have been put in place and can cause unpleasant tastes in the mouth.
5. Possible injuries
Despite careful production, prostheses have imperfections that can cause mucosal injuries. Explain to the patient that the prosthesis can be altered.
Warn the patient of the possibility of mucosal injuries associated with tongue or cheek biting.
6. Other warnings
Clearly explain to patients that their prostheses will partially restore their natural teeth and that there is a period of adaptation to the prostheses which varies depending on the different clinical cases.
There may be a feeling of congestion and discomfort, especially if the patient has been toothless for a long time or if it is a question of renewing prostheses.
Even after prosthetic insertion, a number of complaints about the newly inserted prostheses are expressed by the patient. These objective or subjective complaints are reported immediately or within a more or less short time and must be addressed .
INSERTION OF PROSTHESESINSERTION OF PROSTHESES
IV/Immediate grievances
We often call objectives the complaints for which a technical improvement is justified, leading to their definitive disappearance. These are generally linked to:
- More or less intense painful phenomena, often related to prosthetic instability or localized compressions;
- Aesthetic or functional grievances and in particular phonetic ones
1. DISCOMFORT AND BULKNESS
The prosthesis must not only occupy the “free passive space, the neutral zone”, but also integrate and adapt to the contours and movements of these same muscular walls.
Through their aesthetic, mechanical and functional role, the shapes and volume of the prosthetic extrados contribute to increasing the patient satisfaction index.
2. NAUSEA
They are of reflex origin and can determine the immediate rejection of the prosthesis and the refusal to go further.
Therefore, the gag reflex must be detected from our first contact with the patient.
The origins are of several orders: psychogenic (fear) and somatic.
The treatment will be both psychological, prosthetic and pharmacological.
3. INSTABILITY OF PROSTHESES
-In inocclusion , instability may be due to lack of retention or over-extended prosthetic edges. Interference of these edges with the peripheral musculature causes mucosal injury or prosthetic instability.
- In the maxilla, instability of the prosthesis can also be linked to the presence of a large and poorly located velo-palatal joint.
- In the mandible, the situation is unfortunately different; retention phenomena linked to adhesion and cohesion are reduced due to the reduction in the support surface.
In occlusion; The occlusal concept used in complete removable prosthesis is that of generally balanced occlusion according to GYSI. Any failure in the realization of this concept, whether due to incorrect assembly of the teeth or linked to a settling of the prostheses on their support surface, can lead to the appearance of prosthetic instability in occlusion.
4. TACTILE AND PAINFUL GRIEVANCES
Pain is the most cited complaint by wearers of bimaxillary total prostheses. Tactile complaints consist of painful reactions in centric relation occlusion. All causes of irritation must be eliminated before the patient leaves us.
Our first treatment will consist of eliminating the premature contact points responsible for local overloads, compression and pain. All overextensions and overload areas must be identified and eliminated.
INSERTION OF PROSTHESES
5. PHONETIC COMPLAINTS
It is certain that the fitting of a prosthesis in the mouth can lead to disorders of the articulation of certain phonemes, because the phonetic positions of the tongue, cheeks and lips are modified by the limits imposed by the devices. The adaptation is more or less rapid depending on the patient.
6. AESTHETIC COMPLAINTS
The main aesthetic complaints are:
- teeth too big or too yellow, too visible or not very visible, prosthetic teeth too exposed,
- patient still looks too much like a toothless person
- prosthetic reconstructions appear too artificial.
To these complaints, often subjective, can be added objective reproaches:
- feeling of fullness under the nose,
- antero-superior labial flap too long or too thick,
- recessed upper lip,
- anterior teeth too lingual…
V/ Secondary grievances
Just as immediate grievances can be tactile, reflexive, aesthetic or phonetic, at this stage it will be appropriate to distinguish justified grievances from unjustified grievances.
1. Subjective or unjustified grievances
They are psychological in nature and require early diagnosis.
No treatment or improvement by adjustment can provide a solution to these pathologies. Aesthetic complaints are the most frequent, they are the lot of unstable patients, without their own personality, subject to the judgments of their loved ones.
The treatment is simple: make a few fictitious adjustments.
2. Justified grievances
They are the most frequent, their causes must be systematically sought and eliminated.
- A/secondary nausea : which have as causes
– mobility of the upper prosthesis
-wrong location of the post limit
-excessive thickness of 1/3 post
-narrowed lower arch (grind the lingual surfaces of the molars)
-an underestimated DV: the solution will consist of lining the intrados of the prosthesis with a quick-setting material as soon as the DV is correct and the nausea has disappeared, the base will be repaired.
INSERTION OF PROSTHESES
B/Dry mouth and burning sensation
These two symptoms are located in the anterior half of the palate on the inner side of the lip and in the region of the frenulum, sometimes the burning sensation is accompanied by dry mouth.
- Local causes are due to occlusal disharmonies, insufficiently relieved incompressible zones
- General causes are due to diabetes, senility, avitaminosis; menopause
Local treatment will consist of frequent mouthwashes, vitamin B will be administered for a fairly long period.
C/Loss of taste
- The patient should be explained that most of the taste buds are located on the dorsal surface of the tongue, on its tip and on its edges. However, these regions are free
- The treatment will consist of spicier and more spice up the food in order to excite the taste sensations.
D/Tongue Bites
They can be caused by:
• Teeth mounted too lingually
• Insufficient vertical dimension
• Incorrect occlusal plane
E/Pain points
They can appear on the periphery or under the intrados of the prostheses.
- In the upper jaw
The painful points are located in the paratuberous region when the tuberosities are prominent and undercut. In order not to harm the retention, the adjustments will be made at the level of the internal face of the prosthesis at their level; they can also be located at the level of the incompressible zones such as the intermaxillary suture and the torus (These zones will be unloaded).
- In the mandible
It is at the level of the mandible that painful points are most frequent and least well tolerated.
The first injuries are located at the level of the palatoglossal arch which interferes with the posterior edge of the lower prosthesis. The patient complains of no longer being able to swallow his saliva
The treatment will consist of gradually shortening the length of this lingual extension
Ulcerations may appear in the sublingual seal area.
The retouching will always be carried out to the detriment of the lower portion of the joint, but rarely to the detriment of its distal extension.
Injuries may occur at the internal oblique line
Diffuse pain that does not result in any apparent injury is due either to insufficient free space or to occlusal disharmony that will be eliminated by selective grinding.
INSERTION OF PROSTHESES
Conclusion :
A complete prosthesis never replaces missing teeth. It will only help restore the aesthetics and masticatory function of the edentulous patient. It is therefore imperative that the practitioner implements all the artifices, especially psychological ones, that can promote prosthetic integration. The fact that the patient reports complaints cannot be considered a failure of the prosthetic therapy nor call into question the competence of the practitioner.
Complaints are almost systematic after a delivery, a situation for which the patient must be prepared beforehand.
During the control sessions, the practitioner must be skillful and competent enough to be able to judge the situation (…), act appropriately (…) and abstain when necessary.
INSERTION OF PROSTHESES
Cracked teeth can be healed with modern techniques.
Gum disease can be prevented with proper brushing.
Dental implants integrate with the bone for a long-lasting solution.
Yellowed teeth can be brightened with professional whitening.
Dental X-rays reveal problems that are invisible to the naked eye.
Sensitive teeth benefit from specific toothpastes.
A diet low in sugar protects against cavities.