PROSTHETIC REHABILITATION IN ELDERLY SUBJECTS
The elderly subject presents specific anatomical, physiological and psychological characteristics in their general condition and this does not go unnoticed in the oral cavity.
These are subjects who often have chronic illnesses (diabetes, hypertension, etc.) and therefore are on multiple medications. Apart from these illnesses, they can also have serious illnesses with a poor prognosis (cancer patients undergoing radiotherapy and chemotherapy). Medical and surgical treatments have side effects, especially in the long term, and sequelae or even post-surgical complications.
It is therefore obvious that the elderly toothless person, whether partially or totally, is taken care of with special precautions which will be added to routine procedures.
II-Tissue involution of the oral cavity:
1-Odonta and periodontium:
Neck caries, mylolysis, root denudations and canal calcifications can compromise the limits of prosthetic restorations and canal retention.
3-Resorption: According to Ackermann, resorption means the total or partial disappearance of an organ whose elements are gradually taken up by the blood and lymphatic circulation. The degree of resorption is maximal in the first years following the extraction and stabilizes thereafter. It is less in the maxilla compared to the mandible.
This phenomenon is physiological at any age but more accentuated with aging. 4- Characteristics of a resorbed mandibular ridge:
An enlarged tongue, unevenness between the anterior crest and the TRMs, and a vestibular cul-de-sac that is difficult to read.
- Characteristics of a resorbed maxillary ridge:
A wide vestibule from front to back, a triangular arch, faded tuberosities, large para-tuberosity pocket on one side (asymmetric resorption), a horizontal veil behind the palatal fossae
- Muscles:
Muscle attachments lose their initial positions, and neuromuscular control is less effective. This is especially true in older patients with neurological disorders. Not to mention that with age, an anxious and stressed psychological profile develops, disrupting neuromuscular coordination and concentration. The muscles of older edentulous patients exhibit muscle atony.
- Tissue fragility 8-Hyposialia
9-Nutrition
III-Functions:
Swallowing, an innate function that occurs before the acquired function of phonation, appears to be more important in the mechanisms governing dento-dental contacts, unlike phonation, which intervenes in problems of anterior stability and
posterior of the PTAs while there is no contact between the opposing artificial teeth. The tongue takes part in each of the functions described as praxis.
Everything is governed by the nervous system, which is deficient in the elderly, resulting in disturbed speech, further aggravated in the deaf and hard of hearing, with probable false routes when swallowing.
IV-Aesthetics:
- Neuromuscular pressures:
1 – Neuromuscular control:
- Solutions:
Conventional removable prostheses (PTA, PAP):
- Clinical examination: Ensure appointments are kept on time, with short sessions. The patient is accompanied, and the patient is seated in a reclined position.
- Fingerprints:
- Materials: Required criteria:
-Biocompatibility
-Fluidity
-Wetting: depending on the amount of saliva
-Corrigible, reversible setting reaction
-Short setting time
-Resistance to undercuts (elasticity)
Type 1 alginates, type A and C silicones, and delayed-setting resins are the materials that most closely meet these criteria.
- techniques:
-Primary prints:
For total negative ridges, the Klein phonetic impression is good because it is sectional, however, thiocol is an irritating material. The use of the Landé guide impression is preferable thanks to the alginates although it is not sectional.
Wax stops at the impression tray prevent compression (partial and total)
If the resorbed ridges are not negative, the alginate impression remains the standard reference
-Secondary prints:
Creation of the peripheral joint by section with Kerr paste Impression of the support surface with a fluid silicone
McCracken’s thermoplastic wax impression remains indicated
-Piezographic impressions and tertiary impressions with dimethylpolysiloxanes materialize the prosthetic corridor but also sculpt the stabilizing polished surfaces in a functional way.
-The delayed-setting resin conditioning impression allows for progressive tissue adaptation and neuro-articular rehabilitation in order to prepare the ground for the prosthesis in use.
-Rebasing impressions with delayed setting resin are also a solution for elderly edentulous people already fitted with their prosthesis, especially if they refuse a new prosthesis.
- Occlusion:
- Reference occlusion: choice between RC and OIM according to:
🡪The state of ATMs
🡪The nature of the antagonistic arcade
🡪Posterior adjustment 3-1-POP adjustment:
Clinical advances in oral neuromuscular activity and the advent of piezography give this plane its third dimension: the vestibulolingual width, so important in the resorbed mandible.
The Camper plan nevertheless retains the consideration of piezologists but remains mostly supplanted by; the linguo-mandibular plan tongue at rest (plan
occlusion with physiological reference) and by the piezological plan (tongue and labio-jugal strap in activity)
Care must be taken not to give as much visibility to the anterior-upper teeth as in young individuals, which would most often lead to incorrect vertical positioning of the occlusal plane.
- The DV:
The DVR is considered the key to determining the height of the lower face in the totally edentulous (LUSSAC).
At a party, any loss of alignment requires the use of DVR (not just total toothlessness). Breathing techniques are preferred over phonation and swallowing.
ELIM: This is a space of 1 to 3 mm measured between the molars in the resting position.
It is a dynamic space that increases with age if the neuromuscular balance has remained good. (no muscular hypotonia or hypertonia)
This inocclusion in the vertical direction is equal to the difference between the vertical dimension of rest and the vertical dimension of occlusion
The clearance of inocclusion varies depending on different factors:
- sex: more important in men than in women;
- age: with age, ligament laxity increases, the head tilts forward and the free space for occlusion decreases (change in posture);
- Angle class: it is increased in retrognathic people and can reach, in class II, 10 to 12 mm; it is decreased in prognathic people, being reduced in class III to between 0.5 and 1 mm.
The DVO:
🡪Pre-extraction methods
🡪The mandibular rest method: DVR-ELIM=DVO
🡪Aesthetic assessment:
The assessment of ‘DVO’ by appearance is based on establishing aesthetic harmony of the lower third of the face.
The ideal DVO is associated with an unconstrained face, and lips in light contact.
Aging and tissue sagging lead to increased visibility of the mandibular teeth; these considerations should be modulated according to gender, facial and lip typology, as well as age.
Aesthetically: The incisal discovery should not be estimated in a stereotypical way, it varies depending on the personality, age, and sex of the patient.
As we age, the maxillary incisors become less and less visible, this reduction is more pronounced in men than in women.
Generally, in older women, there is a slight overhang of the upper incisors (approximately 1 mm) whereas in men of the same age, the upper lip covers all of the maxillary central incisors.
🡪Swallowing DV = DVO
🡪DV of Phonation – 1mm = DVO 3-3-The RC:
The techniques indicated are the chevron technique and Brill blade, with bimanual guidance by the practitioner.
3-4-Mounting the models on a semi-adaptable articulator
3-5-Assembly of prosthetic teeth according to the chosen occlusal concept:
According to Nabid, it is a piezological assembly, the steps are as follows:
🡪Mandibular piezography
🡪 Piezological occlusion plan
🡪 Maxillary semi-piezography
🡪 Non-adaptable articulator
🡪Non-anatomical teeth made of acrylic or composite resin
🡪 Unbalanced occlusion type De Van:
This is a Monoplane assembly: flat POP and no vertical overlap. This assembly is done with non-anatomical teeth. On a non-adaptable (Nabid) or semi-adaptable articulator. During eccentric movements of the mandible, the posterior teeth are not necessarily in contact.
Due to the absence of occlusal reliefs, this assembly easily allows for assembly in class III, but especially in class II div. 1.
- Insertion of the usual prosthesis: advice on hygiene, diet, prescriptions for adhesion adjuvants, and medications for salivary problems.
- Occlusal controls and equilibration
Root-stabilized removable prosthesis (PACSR/PAPSR):
In a subtotally edentulous person, preservation of roots or teeth with good extrinsic and intrinsic values may be considered as long as extraction is not indicated.
The transition to total edentulism can be achieved with a gentle transition phase thanks to this solution (the trauma of losing all natural teeth constitutes a psychological handicap)
Proprioception is improved (food perception and mandibular movements).
The means of retention are supra or intra radicular attachments (bars and axial attachments) on which the removable prosthesis is retained. Support and stability remain ensured by the osteo-mucosal support surface.
The imprint: The materials are chosen and indicated by the same logic as above.
The impression technique: it is a two-step impression in order to take into consideration the tissue duality.
First step: Functional impression of the mucosal support surfaces
Second step: Functional bonding of the copings: The copings and then the impression are replaced in the mouth, then self-polymerizing resin is deposited to bond the PEI with the copings under digital pressure.
Occlusion: The concepts are governed by the same laws as conventional removable prosthetics. Indeed, proprioception should not be used during functions (establishing occlusal contacts during chewing and swallowing). It is the posteriorly located prosthetic teeth that ensure occlusion, which means that mucosal depressibility is expressed and the stability of the prosthetic bases in this case is treated as for a totally edentulous person.
Extra-radicular axial attachments in the mouth Patient with 33-43 remaining (but the roots are exploited)
Intrados of a PACSR with riders (the bar is in the mouth)
Fixed tooth-supported prosthesis:
To avoid pulp damage and the risk of infection, avoid excessive peripheral preparations on living teeth.
Protect worn or devitalized teeth with crown prosthetic restorations.
Periodontal imperatives require specific contour shapes that facilitate cleaning, through clearance of embrasures, reduction of bulges and non-compressive bridge intermediaries.
As often as possible, the prosthetic limit is located at a distance from the marginal gingiva, at most juxtagingival to reconcile aesthetics, retention and hygiene.
A certain stable tooth mobility is accepted in the context of a healthy periodontium, optimal oral hygiene, a large number of remaining teeth, a balanced occlusion and regular check-ups. In fact, large joint prosthetic reconstructions must allow for their modification and easy adaptation to the possible failure of questionable abutments transforming into intersupplementary without compromising the extent of the fixed restoration.
The occlusal concept: choice between canine function, group, balanced, or unbalanced according to the antagonist prosthesis
Implant prostheses:
This part will be covered in the next course (implant treatment in the elderly)
- CONCLUSION :
Often the term geriatric prosthesis is associated with the image of elderly wearers of total dentures (geriatric prosthesis = total prosthesis). This preconceived idea is no longer true. Nowadays, geriatric prostheses are available on all types of removable prostheses , including complete implant-retained appliances and fixed tooth-supported prostheses. This means that dental technicians, but also manufacturers of prosthetic teeth, are facing new challenges.
PROSTHETIC REHABILITATION IN ELDERLY SUBJECTS
Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.