Orthopedic treatment of extensive dentition defects. Examination of patients with partial dentition defects
As a result of pathological processes of carious and non-carious origin, defects in the hard tissues of teeth arise. At the same time, the anatomical shape of the crowns of the teeth changes, which leads to disturbances in the function of chewing, speech, and aesthetic disorders of the face.
In order to determine the nature and extent of morphological changes associated with the disease, functional disorders caused by this disease, as well as to establish a diagnosis, select a treatment method and develop preventive measures, the patient is examined.
The examination of patients is carried out according to the generally accepted method, including in the examination scheme the patient’s complaints and anamnesis data (verbal methods), clinical data (examination, palpation, probing, percussion, examination of diagnostic models) and paraclinical examination (x-ray examination, electroodontometry, etc.).
Clinical examination of individual teeth is part of a complete examination of the patient before performing a treatment procedure and includes visual, manual, and instrumental examination methods to assess the integrity of the clinical crown of the tooth.
When examining each tooth, pay attention to the following:
shape, color and position in the dentition;
Condition of hard tissues (carious and non-carious lesions);
The degree of destruction of the coronal part;
The presence of fillings, inlays, artificial crowns, their condition;
The ratio of its extra-alveolar and intra-alveolar parts;
Sustainability;
Position in relation to the occlusal surface of the dentition.
When assessing the quality of a filling, the tightness of its adherence to the tooth tissue, the absence or presence of signs of secondary caries, and the aesthetic optimum are determined.
The degree of destruction of the hard tissues of the crown and root of the tooth is determined in two stages: before and after the removal of all softened tissues. Only after removing all softened tissues can we speak with confidence about the possibility of preserving the remaining part of the hard tissues of the teeth.
In parallel with visual analysis, manual (palpation) and instrumental methods are used: probing, percussion, determination of tooth mobility.
Probing carried out to determine the integrity of hard tissues, their density, identify a defect, determine the sensitivity of tissues, study the gingival sulcus or gingival pocket, the edges of fillings, tabs or artificial crowns. Normally, the dental probe glides freely over the surface of the tooth without getting stuck in the folds and depressions of the enamel. In the presence of a pathological process, sometimes undetectable visually, the probe is retained in the tooth tissue. Changes in the supporting-retaining apparatus of the tooth are detected using percussion.
Important information is obtained by analysis of diagnostic jaw models. The volume of hard tissue loss, the topography of the defect, the relationship with adjacent teeth and antagonists are examined. It is possible to conduct morphometric studies (measurement of the size of the tooth crown) and comparison with the norm, etc.
Invaluable information when examining patients with pathology of hard dental tissues gives X-ray examination(orthopantomogram, panoramic and targeted radiographs): assessment of the topography of the pulp chamber and crown defect, assessment of the condition of periapical tissues, marginal fit of fillings, inlays, crowns, etc.
Electroodontometry provides important information about the functional state of the dental pulp, which is important for optimal treatment planning.
Based on the data obtained during the examination of the patient, a diagnosis is formulated, a treatment plan is drawn up, which should include preparation of the oral cavity for prosthetics, the actual orthopedic treatment of the defect in the hard tissues of the coronal part of the tooth, and rehabilitation and preventive measures.
A feature of the diagnosis in an orthopedic dentistry clinic is that the main disease for which the patient consulted an orthopedic dentist is usually a consequence of other diseases (caries, periodontitis, trauma, etc.).
When making a diagnosis, it is necessary to highlight:
underlying disease of the dental system and complication of the underlying disease;
Concomitant dental diseases;
Concomitant diseases are common.
To facilitate the planning of reasonable treatment and rehabilitation measures, it is advisable to carry out the diagnostic process in a certain sequence, in which the following are assessed:
integrity of the dentition;
Condition of hard dental tissues;
Periodontal condition;
Condition of occlusion, temporomandibular joints and muscles;
Condition of existing dentures and prosthetic field (mucous membrane of the mouth, tongue, vestibule, lips, toothless alveolar ridges).
Paraclinical methods
Paraclinical methods are carried out using various devices or instruments (instrumental), as well as in special laboratories (laboratory).
X-ray methods stand apart.
Radiography of the organs of the masticatory apparatus is one of the most common research methods, since it is accessible, uncomplicated and with its help you can obtain valuable information about the condition of the hard tissues of the crown and root, the size and characteristics of the tooth cavity. root canals, bone condition. To study the shape, structure and relationship of the elements of the temporomandibular joint, survey and layer-by-layer radiography (tomography, zonography) is used. The temporomandibular joints can be examined using the arthrography method - injection of a contrast agent into the joint space followed by radiography. In addition to the above methods, orthopedic dentistry also uses panoramic photographs, orthopantomograms, teleroentgenograms, and radiovisiography data.
Currently, dentists have acquired the opportunity to obtain a digital three-dimensional image during a diagnostic examination thanks to a new diagnostic device – three-dimensional dental computed tomograph. Recently, a fundamentally new device has been developed and put into mass production - a specialized dental computed tomograph, which makes it possible to obtain a digital three-dimensional X-ray image of the dental system, maxillofacial area and maxillary sinuses of the patient.
belongs to the new third generation of computed tomographs.
This machine uses a conical X-ray beam focused on a circular detector (cone beam tomography). In such a system, all anatomical information is collected in one rotation of the X-ray tube around the patient's head. As a result, the patient's radiation exposure is significantly reduced. 3D reconstructions can be rotated and viewed from different angles. The unique diagnostic capabilities of this device can be successfully used in various fields of dentistry and maxillofacial surgery.
Bridge prosthesis
Bridge prosthesis- This is a type of fixed dental prosthesis, used to replace included defects in the dentition. It is used in cases where several consecutive teeth, so this prosthesis can be attached to healthy teeth that are spaced apart from each other or to closed teeth crowns.
Advantages
1. Minimal preparation of supporting teeth, mostly within enamels.
2. Excellent aesthetic results.
3. Reversibility orthopedic treatment.
4. Absence metal.
5. Natural light refraction of the structure.
6. No need for temporary crowns.
7. Few cases of need pain relief.
8. almost deprived of contact with the mucous membrane, with the exception of the gum edge.
9. Relatively low cost prosthesis.
Flaws
1. Qualities characteristic of composites (possible color change over time, abrasion, several times greater than the natural abrasion of tooth enamel, shrinkage, toxic And allergic action).
2. Increased abrasion if present ceramic antagonists.
3. Impossibility of temporary fixation.
4. Possible chips of the restoration material.
5. Preparation of healthy teeth under supporting elements
6. Possibility of functional overload of the periodontium due to incorrect choice of prosthesis design
7. Irritating effect of the edge of an artificial crown on the periodontal cover
Related information.
DENTISTRY
UDC 616.314.2-089.23-08 (048.8) Review
METHODS OF ORTHOPEDIC TREATMENT OF DENTAL DEFECTS (REVIEW)
V.V. Konnov - Federal State Budgetary Educational Institution of Higher Education “Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, head of the department of orthopedic dentistry, associate professor, doctor of medical sciences; M. R. Harutyunyan - Federal State Budgetary Educational Institution of Higher Education "Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, graduate student of the Department of Orthopedic Dentistry.
METHODS OF ORTHOPEDIC TREATMENT OF DENTITION DEFECTS (REVIEW)
V. V. Konnov - Saratov State Medical University n.a. V. I. Razumovsky, Head of Department of Orthopedic Dentistry, Assistant Professor, Doctor of Medical Science; M. R. Arutyunyan - Saratov State Medical University n.a. V. I. Razumovsky, Department of Orthopedic Dentistry, Post-graduate.
Date of receipt - 04/13/2015. Date of acceptance for publication - 09/07/2016.
Konnov V.V., Arutyunyan M.R. Methods of orthopedic treatment of dentition defects (review). Saratov Scientific and Medical Journal 2016; 12 (3): 399-403.
To restore the functional usefulness and individual aesthetic standards of the dental system in case of various types of partial tooth loss, depending on the anatomical and topographic conditions in the oral cavity, various types of fixed (bridge, cantilever, adhesive) and removable (plate, clasp) structures are used, as well as their combinations.
Key words: dentition defects, orthopedic treatment methods.
Konnov VV, Arutyunyan MR. Methods of orthopedic treatment of dentition defects (review). Saratov Journal of Medical Scientific Research 2016; 12 (3): 399-403.
The article is devoted to the methods of orthopedic treatment of dentition defects. To restore the functionality and individual aesthetic standards of the dental system, with different types of partial loss of teeth, depending on the anatomical and topographical conditions, various kinds of dental prosthesis designs are used in the oral cavity: non-removable (bridges, cantilever, adhesive) dentures and removable (laminar and clasp dental) prostheses, as well as their combinations.
Key words: dentition defects, methods of orthopedic treatment.
Partial absence of teeth is one of the widespread pathologies of the dental system and the main reason for seeking dental orthopedic care. According to WHO, it affects up to 75% of the population in various regions of the globe. In our country, this pathology accounts for 40 to 75% of cases in the overall structure of dental care.
Despite the achievements of therapeutic and surgical dentistry in the treatment of complicated forms of caries and periodontal diseases, the number of patients with partial absence of teeth, according to the forecasts of a number of authors, will continuously increase. In this regard, the population's need for orthopedic dental care is significantly increasing. In Russia, such a need among people seeking dental care ranges from 70 to 100% (depending on the region).
The leading symptoms of this pathology are disruption of the continuity of the dentition, functional
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national overload of the teeth, deformation of the dentition and, as a consequence, dysfunction of chewing, speech and anatomical and aesthetic norms. In the absence of timely treatment for a long time, dental defects are complicated by distal displacement of the lower jaw, resulting in disruption of the function and topography of the temporomandibular joint (TMJ) and the activity of the neuromuscular system.
Significant morphological and functional changes in the dental system, characteristic of this pathology, progress with increasing defects and time elapsed after tooth loss, and, as a rule, negatively affect the social status and psycho-emotional state of patients, which indicates the need for a timely and adequate approach in choosing method of treatment.
To restore the integrity of the dentition, various types of fixed (bridge, cantilever, adhesive) and removable (plate, clasp, small saddle) structures, as well as their combinations, are used.
The most common type of fixed prosthetics are bridges, the need for which ranges from 42 to 89% of cases. These structures consist of supporting elements, with the help of which they are held on the teeth that limit the defect, and the body of the prosthesis. According to research, the use of composite and ceramic structures provides a high level of aesthetics, function and psychological comfort for patients.
The main disadvantage of bridges is the mandatory preparation of hard dental tissues, as a result of which, even with gentle treatment, in 5-30% of cases there is death of the dental pulp, as well as sometimes forced depulpation of intact teeth. In addition, according to the literature, the use of bridges often leads to the development of complications such as thermal burns of the pulp, periodontal diseases of abutment teeth, traumatic occlusion, caries of abutment teeth and, as a consequence, their destruction or fracture, inflammation of the marginal periodontium, decementation and breakage prostheses (chipped lining, desoldering), dysfunction of the masticatory muscles and TMJ, most of which are due to the inappropriate use of bridges.
According to research, the use of these structures is limited by the reserve forces of the periodontium of the supporting teeth and the size of the defect, since when restoring three or more missing teeth, there is an overload of the periodontium of the supporting teeth and overstrain in the area of the distal support, which subsequently leads to periodontal destruction and disruption of the functioning of the dentition.
The use of cantilever dentures, according to the literature, is strictly determined and is a risk factor for supporting teeth, since it contributes to a significant reduction in their physiological capabilities. However, some authors suggest using these structures to replace individual anterior teeth and distally unlimited defects, subject to mandatory adherence to practical recommendations.
For the purpose of a minimally invasive and, as a result, more gentle treatment of abutment teeth, some experts recommend using adhesive bridges when replacing small included defects. The success of this method is confirmed by the results of many studies.
The greatest difficulty for orthopedic treatment is represented by extensive included defects and end defects of the dentition, for the restoration of which various types of removable dentures are used, as well as combined designs, which are especially relevant at the present time.
When planning treatment with removable structures, it is necessary to ensure good fixation and stabilization of the prosthesis, restore chewing efficiency, eliminate or reduce the negative impact of the prosthesis, ensure rapid adaptation and maximum aesthetic effect, as well as convenient operation and oral hygiene.
The choice of design is largely determined by the anatomical and topographical conditions in the oral cavity, the decisive ones being the topography of the defect, the number of remaining teeth, the periodontal condition of the supporting teeth, the nature and degree of atrophy of the alveolar process, the condition of the mucous membrane and the degree of its compliance.
According to research, the most common are partial removable plate dentures, the main advantage of which is accessibility and ease of manufacture. In turn, clasp dentures provide a high level of functionality, and thanks to modern methods of fixation (locking fastenings, telescopic crowns) - also aesthetics.
Regardless of the type of removable structure, their use is associated with a number of negative consequences. When using removable dentures, there is a non-physiological distribution of chewing pressure on the mucous membrane and bone tissue of the jaws, which are phylogenetically not adapted to perform this function. As a result, atrophic changes occur in the tissues of the prosthetic bed, a discrepancy between the basis of the prosthesis and the microrelief of the underlying tissues occurs, which, in turn, leads to an uneven distribution of chewing pressure, the formation of overloaded areas and the progression of atrophic processes.
To a greater extent, these changes are observed when using plate prostheses with a clasp fixation system, which transfer the main part of the load to the mucous membrane of the prosthetic bed, resulting in a non-physiological distribution of the load in relation to the supporting teeth, a decrease in the reserve forces of the periodontium of these teeth, resulting in their mobility. Clasp dentures are more favorable in this regard, since they ensure the distribution of the chewing load between the mucous membrane of the alveolar part and the supporting teeth, thereby increasing the functional value of these structures.
The properties of the base materials used for the manufacture of removable structures are also important. The use of currently widespread acrylic plastics is accompanied by a number of negative effects (mechanical, toxic, sensitizing, thermal insulating) and, as a result, leads to the development of various pathological changes in the mucous membrane of the prosthetic bed.
As an alternative, experts suggest using structures based on thermoplastic polymers, which, according to research, have a higher degree of biocompatibility and elasticity, are less toxic and safe for the mucous membrane, and also have better functional and aesthetic properties.
Conditions in the oral cavity do not always allow traditional treatment methods to restore the anatomical and functional integrity of the dentition. An effective solution in such conditions is the method of orthopedic treatment on dental implants, which provides a high level of functional, aesthetic and social rehabilitation of patients with various types of dentition defects.
Dental implantation allows you to expand the conditions for the use of various types of fixed and conditionally removable structures, as well as improve the quality of fixation of removable structures in difficult clinical conditions. In addition, dental implantation helps slow down atrophic processes in the bone tissue of the alveolar process,
since it ensures the occurrence of metabolic processes close to natural conditions.
A wide variety of implants requires a careful approach in choosing an implant system and planning the surgical and orthopedic stages of treatment, as well as an understanding of the biological basis of the functioning of the dentofacial system.
According to the literature, thanks to modern technologies and advances in the field of implantology, successful integration of implants into bone tissue is noted in 90% of cases.
The most common currently are various types of intraosseous screw implants made of titanium alloys. The decisive factors when choosing these structures are the height and structure of the alveolar process, which, in turn, depend on the age of the patient, the extent and location of the defect, as well as the statute of limitations.
Most specialists are supporters of the delayed two-stage technique, according to which the process of osseointegration occurs under the cover of the mucosa, without infection and without functional load. At the first stage, the intraosseous part of the implant is installed, and at the second stage, after 3-6 months, depending on the jaw, the head or gingival cuff former is installed, and only after this functional loading is possible.
In conditions of bone tissue deficiency in the area of implantation, various methods of osteoplastic operations have been developed and widely used, aimed at restoring not only quantitative, but also qualitative parameters of the missing bone tissue. The most popular in clinical practice are: the method of directed bone tissue regeneration using various biocomposite materials, autotransplantation of bone blocks, sinus lifting.
Research results indicate the high effectiveness of these treatment methods, however, their complexity, multi-stage and high cost, as well as strict restrictions on clinical (general somatic) indications prevent their availability to wide groups of the population. In addition, most patients perceive extremely negatively “multi-stage” treatment methods, which are associated with significant trauma and a difficult rehabilitation period.
Thus, our analysis of the literature indicates that the issue of rehabilitation of patients with various types of dentition defects is still relevant, since this pathology leads to the development of a complex symptom complex of pathological changes in the tissues and organs of the dental system and requires timely, individual and thorough approach in choosing a treatment method with the aim of producing high-quality and complete dentures that allow restoring the functional and aesthetic standards of the dental system and preventing its further damage.
References (Literature)
1. Kresnikova YuV, Malyy AYu, Brovko VV, et al. The clinical and epidemiological analysis of results of orthopedic treatment of
patients with partial lack of teeth in regions of Russia. Problemy standartizatsii v zdravookhranenii 2007; (6): 21-28. Russian (Kresnikova Yu. V., Maly A. Yu., Brovko V. V. et al. Clinical and epidemiological analysis of the results of orthopedic treatment of patients with partial absence of teeth in the regions of Russia. Problems of standardization in healthcare 2007; (6): 21- 28).
2. Nurbaev AZh. About the prevalence of partial and total absence of teeth at persons of advanced and senile age in Kyrgyzstan. Vestnik KRSU 2010; 10 (7): 144-148. Russian (Nurbaev A. Zh. On the prevalence of partial and complete absence of teeth in elderly and senile people in Kyrgyzstan. Vestnik KRSU 2010; 10 (7): 144-148).
3. Roshkovskiy EV. Studying of needs in the orthopedic stomatological help of persons of advanced and senile age, and also long-livers and feature of its rendering in gerontological hospitals: PhD abstract. M., 2008; 25s. Russian (Roshkovskiy E.V. Study of the need for orthopedic dental care of elderly and senile people, as well as long-livers and the features of its provision in gerontological hospitals: abstract of thesis.... Candidate of Medical Sciences. M., 2008; 25 p.).
4. Masliy VG. Factors of success of dental rehabilitation of elderly patients. Dental South 2011; (3): 12-17. Russian (Masliy V.G. Success factors in dental rehabilitation of elderly patients. Dental South 2011; (3): 12-17).
5. Bykovskaya TYu, Novgorodskiy SV, Martynenko VV, et al. Ways of improvement of the organization of the orthopedic stomatologic help to the population of the Rostov region. Glavnyy vrach Yuga Rossii: Stomatologiya 2012; 2-4. Russian (Bykovskaya T.Yu., Novgorodsky S.V., Martynenko V.V. et al. Ways to improve the organization of orthopedic dental care for the population of the Rostov region. Chief physician of the South of Russia: Dentistry 2012; special issue: 2-4).
6. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Program. Community Dent Oral Epidemiol 2005; 33 (2): 81-92.
7. Shemonaev VI, Kuznetsova eV. Morphological and functional changes that take place dyschie in dentition due to loss of teeth. In: Actual problems of dentistry: collection part rials scientific and practical conference dedicated to the 75th anniversary of Professor V. Y. Milikevich. Volgograd, 2007; p. 3336. Russian (Shemonaev V.I., Kuznetsova E.V. Morphological and functional changes occurring in the dentofacial system due to tooth loss. In the collection: Current issues in dentistry: a collection of materials from a scientific and practical conference dedicated to the 75th anniversary of Professor V. Yu. Milikevich (Volgograd, 2007; pp. 33-36).
8. Konnov VV, Nikolenko VN, Googe LA. The morphometric characteristics of temporomandibular joint at the middle-aged people with orthodontic bite. Morphological statements 2005; (3-4): 181-182. Russian (Konnov V.V., Nikolenko V.N., Goo-ge L.A. Morphometric characteristics of the temporomandibular joint in mature people with orthognathic occlusion. Morphological statements 2005; (3-4): 181 -182).
9. Lepilin AV, Konnov VV. Comparative characteristics of temporomandibular joint in middle-aged people with orthognatic bite and distal occlusion. Russian Journal of Dentistry 2006; (3): 29-31. Russian (Lepilin A.V., Konnov V.V. Comparative characteristics of the structure of the temporomandibular joint in mature people with orthognathic occlusion and distal occlusion. Russian Dental Journal 2006; (3): 29-31).
10. Konnov V., Nikolenko V.N., Googe LA. The morphometric characteristics of temporomandibular joint at the middle-aged people with distal occlusion. Morphological statements 2007; 1 (1-2): 252-253. Russian (Konnov V.V., Nikolenko V.N., Goo-ge L.A. Morphometric characteristics of the temporomandibular joint in mature people with distal occlusion. Morphological statements 2007; 1 (1-2): 252- 253).
11. Konnov VV, Nikolenko VN, Lepilin AV. Morphological and functional changes of temporomandibular joints in patients with terminal dentition defects. Bulletin of Volgograd State Medical University 2007; (3): 81-84. Russian (Konnov V.V., Nikolenko V.N., Lepilin A.V. Morphofunctional changes in the temporomandibular joints in patients with terminal defects of the dentition. Bulletin of the Volgograd State Medical University 2007; (3): 81-84) .
12. Muzurova LV, Rezugin AM, Konnov VV. Age and individual variability of the upper and lower jaw in patients with orthognatic bite. Saratov Journal of Medical Scientific Research 2007; 3 (3): 34-36. Russian (Muzurova L.V., Rezugin A.M., Kon-nov V.V. Age-related and individual variability of the upper and lower jaw in individuals with orthognathic occlusion. Saratov Medical Scientific Journal 2007; 3 (3): 34-36 ).
13. Konnov V.V. Orthodontic and orthopedic treatment of adult patients with different variants of the temporomandibular joint: DSc abstract. Volgograd, 2008; 34 p. Russian (Kon-nov V.V. Orthodontic and orthopedic treatment of adult patients with various types of the temporomandibular joint: abstract of thesis.... Doctor of Medical Sciences. Volgograd, 2008; 34 p.).
14. Lepilin AV, Konnov VV, Bagaryan EA. Methods of examination of patients with pathology of the temporomandibular joints and masticatory muscles (review). Saratov Journal of Medical Scientific Research 2011; 7 (4): 914-918. Russian (Le-pilin A.V., Konnov V.V., Bagaryan E.A. Methods for examining patients with pathology of the temporomandibular joints and masticatory muscles (review). Saratov Medical Scientific Journal 2011; 7 (4): 914 -918).
15. Sheludko SN, Muzurova LV, Konnov VV. The variability of kefalometric parameters of men orthognatic and bite. Saratov Journal of Medical Scientific Research 2014; 10 (1): 52-55. Russian (Sheludko S.N., Muzurova L.V., Konnov V.V. Variability of cephalometric parameters of men with orthognathic and straight bites. Saratov Medical Scientific Journal 2014; 10 (1): 52-55).
16. Dolgalev AA, Tsogoev VK. Traditional prosthetics or implantation? Review of modern methods of treatment of loss of teeth. Dental South 2009; (11): 32-34. Russian (Dolgalev A.A., Tsogoev V.K. Traditional prosthetics or implantation? Review of modern methods of treating tooth loss. Dental South 2009; (11): 32-34).
17. Farashyan Av. Comparative clinical and economic research of methods of treatment of a partial secondary adentiya with use of various fixed orthopedic designs: PhD abstract. M., 2005; 25 p.m. Russian (Farashyan A.V. Comparative clinical and economic study of methods for treating partial secondary adentia using various non-removable orthopedic structures: abstract of thesis. Candidate of Medical Sciences. M., 2005; 25 p.).
18. Fidarov RO. Assessment of effectiveness of prosthetics of patients removable artificial limbs with castle fixing: PhD abstract. Stavropol", 2011; 24 p. Russian (Fidarov R. O. Evaluation of the effectiveness of prosthetics for patients with removable dentures with locking fixation: abstract of thesis. Candidate of Medical Sciences. Stavropol, 2011; 24 p.).
19. Naumovich SA, Borunov AS, Kaydov IV. Orthopedic treatment of the included defects of a tooth alignment by adhesive bridge-like artificial limbs. Sovremennaya stomatologiya 2006; (2): 34-38. Russian (Naumovich S.A., Borunov A.S., Kai-dov I.V. Orthopedic treatment of included dentition defects with adhesive bridges. Modern Dentistry 2006; (2): 34-38).
20. Rathke A. Clinical and technical aspects of production of ceramic-metal bridge-like artificial limbs. Novoe v stomatologii 2007; (1): 20-36. Russian (Rathke A. Clinical and technical aspects of the manufacture of metal-ceramic bridges. New in Dentistry 2007; (1): 20-36).
21. Pavlenko YuN. Ways of treatment of the included defects of tooth alignments by means of low-invasive technologies. Stomatologiya 2010; (4): 73-76. Russian (Pavlenko Yu. N. Methods of treating included dentition defects using minimally invasive technologies. Dentistry 2010; (4): 73-76).
22. Gazhva SI, Pashinyan GA, Aleshina OA. The analysis of mistakes and complications at prosthetics with application of fixed orthopedic designs. Stomatologiya 2010; (2): 65-66. Russian (Gazhva S.I., Pashinyan G.A., Aleshina O.A. Analysis of errors and complications in prosthetics using fixed orthopedic structures. Dentistry 2010; (2): 65-66).
23. Shemonaev VI, Poljanskaja OG, Motorkina TV. Complications in the use of ceramic-metal phases designs, methods of prevention and treatment. Volgograd Journal of Medical Science. 2012; (1): 11-13. Russian (Shemonaev V.I., Polyanskaya O.G., Motorkina V.I. Complications at the stages of using metal-ceramic structures, methods of pro-
prevention and treatment. Volgograd Scientific and Medical Journal 2012; (1): 11-13).
24. Chvalun EK. Justification of application of fixed artificial limbs with a unilateral support at partial loss of teeth: PhD abstract. Stavropol", 2006; 25 p. Russian (Chvalun E.K. Rationale for the use of fixed dentures with unilateral support for partial loss of teeth: abstract of thesis. Candidate of Medical Sciences. Stavropol, 2006; 25 p.).
25. Samteladze ZA. The clinical and morphofunctional characteristic of structures of parodont when using a console artificial limb with a support on a canine of the top jaw: PhD abstract. M., 2008; 25 p.m. Russian (Samteladze Z. A. Clinical and morphofunctional characteristics of periodontal structures when using a cantilever prosthesis supported on the canine of the upper jaw: abstract of thesis. Candidate of Medical Sciences. Moscow, 2008; 25 p.).
18. Shemonaev VI, Pchelin IY, Brawlers EA. The use of adhesive bridges for aesthetic and functional rehabilitation of dental patients. Dental South 2012; (5): 8-10. Russian (Shemo-naev V.I., Pchelin I.Yu., Buyanov E.A. The use of adhesive bridges for the aesthetic and functional rehabilitation of dental patients. Dental South 2012; (5): 8-10).
27. Ahlstrand WM, Finger WJ. Direct and indirect fibe-reinforced fixed partial dentures: Case reports. Quintessence international 2002; 33 (5): 359-365.
28. Kalivradzhiyan ES. Prosthetics with application of castle fastenings. Sovremennaya ortopedicheskaya stomatologiya 2005; (4): 2-3. Russian (Kalivradzhiyan E. S. Prosthetics using locking fastenings. Modern orthopedic dentistry 2005; (4): 2-3).
29. Maksyukov SYu. Clinical and epidemiological assessment of the reasons of repeated orthopedic treatment of patients with defects of tooth alignments and ways of its optimization: DSc abstract. M., 2011; 38 p. Russian (Maksyukov S. Yu. Clinical and epidemiological assessment of the reasons for repeated orthopedic treatment of patients with dentition defects and ways to optimize it: abstract of thesis. Doctor of Medical Sciences. Moscow, 2011; 38 p.).
30. Parkhamovich SN, Naumovich SA, Tsvirko OI. Prosthetics of patients with the extensive included defects of tooth alignments. Sovremennaya stomatologiya 2005; (4): 55-58. Russian (Par-khamovich S.N., Naumovich S.A., Tsvirko O.I. Prosthetics for patients with extensive included dentition defects. Modern Dentistry 2005; (4): 55-58).
31. Tlustenko VP, Komlev SS, Kulikova ES. A way of production of a byugelny artificial limb with castle artificial limbs. Clinical dentistry of 2016; (1): 56-58. Russian (Tlusten-ko V.P., Komlev S.S., Kulikova E.S. Method of manufacturing a clasp denture with locking dentures. Clinical dentistry 2016; (1): 56-58).
32. Malyy AYu, Nevskaya VV, Morozov KA, et al. Influence of removable artificial limbs on intensity of atrophic processes of fabrics of a prosthetic bed. Parodontologiya 2009; (3): 62-66. Russian (Maly A. Yu., Nevskaya V. V., Morozov K. A. et al. The influence of removable dentures on the intensity of atrophic processes in the tissues of the prosthetic bed. Periodontology 2009; (3): 62-66).
33. Nevskaya VV. Comparative assessment of influence of various designs of removable artificial limbs on a prosthetic bed at partial lack of teeth: PhD abstract. M., 2011; 23 p.m. Russian (Nevskaya V.V. Comparative assessment of the influence of various designs of removable dentures on the prosthetic bed with partial absence of teeth: abstract of thesis. Candidate of Medical Sciences. Moscow, 2011; 23 p.).
34. Gargari M, Corigliano JVL, Ottria L. Inglese Tor Vergata University Early load on bone Pri tary healing Implant. JADR-CED 2001; (3): 271.
35. Tlustenko VP, Sadykov MI, Nesterov AM, Golovina ES. An assessment of results of orthopedic treatment of patients with use of new basic material (clinical trial). Ural medical magazine 2014; (1): 19-21. Russian (Tlustenko V.P., Sadykov M.I., Nesterov A.M., Golovina E.S. Evaluation of the results of orthopedic treatment of patients using new basic material (clinical study). Ural Medical Journal 2014; (1): 19- 21).
36. Konnov V.V., Arutyunyan MR. Clinical and functional evaluation of the use of polyoxymethylene-based laminar removable partial dentures with retaining clasps and an acrylic
basis. Modern problems of science and education 2015; (2). Russian (Konnov V.V., Arutyunyan M.R. Clinical and functional assessment of the use of partial removable laminar dentures based on polyoxymethylene with retaining clasps and an acrylic plastic base. Modern problems of science and education 2015; (2)).
37. Konnov V.V., Arutyunyan MR. Comparative analysis of clinical and functional adaptation to removable partial dentures based on nylon and acrylic plastic. Modern problems of science and education 2015; (3). Russian (Konnov V.V., Aru-tyunyan M.R. Comparative analysis of clinical and functional adaptation to partial removable dentures based on nylon and acrylic plastic. Modern problems of science and education 2015; (3)).
38. Trezubov Vv, Kosenko GA. The qualitative characteristic of laminar removable dentures with thermoplastic bases. Institut stomatologii 2011; (1): 58-59. Russian (Trezubov V.V., Kosenko G.A. Qualitative characteristics of removable plate dentures with thermoplastic bases. Institute of Dentistry 2011; (1): 58-59).
39. Ryzhova IP., Bavykina TYu., Salivonchik MS. Improving final treatment of dentures made of thermoplastic polymers. Saratov Journal of Medical Scientific Research 2011; 7 (1): 271. Russian (Ryzhova I. P., Bavykina T. Yu., Salivonchik M. S. Improving the final processing of dentures made of thermoplastic polymers. Saratov Medical Scientific Journal 2011; 7 (1): 271).
40. Kolesov OYu. Assessment of the remote results of prosthetics with use of implants: PhD abstract. St. Petersburg, 2008; 20 p.m. Russian (Kolesov O. Yu. Evaluation of long-term results of prosthetics using implants: abstract thesis.... Candidate of Medical Sciences. St. Petersburg, 2008; 20 p.).
41. Bilt van der A., Kampen van FMC, Cune MS. Masticatory function with mandibular implant-supported overdentures fitted with different attachment types. Eur J Oral Sci 2006; (114): 191196.
42. Believskaya RR, Sel"skiy NE, Sibiryak SV. Metabolism of bone fabric and efficiency of dental implantation: "Osteogenon"s" preventive use. Sovremennaya stomatologiya 2011; (1): 89-92. Russian (Believskaya R.R., Selsky N.E., Sibiryak S.V. Metabolism of bone tissue and the effectiveness of dental implantation: prophylactic use of Osteogenon. Modern Dentistry 2011; (1): 89-92).
43. Yarulina ZI. Complex clinical and radio-diagnosis of dentition by preparation for dental implantation: PhD abstract. Kazan", 2010; 23 p. Russian (Yarulina Z. I. Complex clinical and radiological diagnostics of the dentoalveolar system in preparation for dental implantation: abstract of thesis. Candidate of Medical Sciences. Kazan, 2010; 23 p.).
44. Kuznetsova EA, Gilmiyarova FN, Tlustenko VP, Tlustenko VS, et al. Preclinical diagnostics of a dental periimplantit. Russian stomatologic magazine 2011; (2): 28-29. Russian (Kuznetsova E. A., Gilmiyarova F. N., Tlustenko V. P., Tlustenko V. S. et al. Preclinical diagnosis of dental peri-implantitis. Russian Dental Journal 2011; (2): 28-29).
45. Aga-zade RR. Determination of density of bone tissue of jaws at dental implantation on the basis of photodensitometry. Sovremennaya stomatologiya 2010; (1): 77-78. Russian (Aga-zade R.R. Determination of jaw bone density during dental implantation based on photodensitometry. Modern Dentistry 2010; (1): 77-78).
46. Solov"eva LG. The delayed tooth implantation after removal of teeth and plasticity of jaws: PhD abstract. M., 2008; 25 p. Russian (Solovyova L. G. Delayed dental implantation after removal of teeth and plasticity of jaws: abstract. diss.. Candidate of Medical Sciences. Moscow, 2008; 25 p.).
47. Golovina ES, Gilmiyarova FN, Tlustenko VP. Use of metabolic indicators of oral liquid for an assessment of reparativ osteogenesis at bone plasticity. Dentistry 2013; (3): 5658. Russian (Golovina E. S., Gilmiyarova F. N., Tlustenko V. P. Use of metabolic parameters of oral fluid to assess reparative osteogenesis during bone grafting. Dentistry 2013; (3): 56-58 ).
48. Sevetz EB, Jr. Treatment of the severely atrophic fully edentulous maxilla: the zygoma implant option. Atlas Oral Maxillofac Surg Clin North Am 2006; (14): 121-136.
49. Bondarenko IV, Erokhin AI, Bondarenko OV. Assessment of quality of life of patients at stages of preimplantological augmentation and dental implantation. Institut stomatologii 2010; (2): 42-44. Russian (Bondarenko I.V., Erokhin A.I., Bondarenko O.V. Assessment of the quality of life of patients at the stages of pre-implantological augmentation and dental implantation. Institute of Dentistry 2010; (2): 42-44).
50. Sliwowski K. The new concept of treatment of edentulous mandible. Clinical Oral Implants Research 2008; 19 (9): 842-843.
UDC 616.311.2-008.8:612.015.6:611.018.1] -07-08 (045) Original article
INFLUENCE OF VITAMIN D ON CYTOKINE SYNTHESIS ACTIVITY OF CELLS
GINGIVAL LIQUID
L. Yu. Ostrovskaya - Federal State Budgetary Educational Institution of Higher Education “Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, Associate Professor of the Department of Therapeutic Dentistry, Doctor of Medical Sciences; N. B. Zakharova - Federal State Budgetary Educational Institution of Higher Education “Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, head of the Central Scientific Research Laboratory, professor of the department of clinical laboratory diagnostics, doctor of medical sciences; A. P. Mogila - Federal State Budgetary Institution of Higher Education “Saratov State Medical University named after. V.I. Razumovsky" of the Ministry of Health of Russia, graduate student of the Department of Therapeutic Dentistry; L. S. Katkhanova - Federal State Budgetary Educational Institution of Higher Education "Saratov State Medical University named after. V.I. Razumovsky" Ministry of Health of Russia, Department of Therapeutic Dentistry, postgraduate student; E. V. Akulova - Federal State Budgetary Educational Institution of Higher Education “Saratov State Medical University named after. V.I. Razumovsky" Ministry of Health of Russia, Department of Therapeutic Dentistry, postgraduate student; A. V. Lysov - Federal State Budgetary Educational Institution of Higher Education “Saratov State Medical University named after. V.I. Razumovsky" Ministry of Health of Russia, Department of Therapeutic Dentistry, postgraduate student.
EFFECT OF VITAMIN D3 ON THE CYTOKINE SYNTHESIZING ACTIVITY OF CELLS
OF GINGIVAL FLUID
L. U. Ostrovskaya - Saratov State Medical University n.a. V. I. Razumovsky, Department of Dental Therapy, Assistant Professor, Doctor of Medical Science; N. B. Zakharova - Saratov State Medical University n.a. V. I. Razumovsky, Head of Scientific Research Laboratory, Department of Clinical Laboratory Diagnostics, Professor, Doctor of Medical Science; A. P. Mogila - Saratov State Medical University n.a. V. I. Razumovsky, Department of Dental Therapy, Post-graduate; L. S. Katkhanova - Saratov State Medical University n.a. V. I. Razumovsky, Department of Dental Therapy, Post-graduate; E. V. Akulova - Saratov State Medical University n.a. V. I. Razumovsky, Department of Dental Therapy, Post-graduate; A. V. Lysov - Saratov State Medical University n.a. V. I. Razumovsky, Department of Dental Therapy, Post-graduate.
Date of receipt - 06/24/2016. Date of acceptance for publication - 09/07/2016.
Ostrovskaya L. Yu., Zakharova N. B., Mogila A. P., Katkhanova L. S., Akulova E. V., Lysov A.V. The effect of vitamin D3 on the cytokine-synthesizing activity of gingival fluid cells. Saratov Scientific and Medical Journal 2016; 12 (3): 403-407.
LE CENTION OF ASSOCIATE PROFESSOR OF THE DEPARTMENT OF ORTHOPEDIC DENTISTRY KNMU GENNADY GRIGORIEVICH GRISHANIN
ON THE TOPIC
EXAMINATION OF PATIENTS SUFFERING WITH COMPLETE EDENTILIA.
LECTURE PLAN:
1. INTRODUCTION TO THE PROBLEM
2. EXAMINATION OF THE PATIENT - DEFINITION OF THE CONCEPT
3. SEQUENCE OF IMPLEMENTING PATIENT STUDIES IN AN OUTPATIENT DENTAL APPLICATION
4. FEATURES OF STUDIES OF PATIENTS WITH DEFECTS OF DENTAL ARCHES, DIAGNOSIS
5. DRAFTING ORTHOPEDIC TREATMENT PLANS FOR PATIENTS
6. RECOMMENDATIONS FOR THE PATIENT. CONCLUSION
Leading into the problem. Complete edentia is a pathological condition of the dental system caused by operations to remove all teeth.
According to statistics, completely edentulous (PA) a consequence of tooth extraction operations, trauma or periodontal disease is quite common. PA rates increase progressively (fivefold) in each subsequent age group: in the population aged 40-49 years it is 1%, in people aged 50-59 years - 5.5%, and in people over 60 years old - 25%.
In the general structure of medical care for patients in dental treatment and prevention institutions, 17.96% of patients are diagnosed with PA of one or both jaws.
PA negatively affects the quality of life of patients. PA causes disturbances up to the final loss of important functions of the maxillofacial system - biting, chewing, swallowing. It affects the digestion process and the intake of necessary nutrients into the body, causing the development of inflammatory diseases of the gastrointestinal tract and dysbiosis. No less serious are the consequences of PA for the social status of patients: disorders of articulation and diction affect the patient’s communication abilities; these disorders, together with changes in appearance due to loss of teeth and developing atrophy of the masticatory muscles, can cause changes in the psycho-emotional state, including mental disorders.
PA is also one of the reasons for the development of specific complications in the maxillofacial area, such as dysfunction of the temporomandibular joint and the corresponding pain syndrome.
PA is a consequence of a number of diseases of the dental system - caries and its complications, periodontal diseases, as well as injuries.
These diseases, if untimely and poorly treated, can lead to spontaneous loss of teeth due to pathological processes in periodontal tissues of an inflammatory and/or dystrophic nature, to loss of teeth due to the removal of teeth that cannot be treated and their roots due to deep caries, pulpitis and periodontitis.
Untimely orthopedic treatment of PA, in turn, causes the development of complications in the maxillofacial area and pathology of the temporomandibular joint.
The clinical picture is characterized by changes in the configuration of the face (recession of the lips), pronounced nasolabial and chin folds, drooping of the corners of the mouth, a decrease in the size of the lower third of the face, in some patients - maceration and “jamming” in the area of the corners of the mouth, and impaired chewing function. PA is often accompanied by habitual subluxation or dislocation of the temporomandibular joint. After the loss or removal of all teeth, gradual atrophy of the alveolar processes of the jaws occurs, progressing over time.
The examination of a patient in an outpatient dental facility is documented by filling out Dental patient medical record (MDC)/form No. 043/0/, according to the order of the Ministry of Health of Ukraine No. 302 dated December 27, 1999.
ICSB is a document that represents primary, expert, legal material for scientific research, expert medical and legal opinions. When analyzing the chart, the correctness of the examination and diagnosis, agreement with the patient on the treatment plan, the adequacy and level of the treatment provided, the possible outcome of the disease and the consequences that occur are determined.
It is important to note that a thorough examination of the patient and its correct, and most importantly, timely documentation, will allow the dentist to avoid undesirable legal consequences, such as compensation for material damage and moral harm, if a legal dispute arises regarding the correctness of the examination, diagnosis, adequacy of the plan, possible complications during treatment and complications of the disease.
Examination of a patient is a sequence of medical studies carried out in a logical sequence and necessary to identify the individual characteristics of the manifestation and course of the disease, culminating in the establishment of a diagnosis and drawing up a treatment plan. In addition, the medical history includes a treatment diary, epicrisis and prognosis of the disease.
Medical history, ICSB is a document that objectively reflects the professionalism, level of clinical thinking, qualifications and intelligence of the dentist.
One of the main objectives of training students of the Faculty of Dentistry is to consolidate skills, methods of examination and treatment of patients in an outpatient setting. At the same time, it is relevant to develop stereotypes for impeccable documentation of the process and results of the examination - IKSB. At the registry, the patient’s passport data is entered into the ICSB: last name, first name, patronymic, gender, profession, year of birth or age, number of completed years at the time of filling out the document.
Patient examination- a set of studies conducted in a certain sequence, namely: subjective, objective and additional.
Subjective studies, is carried out by questioning in the following sequence: first - clarification of complaints, then - medical history and then life history.
Objective studies are carried out in the following sequence: from the beginning - inspection (visual examination), then - palpation (manual, instrumental, (probing), percussion, auscultation.
Additional Research- radiography (sighting, panoramic, teleradiography), laboratory, etc.
Advice: we recommend starting the patient’s appointment with checking compliance with the ICDB and the correctness of filling out its passport part.
4. Examination sequence:
4.1. The examination of the patient begins with clarification of complaints. When questioning, the patient’s complaints are not recorded “mechanically”, compiling a so-called register of complaints, but the main (main) motivation for going to the dental orthopedic clinic is clarified and clarified.
It should be remembered that a thorough clarification of the motivation for treatment is of decisive importance for the patient’s satisfaction with the result of orthopedic treatment. This is a psychological aspect: motivation for appeal defines a model of positive emotions of recovery created by the patient even before going to the clinic - such as rehabilitation of the functions of biting, chewing, aesthetic standards of the smile and face, elimination of spattering of saliva during conversation, normalization of diction.
When clarifying and clarifying complaints, the patient’s level of claims for the rehabilitation of functions, as well as aesthetic standards and diction are clarified, clarified and adjusted.
Patients' complaints in terms of motivation are, as a rule, functional in orientation and the dentist needs to establish their cause-and-effect relationship with anatomical disorders.
For example, difficulties or disturbances in the function of biting chewing, a decrease in the aesthetic standards of the smile and face, due to defects in the crown parts of the teeth, defects in the dentition, complete edentia.
The patient may complain about changes in color and violation of the anatomical shape of the crown parts of the teeth, splashing of saliva during communication, disturbances in diction, aesthetic standards of the smile and face. Next, the patient is asked, again by questioning:
4.2. HISTORY OF THE DISEASE
At the same time, they question the patient in detail, and then write down in the column “Development of the present disease” the information received about how much time has passed since the first signs of the disease appeared. It is clarified that, due to complications of the course of which particular diseases of caries, periodontitis, periodontal disease or injury, tooth extraction operations were performed. Finds out over what period of time tooth extraction operations were carried out, and how much time has passed since the last operation. At the same time, the dentist focuses on the manifestation of clinical symptoms, the course of diseases, or the circumstances of the injury. Be sure to find out whether orthopedic dental care was previously provided, and if so, establish what designs of prostheses, and for what period of time the patient used or is using prostheses.
4.3. ANAMNESIS OF LIFE
Next, using the questioning method, they obtain information both from the patient’s words and on the basis of documents compiled by other specialists, analyze the information received and enter it in the ICD column “Previous and concomitant diseases.”
A special note is made about the sources of information: “According to the patient...”“Based on an extract from the medical history...” “Based on the certificate...” In this case, the doctor must find out whether the patient is or has previously been registered with a dispensary, whether he was treated and for what period of time. Has he undergone treatment for infectious diseases (hepatitis, tuberculosis, etc), presenting an epidemiological danger of infecting others.
In a separate line, the doctor notes whether the patient is currently suffering from cardiovascular, neuropsychiatric diseases that pose a threat of exacerbation or crisis during treatment. This information is current so that the dentist can take measures to prevent and treat possible complications (fainting, collapse, hyper- and hypotensive crises, angina, hypo- and hyperglycemic coma, epileptic seizure). Pay attention to the presence of gastrointestinal diseases and endocrine disorders in the patient.
In a separate line, the doctor notes the presence or absence of a history of allergic manifestations and reactions, and notes the patient’s current state of health.
5. OBJECTIVE RESEARCH.
The initial method of objective research is examination /visual examination/. It is carried out in good lighting, preferably natural, using a set of dental instruments: a mirror, a probe, a throat spatula, and eye tweezers. Before starting the examination, the dentist must wear a mask and gloves.
5.1. Most authors recommend the following examination sequence: A - face, head and neck; B - perioral and intraoral soft tissues; C - teeth and periodontal tissues.
A - analyzes changes in sizes, their ratios, color and shape.
B - we recommend that the examination be carried out in the following sequence: red border, transitional fold, mucous membrane of the lips, vestibule of the oral cavity; corners of the mouth, mucous membrane and transitional folds of the cheeks; mucous membrane of the alveolar processes, gingival margin; tongue, floor of the mouth, hard and soft palate.
Pay attention to the symmetry of the face, the proportionality of the upper, middle and lower thirds of the face, the size of the oral fissure, the severity and symmetry of the nasolabial folds, mental groove, and protrusion of the chin. Pay attention to the color of the facial skin, the presence of deformations, scars, tumors, swelling, the degree of exposure of teeth and alveolar processes when talking and smiling. The degree of freedom of mouth opening, volume, smoothness, and synchronization of movements in the temporomandibular joints are determined. The degree of deviation of the line passing between the central incisors of the upper and lower jaws to the right or left. The temporomandibular joints are palpated in the resting position of the lower jaw and during opening and closing of the mouth. At the same time, place the index fingers in the external auditory canals in the area of the articular heads and determine the size, smoothness, and uniformity of excursions of the articular heads during movements of the lower jaw. Further studies are carried out using a combination of research methods: inspection, palpation, percussion, auscultation.
Regional lymph nodes are palpated. Pay attention to the size of the nodes, their consistency, pain, adhesion of the nodes to each other and surrounding tissues. Palpate and determine the soreness of the exit sites of the terminal branches of the trigeminal nerve /Vale points/.
First, the patient's lips are examined with the mouth closed and open. The color, shine, consistency, location of the corners of the mouth, the presence of inflammation and maceration in the corners of the mouth are noted. Next, examine the mucous membrane of the lips and transitional folds in the area of the vestibule of the oral cavity. Color, moisture, presence of pathological changes, consistency are noted. Then, using a dental mirror, the mucous membrane of the cheeks is examined. First, the right cheek from the corner of the mouth to the palatine tonsil, then the left. Pay attention to color, the presence of pathological changes, pigmentation, etc, examine the excretory ducts of the parotid salivary glands, located at the level of the coronal parts 17 and 27.
Then the mucous membrane of the alveolar processes is examined, starting from the distal vestibular region of the upper and then the lower jaws, and then the oral surface from right to left, along an arc. The edge of the gums and gingival papillae are examined, first in the upper jaw and then in the lower jaw. Start from the distal area, the vestibular surface of the upper jaw /1st quadrant/ along an arc from right to left.
In the distal vestibular surface of the left upper jaw /2nd quadrant/, move down and examine the vestibular surface of the distal lower jaw on the left /3rd quadrant/ and examine the vestibular surface of the lower jaw on the right /4th quadrant/. Pay attention to the presence of fistulous tracts, atrophy of the gingival margin, the presence and size of periodontal pockets, hypertrophy of the gingival margin. The tongue is examined, its size, mobility, the presence of folds, plaque, humidity, and the condition of the papillae are determined. Examine the floor of the mouth, pay attention to changes in color, vascular pattern, depth, and place of attachment of the frenulum of the tongue. The palate is examined with the patient’s mouth wide open and the patient’s head tilted back, the root of the tongue is pressed with a throat spatula or a dental mirror, and the hard palate is examined. Pay attention to the depth, shape, and presence of a torus. They examine the soft palate and pay attention to its mobility. If there are pathologically altered tissues of the mucous membrane, they are palpated, their consistency, shape, etc. are determined.
The dentition is examined using a dental mirror and probe in the following sequence: first, the dentition is examined, paying attention to the shape of the dentition, and the type of closure of the dentition in the position of central occlusion (bite) is determined. Pay attention to the occlusal surfaces of the dentition; the presence of vertical and horizontal deformation, if any, determine its degree. The presence of diastemas and three contact points is established. The dentition is examined, starting from the distal part of the right upper jaw, and each tooth separately, in the direction of the distal part of the left upper jaw. Then from the distal part of the lower jaw on the left towards the distal part of the lower jaw on the right. Pay attention to crowding, oral, vestibular arrangement of teeth. The stability or degree of pathological mobility of teeth, the presence of carious lesions, fillings, and fixed prosthetic structures: bridges, crowns, inlays, and pin teeth are determined.
5.1.1. Status localis is noted in the clinical formula of the dentition: symbols are placed above and below the numbers indicating each tooth in the first row. In the second row, the degree of pathological tooth mobility according to Entin is noted. If the teeth do not have pathological mobility, then in the second row, and if there is pathological mobility of the tooth, then in the third row, symbols indicate the fixed structures planned for the orthopedic treatment of the patient. Cd - crown, X - cast tooth (intermediate parts of bridge structures)
Moreover, the supporting elements of fixed bridge structures are connected to each other by arcuate lines. The dashes show the supporting elements of fixed structures welded together. Planned designs of fixed splints and prosthetic splints are similarly noted.
The type of closure is determined, that is, the type of spatial position of the teeth in central occlusion - bite and noted in the appropriate section.
5.1.2. Features of examination of the oral cavity of patients and diagnosis of defects in the dentition
Pay attention to the localization of defects - in the lateral, in the anterior areas. The extent of each defect and its location in relation to the existing teeth are determined. Pay attention to the crown parts of the teeth that limit the defects: the condition of the crown parts of the teeth: intact, filled, covered with crowns. If the teeth are filled and will be used to fix the supporting elements of bridge structures, it is necessary to conduct an x-ray examination (sighted x-ray) to determine the condition of the periodontal tissues. In the section “X-ray data...”, the data obtained is recorded in a descriptive form.
6. Diagnosis, definition, parts, components
It should be remembered that in orthopedic dentistry, a diagnosis is a medical conclusion about the pathological state of the maxillofacial system, expressed in terms adopted by the classifications and nomenclature of diseases.
The diagnosis consists of two parts, which are sequentially indicated:
1. the main disease and its complications.
2. associated diseases and their complications.
The diagnosis of the underlying disease contains the following sequence of components:
The morphological component informs about the essence and localization of the main pathoanatomical disorders.
For example. Dental defect class 3, subclass 3, dental defect class 1 according to Kennedy or toothless class 1 according to Schroeder, toothless class 1 according to Keller. The mucous membrane of the prosthetic bed is class 1 according to Supple.
The functional component of the diagnosis informs about the violation of the basic functions of the dentofacial system, usually in quantitative terms. For example. Loss of chewing efficiency 60% according to Agapov.
*The aesthetic component informs about aesthetic violations. For example: violation of diction, violation of aesthetic norms of a smile, violation of aesthetic norms of the face.
*The pathogenetic component links the previous components of the diagnosis into a medical report, informs about their causes and pathogenesis. For example. Due to complications of the carious process that developed over 10 years; Due to generalized periodontitis that developed over 5 years.
* - noted when writing an extended medical history
6.1. To make a diagnosis, Kennedy's classification of dentition defects with Appligate's amendments is used.
It should be remembered that
The first class includes defects located in the lateral areas on both sides, limited only medially and not limited distally;
The second class includes defects located in the lateral areas on one side, limited only medially and not limited distally;
The third class includes defects located in the lateral areas, limited both medially and distally
The fourth class includes defects located in the anterior areas and crossing an imaginary line passing between the central incisors.
Appligate amendments have the following meanings:
1. The class of the defect is determined only after therapeutic and surgical sanitation of the mouth.
2. If the defect is located in the area of the 2nd or 3rd molar and will not be replaced, then the presence of such a defect is ignored, but if the defect is located in the area of the 2nd molar and will be replaced, then it is taken into account when determining the class.
3. If there are several defects, one of them, located distally, is determined as the main one, defining the class, and the remaining defects, by their number, determine the subclass number. The length of defects is not taken into account.
4. The fourth class does not contain subclasses.
6.2. Diagnosis scheme for partial edentia
Dental defect of high grade ______class _____subclass, defect of dentition low grade ______class _____subclass according to Kennedy. Loss of chewing efficiency _____% according to Agapov.
Aesthetic defect of the smile, impaired diction. Due to complications of the carious process (periodontal diseases) that developed over _____ years.
7. Determination of loss of chewing efficiency
according to Agapov
It should be remembered that the coefficients of chewing efficiency of teeth according to Agapov are as follows, starting from the central incisors to the third molars: 2, 1, 3, 4, 4, 6, 5, 0. In order to determine the loss of chewing efficiency, it is necessary to add up the coefficients of chewing efficiency of teeth -antagonists located in places where defects in the dentition are localized from left to right once without adding up the coefficients of the antagonist teeth. The resulting loss of chewing efficiency is doubled. For example.
AA
AAAA
(4 + 4 + 3 + 6) x 2 = 34%
8. Studies of the oral cavity with complete edentia (PA)
PA is a pathological condition of the dental-jaw system associated with the complete loss of all teeth.
It should be remembered that operations to remove all teeth do not stop the process of atrophy of the alveolar processes of the jaws. Therefore, the key word in the descriptive part of the type of toothless jaws is “degree of atrophy” and “change in distance” from the tops of the alveolar processes and the attachment points of the frenulum of the lips, tongue, cords and the transition points of the mobile mucous membrane (transitional fold, lips, cheeks, floor of the mouth ) into a stationary one, covering the alveolar processes and palate.
Depending on the degree of atrophy of the alveolar processes, the tubercles of the upper jaw, and, as a result, the changing distance from the attachment points of the frenulum of the lips, tongue and strands of the mucous membrane to the top of the alveolar processes of the upper jaw and the height of the vault of the palate.
8.1. Schroeder (H. Schreder, 1927) identified three types of upper toothless jaws:
Type 1 - characterized by slight atrophy of the alveolar processes and tubercles, a high arch of the palate. The attachment points of the frenulum of the lips, tongue, cords and transitional fold are located at a sufficient distance from the tops of the alveolar processes.
Type 2 - characterized by an average degree of atrophy of the alveolar processes and tubercles, the vault of the palate is preserved. The frenulum of the lips, tongue, cords and transitional fold are located closer to the tops of the alveolar processes.
Type 3 - characterized by significant atrophy of the alveolar processes. The tubercles are completely atrophied. The sky is flat. The frenulum of the lips, tongue, cords and transitional fold are located at the same level with the apices of the alveolar processes.
Keller (Kehller, 1929) identified four types of lower edentulous jaws:
Type 1 - characterized by slight atrophy of the alveolar process. The places of attachment of muscles and folds are located at a sufficient distance from the apex of the alveolar process.
Type 2 - characterized by significant, almost complete, uniform atrophy of the alveolar process. The places of attachment of muscles and folds are located almost at the level of the apex of the alveolar process. The crest of the alveolar process barely rises above the floor of the oral cavity, presenting a narrow, knife-like formation in the anterior section.
Type 3 - characterized by significant atrophy of the alveolar process in the lateral areas, while being relatively preserved in the anterior area.
Type 4 - characterized by significant atrophy of the alveolar process in the anterior area, while remaining in the lateral areas.
THEM. Oksman proposed a unified classification for the upper and lower toothless jaws:
Type 1 - characterized by slight and uniform atrophy of the alveolar processes, well-defined tubercles of the upper jaw and a high arch of the palate and transitional folds located at the bases of the alveolar slopes and places of attachment of the frenulum and buccal cords.
Type 2 - characterized by moderately severe atrophy of the alveolar processes and tubercles of the upper jaw, a shallower palate and lower attachment of the mobile mucous membrane.
Type 3 - characterized by significant but uniform atrophy of the alveolar processes and tubercles of the upper jaws, flattening of the vault of the palate. The mobile mucous membrane is attached at the level of the apexes of the alveolar processes.
Type 4 - characterized by uneven atrophy of the alveolar processes.
8.2. The mucous membrane of prosthetic beds is classified by Supple into 4 classes, depending on the course of the process of atrophy of the alveolar process, the mucous membrane, or a combination of these processes.
Class 1 (“ideal mouth”) - the alveolar processes and palate are covered with a uniform layer of moderately pliable mucous membrane, the pliability of which increases towards the posterior third of the palate. The attachment points of the frenulum and natural folds are located at a sufficient distance from the apex of the alveolar process.
Class 2 (hard mouth) - the atrophic mucous membrane covers the alveolar processes and palate with a thin, as if stretched, layer. The attachment points of the frenulum and natural folds are located closer to the tops of the alveolar processes.
Class 3 (soft mouth) - the alveolar processes and palate are covered with loose mucous membrane.
Class 4 (loose ridge) - excess mucous membrane is a ridge due to atrophy of the alveolar bone.
8.3. Diagnosis scheme for complete edentia
Toothless upper part ______ type according to Schroeder, toothless lower part ______ type according to Keller. The mucous membrane is ______ class according to Supple. Loss of chewing efficiency is 100% according to Agapov.
Violation of diction, norms of facial aesthetics. Developed as a result of complications of the carious process (periodontal diseases) over _______ years.
Once the diagnosis has been made, the next step is to create an orthopedic treatment plan. First, the dentist must analyze the indications and contraindications for orthopedic treatment with fixed and removable prosthetic structures.
General indications for orthopedic treatment of defects in the coronal parts of teeth with crowns are: violation of their anatomical shape and color, anomalies of position.
Direct indications for orthopedic treatment with fixed structures are defects of the dentition of the 3rd and 4th Kennedy classes of small (1-2 teeth) and medium (3-4 teeth) extent.
Kennedy grade 1 and 2 dental defects are direct indicators for orthopedic treatment with removable denture designs.
During orthopedic treatment with fixed structures, it is necessary to take into account the condition of the periodontal tissues of the supporting teeth, their stability, the height of the crown parts, the type of bite, and the presence of traumatic occlusion.
Absolute contraindications to orthopedic treatment with bridge structures are large defects in the dentition, limited to teeth with different functional orientations of periodontal fibers.
Relative contraindications are defects limited to teeth with pathological mobility of the 2nd and 3rd degrees according to Entin, defects limited to teeth with low crown parts, teeth with a small reserve of periodontal reserve forces, i.e., with high crown parts and short root parts in parts.
Absolute contraindications to orthopedic treatment with removable dentures are epilepsy and dementia. Relative - diseases of the oral mucosa: leukoplakia, lupus erythematosus, intolerance to acrylic plastics.
If we consider the destruction of the dental system sequentially and in stages, then the next stage after a completely destroyed crown and the impossibility of using the root for a pin structure is a defect in the dentition of one tooth. Even such a small defect can cause deformation of the dental arches if treatment is untimely or absent.
The term “defect” refers to the loss of an organ, in this case the dentition. Some manuals use the name “partial defect,” but this is not entirely accurate, since it is always a particle, because the loss of all teeth no longer means a defect, but the complete absence of an organ, that is, the dentition. In the specialized literature, some authors (V.N. Kopeikin) prefer the term “secondary partial adentia” instead of a defect. It should be noted, however, that “edentia” means the absence of one or more teeth in the dentition, which may be the result of a disruption in the development of tooth germs (true edentia) or a delay in their eruption (retention).
V.N. Kopeikin distinguishes between acquired (as a result of disease or injury) and congenital or hereditary adentia. Partial secondary adentia as an independent nosological form of damage to the dental system is a disease characterized by a violation of the integrity of the dentition or dentition of the formed dental system in the absence of pathological changes in the remaining teeth. In the definition of this nosological form of the disease, the term “edentia” is supplemented with the word “secondary”, which indicates that the tooth (teeth) is lost after its eruption as a result of disease or injury, i.e., in this definition, according to the author, there is also a differential a diagnostic sign that allows you to distinguish this disease from primary, congenital, adentia and tooth retention.
Partial edentia, along with caries and periodontal diseases, is one of the most common diseases of the dental system. The prevalence of the disease and the number of missing teeth correlate with age.
The causes of primary partial adentia are disturbances in the embryogenesis of dental tissues, as a result of which there are no rudiments of permanent teeth. Violation of the eruption process leads to the formation of impacted teeth and, as a consequence, primary partial adentia. Acute inflammatory processes that develop during the period of primary occlusion lead to the death of the rudiment
permanent tooth and subsequently to underdevelopment of the jaw. The same processes can cause partial or complete retention. Delayed eruption can be caused by underdevelopment of the jaw bones, non-resorption of the roots of baby teeth, early removal of the latter and displacement of the erupting adjacent permanent tooth in this direction. For example, when the fifth primary tooth is removed, the first permanent molar usually moves anteriorly and takes the place of the second premolar.
The most common causes of secondary partial adentia are caries and its complications - pulpitis and periodontitis, as well as periodontal disease, trauma, surgery for inflammatory processes and neoplasms.
In summary, it should be noted that it is more convenient to use the terms defect instead of “secondary edentia,” true edentia (when there are no teeth in the dentition and their rudiments in the jaw) and false edentia (retention).
After tooth extraction, the dentition changes significantly. The clinical picture is very diverse and depends on the number of lost teeth, their location in the dentition, the function of these teeth, the type of occlusion, the condition of the periodontium and hard tissues of the remaining teeth, and the general condition of the patient.
Clinic. Patients present various complaints. In the absence of incisors and canines, complaints about aesthetic defects, speech impairment, splashing of saliva when speaking, and the inability to bite off food predominate. Patients who lack chewing teeth complain of impaired chewing (however, this complaint becomes dominant only in the absence of a significant number of teeth), more often of inconvenience when chewing, injury and soreness of the mucous membrane of the gingival margin. There are frequent complaints about aesthetic defects in the absence of premolars in the upper jaw. When collecting anamnestic data, it is necessary to establish the reason for the removal of teeth, as well as find out whether orthopedic treatment was previously carried out and with the help of what denture designs.
On external examination, as a rule, there are no facial symptoms. If there are no incisors and canines on the upper jaw, then some retraction of the upper lip may be observed. In the absence of a significant number of teeth, retraction of the soft tissues of the cheeks and lips is often observed. In cases where part of the teeth on both jaws is missing, without preserving the antagonists, that is, with an unfixed bite, the development of angular
Chapter 6.
cheilitis (seizures), during the swallowing movement there is a large amplitude of vertical movement of the lower jaw.
When examining tissues and organs of the oral cavity, it is necessary to determine the type of defect and its extent, the presence of antagonizing pairs of teeth, the condition of hard tissues, mucous membrane and periodontal tissue, and evaluate the occlusal surface of dentures. In addition to the examination, palpation, probing are carried out, the stability of the teeth is determined, etc. An X-ray examination of the periodontium of the proposed supporting teeth is required.
The leading symptoms in the clinic for dental defects are:
1. Violation of the continuity of the dentition.
2. Decay of dentition on your own
existing groups of teeth of two types - functional
failing and dysfunctional.
3. Functional overload of the periodontium remains
loose teeth.
4. Deformation of the occlusal surface of the tooth
ny rows.
5. Violation of chewing and speech functions.
6. Changes in the temporomandibular joint in
connection with tooth loss.
7. Dysfunction of the masticatory muscles.
8. Violation of aesthetic standards.
Moreover, 1,2,5 always accompany partial tooth loss. Other problems may not occur or may not occur immediately but may occur due to ongoing tooth loss or periodontal disease. 1. Violation of the continuity of the dentition is caused by the appearance of defects. A defect in the dentition should be considered the absence of one to 13 teeth. Each defect is characterized by its position in the dentition. If it is limited by teeth on both sides, it is an included defect; if only on the mesial side, it is an end defect. When trying to determine the number of possible options for the loss of one, two, and so on teeth, it turned out that, according to the data of E1clb, it will be equal to 4.294.967.864. Many classifications have been created, in particular by E.I. Gavrilov (Fig. 263). However, it turned out to be impossible even theoretically to create a classification taking into account all available characteristics.
Based on this, taking into account practical needs, simpler classifications have been created based on the characteristics that are most important for clinicians, namely the localization (topography) of the defect in the dental arch; it is limited on one or both sides by teeth; presence of antagonist teeth.
Widespread in Western Europe, America, and in our country is the Kennedy classification (Fig. 264).
Class I. Bilateral end defects.
Class P. Unilateral end defect.
Class III. Included defect in the lateral section.
Class IV. This class includes an included defect in which the toothless area is located in front of the remaining teeth and crosses the midline of the jaw.
The main advantage of the Kennedy classification is its logic and simplicity, which makes it possible to immediately imagine the type of defect and the corresponding design of the prosthesis. The first three classes may have subclasses, determined by the number of additional dentition defects, that is, in addition to the main class.
Rice. 263. Classification of dentition defects according to E. I. Gavrilov: / - unilateral end defect;
2 - bilateral end defects;
3 - one-sided included defect
lateral part of the dentition;
4 - bilateral included defects
lateral sections of the dentition;
5 - included anterior defect
dentition; 6 - combined
defects; 7 - jaw with single
remaining tooth.
Chapter 6. Dental defects. Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
Rice. 264. Classification of dentition defects according to Kennedy.
App 1 egate (1954) supplemented Kennedy's classification by proposing 8 rules for its application.
1. Determination of the class of defect should not be preceded by
recommend tooth extraction as this may change
originally established class of defect.
2. If the third molar is missing, which is not
classifications.
3. If there is a third molar that should
be used as an abutment tooth, then it is taken into account
is included in the classification.
4. If the second molar is missing, which is not
must be replaced, it is not taken into account in
classifications.
5. The class of defect is determined depending on
location of the toothless area of the jaw.
6. Additional defects (not counting the basics)
class) are considered as subclasses and
determined by their number,
7. The length of additional defects is not
is being considered; only their number is taken into account, op
defining the subclass number.
8. Class IV has no subclasses. Toothless areas lying posterior to the defect in the area of the anterior teeth determine the class of the defect.
If in the same dentition there are several defects of different localization, then in this case the dental arch is classified as a lower class.
For example: 765430010034000 0004300|0004560
Here there are fourth and second class defects on the upper jaw. In this case, the upper dentition is classified as the second class, and the lower dentition as the first.
How to define a subclass? - The number of defects included determines the subclass number, excluding the main class. For example, in the above-mentioned dental formula on the upper jaw, the second class, the first subclass. This is the most convenient and the only international classification.
Kennedy's classification is the most acceptable, tested in practice over a long period of time and generally accepted.
Chapter 6. Dental defects. Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
Using this classification, you can quickly make a choice between a prosthesis supported by two teeth, a bridge-type prosthesis (for class III defects) and one supported by teeth, mucous membrane and underlying bone (for class 1 defects).
Kennedy's classification, like other anatomical and topographical classifications, does not give an idea of the functional state of the dentition, which is important for choosing the design of clasps and the method of distributing the load through them between the supporting teeth and the mucous membrane of the alveolar process. When choosing a prosthesis design, the following factors must be taken into account:
a) functional state of periodontal supports
teeth and antagonist teeth;
b) functional (power) ratio an-
pressing groups of teeth;
c) functional (power) tooth ratio
ny rows of the upper and lower jaws;
d) type of bite;
e) functional state of the mucous membrane
ridges of edentulous areas of alveolar processes
(the degree of its compliance and the threshold of pain
telnosti);
f) shape and size of toothless areas of the alveo
polar processes.
The most common types of morphological and functional relationships of the dentition include the following:
1) on the opposite jaw there is a continuous
broken teeth;
2) on the opposite jaw there are de
effects of the same class; a) symmetrical; b)
asymmetrical; c) crossed;
3) on the opposite jaw there are de
Effects of various classes: a) combination of I and IV
classes; I) combination of classes II and IV;
4) absent on the opposite jaw
all teeth, functional relationship of teeth
rows can be equal or unequal: a) with a predominance
giving strength to supporting teeth; b) with predominance
forces of opposing teeth.
Kennedy classifies defects of only one dentition and, when choosing a prosthesis design, does not take into account the type of defects on the opposite jaw and the occlusal relationship of the remaining groups of teeth. The functional relationship of the dentition for different classes of defects is not the same and, depending on their combination on the upper and lower jaw after prosthetics, a new functional relationship of the dentition is created. It may be favorable or unfavorable with respect to the distribution of the load falling on the supporting tissues.
When determining the functional state of the remaining teeth and dentitions, it is convenient to use the Kurlyandsky periodontogram (see Chapter 2). These data make it easier to resolve questions about the method of distributing the functional load, choosing
supporting teeth, and also allow us to judge the effectiveness of treatment.
II. The disintegration of the dentition into independently functioning groups of teeth. Despite the fact that the dentition consists of individual elements (teeth, their groups, different in their form and function), it is united into a whole, both morphologically and functionally. The unity of the dentition is ensured by the alveolar process and interdental contacts. With age, the contact points are erased, turning into platforms, but the continuity of the dentition is maintained due to the mesial shift of the teeth. As a result, with age, the dental arch can be shortened by 1.0 cm. Chewing pressure that occurs in any part of the dentition falls not only on the roots of this group, but is transmitted through interdental contacts, like a chain, to other teeth. A similar mechanism for distributing chewing pressure protects teeth from functional overload. In addition, interdental contacts protect the marginal periodontium from injury from hard food.
The “first blow” to the unity of the dentition is dealt by the removal of the first tooth, and its severity depends on what kind of tooth it is. With the removal of part of the teeth, the morphological and functional integrity of the dental arch ceases to exist, which breaks up into independently operating groups or a number of single-standing teeth. Some of them have antagonists and can bite off or chew food, forming functioning (working) group. Others find themselves deprived of antagonists and do not participate in the act of chewing.
They form a non-functioning (non-working) group (Fig. 265). In this regard, the teeth of the functioning group begin to perform a mixed function, experiencing pressure unusual as both in size and direction. For example, the front teeth, designed for biting food and not for grinding it, have to take a large load for which their periodontium is not adapted and this can lead to functional overload. Gradually cutting
Chapter 6. Dental defects. Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
the edges of the front teeth are worn away, chewing areas are formed instead of them and this leads to a decrease in height crowns, and consequently, to a decrease in the interalveolar height and lower third of the face (Fig> 266). This in turn causes a restructuring of the temporomandibular joint and the function of the masticatory muscles.
In addition, chewing pressure that is unusual in magnitude and direction may cause functional overload remaining teeth if there is no timely prosthetics. The simplest example of traumatic occlusion accompanied by functional/overload is an increase in interalveolar height on a single crown, filling or bridge. At first this causes a feeling of awkwardness, which later goes away. But over time, pathological mobility of the teeth, marginal periodontitis, and then degeneration of the socket appear, revealed by x-rays of the alveolar process. Speaking about functional overload, its causes can be systematized as follows. III. Functional overload of teeth with defects in the dental arches occurs due to changed conditions for the perception of chewing pressure: a decrease in the number of antagonizing teeth or damage to the supporting apparatus of the teeth by some pathological process (periodontal disease, periodontitis, tumor, osteomyelitis, loss of interdental contacts, etc.).
With small defects, functional overload is not felt, since the preserved teeth, without much stress on their periodontium, replenish the lost function. With the expansion of defects, the functioning of the dentition deteriorates, and its overload increases. This in turn causes a restructuring of the masticatory apparatus, its adaptation to new functional conditions. In the periodontium, compensation phenomena are accompanied by increased blood circulation through the involvement of a large number of capillaries in the bloodstream, an increase in the thickness and number of Sharpey's fibers. The bone trabeculae become stronger.
However, the body's possibilities for restructuring in general and the periodontal system in particular are not unlimited. Therefore, the functional load cannot exceed a certain level without degeneration of the supporting tissues of the tooth as a result of circulatory disorders. In this regard, resorption of the alveolar wall appears, the periodontal fissure expands, and tooth movements become noticeable to the naked eye.
The ability of periodontal teeth to withstand increased functional load depends on its reserve forces. The reserve forces of the periodontium* mean the ability of this organ to adapt
* For more information about the reserve forces of the periodontium, see Chapter. 9.
subordinate to changes in functional tension. The periodontium of each tooth has its own supply of reserve forces, determined by the general condition of the body, the size of the tooth root, i.e., the periodontal surface, the width of the periodontal fissure, and the ratio of the length of the crown and root. Reserve forces can be increased through training (N. A. Astakhov, 1938). People who avoid solid foods, especially children, have a lower periodontal strength compared to people who eat coarse and lightly processed food.
Our ancestors, eating rough food, constantly trained the periodontium. Currently, they eat processed and crushed food, which excludes periodontal training.
Reserve forces change with age. It must be assumed that this is primarily due to changes in the functional capabilities of the body's vascular system in general and the periodontium in particular. Along with this, the ratio of the extra- and intra-alveolar parts of the tooth changes with age. Reducing the crown changes the force applied to the root, and reducing the height of the cusps due to abrasion makes chewing movements smoother. The latter circumstances compensate for the decline in reserve forces due to circulatory disorders associated with age.
General and local diseases can also affect reserve forces.
When the adaptive mechanisms of the periodontium are unable to compensate for acute or chronic overload of the teeth, chewing pressure from a factor stimulating metabolic processes turns into its opposite, causing dystrophy in the periodontium. In the clinic of partial tooth loss, a new phenomenon arises - a symptom of traumatic occlusion.
The closure of teeth, in which a healthy periodontium experiences chewing pressure exceeding
Chapter 6. Dental defects. Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
limiting his physical endurance, we call primary traumatic occlusion.
Overload of teeth due to defects in dental arches develops in a certain order. The teeth that hold the interalveolar height are primarily subject to overload. In this case, a typical picture of primary traumatic syndrome develops: tooth mobility, atrophy of the socket and gums, exposure of the neck of the tooth and, as a consequence, the appearance of pain when eating hot and cold food.
After the loss of these teeth, the focus of traumatic occlusion is transferred to another group of teeth that hold the interalveolar height and thus it seems to move along the remaining dentition.
Pathological occlusion. The term “pathological occlusion” has been known for a long time. In the specialized literature, it was used to designate a closure of the teeth in which functional overload occurs, i.e., the term “pathological occlusion” was identified with the term “traumatic occlusion.” This definition of pathological occlusion should be considered imprecise, since there is a significant difference between pathological and traumatic occlusion. For example, severe forms of open bite are accompanied by serious disturbances in chewing function. Reducing the useful chewing surface does not provide mechanical processing of food, so some patients rub it with their tongue; at the same time, there are no symptoms of functional overload of the teeth. Thus, there is a need to give a different, more precise definition of pathological occlusion.
Pathological occlusion should be understood as a closure of teeth in which there is a violation of the form and function of the dental system. It appears in the form of functional overload of the teeth, violation of the occlusal plane, pathological abrasion, trauma to the marginal periodontal teeth, blockade of movements of the lower jaw, etc.
Traumatic occlusion is one of the forms of pathological occlusion. Pathological occlusion is related to traumatic occlusion as the whole is to the particular.
Types of traumatic occlusion. Functional overload of teeth has different origins. It can occur as a result of changed conditions in the oral cavity, as a result of:
1. Malocclusion (for example, very often
background is deep bite)
2. Partial loss of teeth
3. Deformations of the occlusal surface of the tooth
row
4. Mixed function of anterior teeth
5. Pathological abrasion
6. Errors in prosthetics: a) increase
bite on a crown, bridge, b)
changing a cantilever prosthesis with mesial support, c) incorrect clasp fixation, d) orthodontic devices
7. Bruxism and bruxomania;
8. Acute and chronic periodontitis
9. Osteomyelitis and jaw tumors
Functional overload with partial load
Teeth loss appears due to a change in alignment
division of chewing pressure caused by
violation of the continuity of the dentition (reduce
changing the number of teeth in contact with
its antagonists, the emergence of mixed
functions, deformations of the occlusal surface
pain caused by tooth movement. When on
healthy periodontium decreases unusual function
nal load, we are talking about primary injury
tic occlusion.
In another case, chewing pressure becomes traumatic not because it has increased or changed in direction, but because periodontal disease has made it impossible for it to perform normal functions. So traumatic we call occlusion secondary.
The distinction between primary and secondary traumatic occlusion has its reasons. With traumatic occlusion, a vicious circle is created in the dental system. Periodontal disease that arises for any reason generates functional overload, and traumatic occlusion, in turn, enhances periodontal disease.
In this vicious circle, it is necessary to find the leading link, reveal cause-and-effect relationships and outline pathogenetic therapy. This is why it is useful to distinguish between primary and secondary traumatic occlusion.
The mechanism of occurrence of traumatic occlusion. In the pathogenesis of traumatic occlusion, functional overload should be distinguished by magnitude, direction and duration of action.
An example of primary traumatic occlusion, accompanied by an increase in functional load, is an increase in the height of the bite (interalveolar height) on a single crown, filling or bridge. At first, this causes a feeling of awkwardness, a sensation of a tooth that the patient had not previously noticed, and then pain occurs.
With a slight increase in the height of the bite, these symptoms of traumatic occlusion disappear over time, as the periodontium adapts to the changed function. When the increase in the height of the bite turns out to be significant, then awkwardness and pain are followed by pathological mobility of the tooth, gingivitis, and then degeneration of the socket, revealed by radiography of the alveolar process.
This simple example shows how primary traumatic occlusion leads to the development of complex
Chapter 6. Dental defects. Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
new clinical picture, which could be called primary traumatic syndrome.
Primary traumatic syndrome is characterized by a combination of two symptoms: traumatic occlusion and periodontal disease. With this formulation, traumatic syndrome becomes a complex concept that reflects a violation of both the function and structure of an organ.
Primary traumatic syndrome, being a logical development of primary traumatic occlusion, has a certain clinical characteristic. It is characterized by pathological tooth mobility, exposure of its root, gingivitis, socket atrophy, and tooth movement. Periodontal disease, which arises as a result of functional overload, can stop and then recovery occurs. In other cases, it is irreversible, removing the overload does not eliminate the disease and the patient subsequently loses teeth.
The functional load can change not only in magnitude and direction, but also in the duration of action. Thus, in persons suffering from nighttime teeth grinding and epileptic seizures, along with an increase in pressure, the duration of occlusal contacts increases. An increase in the closure time can also be noted on the front teeth with their mixed function, when wide chewing surfaces appear instead of cutting edges.
The time of occlusal contacts is prolonged with some types of anomalies, for example, with a deep bite. With this type of closure, the incisal path time is lengthened. Multiple contacts in the lateral sections of the dentition when closing the mouth occur somewhat later than is the case with normal overlap, as a result of which the lower front teeth experience pressure for a longer time. For this reason, periodontal capillaries remain bloodless for a longer time than is typical for their physiology, periodontal anemia occurs and, as a result, a violation of its nutrition occurs. This is the mechanism of occurrence of periodontal disease during traumatic occlusion, when the functional load increases over time.
The basis of functional overload is rarely just an increase in chewing pressure or a change in its direction and time of action. More often there is a combination of these factors.
The clinic of functional overload is especially pronounced on molars and premolars, which tilt towards the defect, dragging through the interdental ligament and adjacent teeth. In children and adolescents, the unusual functional load is easily compensated by the restructuring of the alveolar process and often the second molars, after the removal of the first, come close to the premolar due to body movement, remaining stable.
In adults, tilting of the tooth towards the defect is accompanied by the formation of a pathological bone pocket on the side of movement, exposure of the neck and the appearance of pain from temperature stimuli. Analysis of occlusion with a similar position of the tooth always reveals a sign of unusual functional load, since contact with the antagonist tooth is maintained only on the distal cusps. These signs are pathognomonic for functional overload.
Functional overload that develops with dental defects does not occur immediately. Partial loss of teeth, as an independent form of damage to the dental system, is accompanied by pronounced adaptation and compensatory processes. Subjectively, a person who has lost one, two or even three teeth may not notice any disturbances in chewing function. However, despite the absence of subjective symptoms of damage, significant changes occur in the dental system, which depend on the topography and size of the defect. In this case, an important role is played by the number of antagonist pairs that maintain the bite height (interalveolar height) during chewing and swallowing and take on the pressure developed during contraction of the masticatory muscles. Functional overload develops especially quickly with the formation of bilateral end defects that arise against the background of a deep bite.
In the area of teeth that do not have antagonists, various morphological and metabolic changes occur in the dental tissues, periodontium and alveolar process. According to V.A. Ponomareva (1953, 1959, 1964, 1968), who studied the tissue reactions of the alveolar process of teeth devoid of antagonists, two groups of people should be distinguished: in some, in the absence of antagonist teeth, dentoalveolar restructuring occurs without exposing the neck of the teeth, that is the ratio of the extra- and intra-alveolar parts of the tooth does not change; let’s call this the first form (Fig. 267). In the second form, an increase in the alveolar process does not occur, accompanied by exposure of the neck and a change in the ratio of the extra- and intra-alveolar parts of the tooth in favor of the first, that is, an increase clinical crown tooth
The periodontal gap of teeth devoid of antagonists is narrowed (V. A. Ponomareva; 1964, A. S. Shcherbakov, 1966). In the periodontium, the volume of loose connective tissue increases, collagen fibers acquire a more oblique direction than in the periodontium of functioning teeth, and sometimes are located almost longitudinally; hypercementosis is often observed, especially in the area of the root apex.
IV. Deformations of the occlusal surface of the dentition. The movement of teeth caused by their partial absence has been known for a very long time. It was noted by Aristotle, then Hunter in his book “Natural History of Teeth”, published in 1771, described the inclination of molars in the absence of adjacent teeth (Fig. 268).
Chapter 6. Dental defects. Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
Rice. 267. Deformation of the occlusal surface of the dentition with unilateral vertical displacement of the upper teeth on the left 15 years after extraction (first form). The teeth that have descended into the defect have well-preserved cusps, since their antagonists were removed a long time ago. The occlusal surface of the lateral teeth has a stepped appearance, which indicates that the teeth were removed at different times. Models of the jaws of patient P., 40 years old, deep bite.
Rice. 268. Mesial inclination 7] into the lumen
dentition defect (Hunter, 1771).
The data from his experiments cannot be transferred to the clinic, since elongation of the teeth themselves does not occur in humans. Human teeth have a complete development cycle and after the formation of the apical foramen is completed, they do not increase in length, but, on the contrary, decrease due to wear.
Articulatory balance. Ch. Godon (1905), trying to explain the pathogenesis of some forms of tooth movement, created theory of articulatory balance. By articulatory balance he understood the preservation of the dental arches and the uninterrupted adhesion of the teeth to each other. He depicted this position as a parallelogram of forces. Under the condition of continuity of the dental arch, each element of it is in a closed chain of forces that not only hold it, but also preserve the entire dentition. Gaudin presented this chain of forces in the form of a diagram (Fig. 269). According to this scheme, the loss of even one tooth leads to disruption of the stability of the entire dentition and antagonists. Based on this theory, prosthetics are necessary if even one tooth is lost, regardless of its functionality.
In the domestic literature, deformations associated with tooth extraction are known as the “Popov-Godon” phenomenon. This can be explained as follows.
The fact is that V. O. Popov’s research, described in his dissertation “Changes in the shape of bones under the influence of abnormal mechanical conditions in the environment” (1880), was experimental in nature. The experiments were carried out on guinea pigs. V.O. Popov pointed out: “Tearing out the first incisors of a guinea pig caused a curvature of both jaws to the left side. The left lower incisor curved to the right, heading towards the tooth located in a diagonal direction from it. The tooth, not encountering any obstacle to its longitudinal development, continued to grow in this direction.”
It is known that rodents have constantly growing teeth, since they retain the enamel organ. The change in the position of the teeth and their growth in the experiments of V. O. Popov are associated not so much with changes in the jaws, but with the true growth of the teeth.
Rice. 269. Articulatory balance diagram
1 - four forces act on the tooth, their resultant is zero; 2 - with the loss of the upper molar, the resultant of the forces acting on the lower molar is directed upward; 3 - when a premolar is lost, the resultant of the forces acting on the premolar is directed towards the defect, as a result of which a tipping moment occurs, tilting the tooth; 4 - with the loss of the second molar, a tipping moment also occurs, displacing the tooth back.
Chapter 6. Dental defects. Changes in the dental system.
^Classification of defects. Diagnostics. Medical tactics and treatment methods.
Deformations that occur after the appearance of defects in the dentition have an age-related characteristic. They develop most quickly in childhood. This is due to the great plasticity of the alveolar bone and the high reactivity of the child’s body. Thus, in children, after the removal of permanent teeth, most often the first molars, movement of the second molars, ichmesial inclination and, as a consequence, severe occlusion disturbances in the area of the defect, and possibly disturbances in the development of the jaw, quickly occur. At the same time, it is difficult to exclude the influence of occlusal disorders on the function of muscles and the temporomandibular joint. This finding is very important for planning the prevention of deformity. It is quite obvious that you should not rush into removing permanent teeth, but take all measures to preserve them. If it is not possible to save the tooth, then in childhood it is necessary to use appropriate dentures.
As the plasticity of the jaw bones decreases, the rate of development of deformation decreases, but in adolescence it still remains quite significant. The preventive focus of dental therapy at this age remains, although in a slightly different form. After the removal of permanent first molars, the patient is subject to clinical observation with a mandatory examination once a year. When the first signs of tooth movement and occlusion disorders appear, immediate prosthetics are necessary. When two or more teeth or even one incisor or canine are removed, prosthetics are also carried out immediately. Similar tactics should be followed in other age groups (up to approximately 30-35 years). At this age, the risk of deformation after tooth extraction decreases, and in older people it completely disappears, and the indications for prosthetics for small defects that arise when one molar is removed are sharply reduced, unless another pathology prompts this (periodontitis, periodontal disease, arthrosis and etc.). The slowdown in the development of deformities in old age is explained by the low plasticity of the jaw bones, and, consequently, the weak reactivity of the body.
Knowledge of the features of the development of deformation after tooth extraction made it possible to correctly resolve the issue of prosthetics for patients with minor defects in the dentition, in particular those that arose during the removal of the first molars. Typically, indications for prosthetics were considered only taking into account dysfunction and aesthetics. Since those after the removal of the first molars are small, and the surgical trauma during the preparation of teeth for fixed dentures is significant, the evidence in favor of abandoning prosthetics prevailed. But this decision was erroneous in relation to young people, since the likely possibility of developing deformity was not taken into account. If we remember about the danger of this complication,
If you disagree, it will become clear that in childhood prosthetics should be carried out without delay. In this situation, it is purely preventive in nature. In adolescence, prevention remains important along with treatment. Only in older and older ages, when the danger of developing deformity disappears, does the preventative focus recede into the background and therapeutic goals take first place. Thus, in the light of data on age-related characteristics of deformities, the issue of prosthetics for patients of different ages after removal of the first molars is being resolved. In case of defects in the dentition, during their closure, pressure arises that displaces the tooth in one of four directions. This disrupts articulatory balance and creates conditions under which individual components of chewing pressure begin to act as traumatic factors (Fig. 270).
Despite the shortcomings of the pattern of chewing pressure acting on the tooth, the basic fundamental position of Cn. Godon that the integrity of the dentition is a necessary condition for its normal existence is correct. It can be considered one of the important theoretical principles of prosthetic dentistry. But many authors of modern works and textbooks have forgotten about this and only persistently describe the “Hodon phenomenon.”
In the textbook “Orthopedic Dentistry” by N. A. Astakhov, E. I. Gofung, A. Ya. Katz (1940), the term “deformation” was used to denote the described symptom, which most correctly reflects the essence of the clinical picture, which is based on the movement of teeth . Deformations of the dentition in this case are symptomatic.
Some authors call anomalies of the dentition and bite deformities, that is, those disorders that arose during the formation of the dentofacial system. It is more correct to call deformations only those violations of the shape of the dentition, occlusion and position of individual teeth that arose as a consequence of pathology, but after the formation of the dentofacial system. Deformations, unlike many anomalies, are not genetically determined.
The term “Hodon’s phenomenon” attracted the attention of doctors only to the deformation of the dentition in the area of the defect, where the teeth had lost their antagonists or neighbors. Our interpretation of deformities connects their origin with a variety of pathologies of the maxillofacial region (dentition defects, periodontal diseases, trauma, tumors, etc.) and thereby expands the clinical horizons of the orthopedic dentist in relation to a complex clinical and theoretical problem. One aspect of this problem is the special preparation of patients before prosthetics (preparation is outlined in Chapter 3). The theory of articulatory balance was criticized by a number of domestic scientists, who
Chapter 6. Dentition defects Changes in the dental system.
Classification of defects. Diagnostics. Medical tactics and treatment methods.
Closing the dentition in the sagittal direction:a - sagittal occlusal curve with orthognathine bite, b - incisal-tubercle contact; c - mesiodistal relationship of the first permanent molars
EXAMINATION OF PATIENTS WITH PARTIAL DETECTIVES. INDICATIONS FOR PROSTHETICS
Despite advances in dentistry, caries and periodontal disease continue to be the main causes of partial or complete tooth loss. Persons aged 40-50 years in 70% of cases require orthopedic treatment, and at this age partial defects of the dentition are most often observed. After the removal of teeth or their roots, the relationship between the dentition is disrupted. The necks of the teeth limiting the defect are exposed, the teeth lose proximal support, the chewing load on them increases, and the antagonist teeth do not take part in the act of chewing - their articulatory balance is disrupted, the teeth are shifted towards the defect, which leads to disruption of the occlusal curves. All this to some extent complicates prosthetics. Loss of teeth in the frontal area leads to cosmetic defects and speech impairment. In cases where there are few antagonizing teeth left in the oral cavity, their increased wear is observed as a result of functional overload, a decrease in bite occurs, and the function of the temporomandibular joint is impaired.
Thus, defects in the dentition lead to a decrease in the functional value of the masticatory apparatus, and this in turn affects the function of the gastrointestinal tract and the body as a whole. The experiments of I.P. Pavlov showed the influence of the act of chewing on the function of digestion and gastric motility. And diseases of the gastrointestinal tract, in turn, cause pathological changes in the tissues and organs of the oral cavity. This feedback is also observed in many common diseases (measles, scarlet fever, influenza, blood diseases, hypovitaminosis, capillary toxicosis, diabetes), which in periodontal tissues cause a decrease in the resistance of blood capillaries, symptomatic stomatitis, and reduce the compensatory capabilities of the periodontium.
The doctor must remember all this when examining a patient, since making a diagnosis, determining indications for orthopedic treatment and choosing the correct design of the prosthesis is directly dependent on an objective assessment of the compensatory capabilities of the entire masticatory apparatus. The peculiarity of orthopedic treatment is that the compensation of dentition defects with prostheses is associated with an increase in the functional load on the supporting tissues. Clasp dentures transmit the chewing load in a combined manner - through the periodontium (along the axis of the tooth through a support-retaining clasp) and the denture base to the mucous membrane. The bases of removable dentures change blood circulation, disrupt metabolism and the morphology of supporting tissues. With chewing loads on the denture, temporary hypoxia may develop in the tissues underneath it. Even more pronounced changes occur in periodontal tissues when the supporting teeth are overloaded with clasps, especially with marginal defects. In these cases, the periodontal gap widens, a bone pocket forms, and teeth become loose and lost. All this must be taken into account when making a diagnosis and designing a prosthesis. The compensatory capabilities of supporting tissues should be carefully studied to make a functional diagnosis.
However, until now, the diagnosis of a patient is made most often on the basis of anamnesis, clinical and radiological data, at best, taking into account some laboratory information. Meanwhile, examination of organs and tissues at rest most often reveals only pronounced organic changes. Such a diagnosis is not enough to determine the state of the functions of the affected organs and to judge the state of adaptive or compensatory mechanisms. An anatomical diagnosis characterizes the masticatory apparatus only at rest and does not solve the main question - what will happen to the supporting tissues after prosthetics, are their reserve capabilities sufficient to compensate for the additional load, how will natural teeth and mucous membranes react to certain prostheses?
A diagnosis made at rest does not characterize the functional capabilities of the peripheral blood circulation of connective tissue and other structures, their compliance in various parts of the prosthetic bed, on which the dentures actually rest and transmit chewing pressure. Consequently, the treatment of patients and the determination of indications for a particular prosthetic design are carried out, mainly, without taking into account the functional state of the supporting tissues. The compliance of the soft tissues of the prosthetic bed is not taken into account in the manufacture of plate and clasp dentures, and bridge dentures often lead to overload of the supporting teeth. As a result, complications often occur after orthopedic treatment: poor fixation of dentures, inflammatory processes in the mucous membrane of the prosthetic field, loosening of supporting teeth, proliferative growths of the mucous membrane, etc.
Most of these complications could be prevented if clinical diagnosis were complemented by modern functional testing methods.
This is all the more important because a person is never in a state of absolute rest and always interacts with the external environment. Such factors in orthopedic dentistry are prosthetics, which significantly change the function of the biological substrate on which they rest.
Consequently, for a deeper understanding of the reserve capabilities of the body and local tissues, it is necessary to characterize them under one or another pathology, not only at rest, but also under a functional load close to that which the tissues will experience under the influence of the prosthesis. Only in this case will it be possible to make a functional diagnosis, which is a necessary and important part of modern clinical diagnosis.
In various pathological processes, great importance was attached to changes in connective tissue, since the nature of the development and course of the disease, and in this case, complications associated with their overload, depended on its functional state.
The main biological substrate on which prostheses rest and in which various complications develop are connective tissue structures and peripheral vessels. Pathological effects on these tissues can be general and local.
Therefore, an objective study of functional and anatomical changes in connective tissue and peripheral vessels is of great theoretical importance for the correct justification of orthopedic treatment and the prevention of complications. As for morphological studies of these tissues, they are significantly ahead of functional diagnostic methods. While modern methods of histochemistry and electron microscopy make it possible to conduct research at the cellular and molecular level, in the clinic, unfortunately, few objective tests are used to determine the functional state of the peripheral circulation and connective tissues.
There are two main diagnostic methods: anatomical (morphological) - determines the change in shape and functional - determines the degree of dysfunction. In recent years, a number of functional research methods have been developed, the purpose of which is to determine the earliest abnormalities in the body and its tissues, and to determine their compensatory and adaptive capabilities. This is achieved with the help of special devices that create loads in the tissues that are close to those that will occur after prosthetics. The data obtained, expressed in numbers, are basic for clinical diagnosis and selection of the correct design of prostheses, taking into account the general condition of the body and local tissues. Moreover, functional research methods should characterize not only chewing efficiency, but also the tissues on which the dentures rest. To study the degree of disturbance of the act of chewing, tests are used (X. Christiansen, S. E. Gelman, I. S. Rubinov), and to determine the functional state of supporting tissues, some objective tests have recently been developed to characterize the state of their peripheral circulation and connective tissue structures. Early detection of functional deficiency is the basis for prevention and effective treatment. One of the theoretical foundations of functional diagnostics is the doctrine of the so-called functional systems (P.K. Anokhin, 1947).
This theory is based on the idea that the most important functional functions of the body are carried out not by individual organs, but by systems of organs and tissues, the functions of which closely interact (integrate) with each other.
All known methods of orthopedic research can be divided into two groups:
/ group - methods characterizing supporting tissues and the masticatory apparatus at rest (anatomical methods).
// group - methods characterizing periodontal tissues and the masticatory apparatus in a state of functional or close to it load (functional methods).
Anatomical research methods: 1) radiography (tomography, teleradiography, panoramic radiography, orthopantomography); 2) anthropometric research methods; 3) determination of chewing efficiency according to N. I. Agapov (1956), I. M. Oksman.
(1955); 4) periodontogram according to V. Yu. Kurlyandsky.
(1956); 5) morphological studies of oral tissues (cytology, biopsy); 6) determination of the color of the mucous membrane using special colors (V.I. Kulazhenko, 1960); 7) photography.
Functional research methods: 1) gnathodynamometry according to Black (1895), D. N. Konyushko (1950-1963), JI. M. Perzashkevich, (I960); 2) functional tests to determine chewing efficiency (Christiansen, 1923; S. E. Gelman, 1932; I. S. Rubinov, 1948); 3) capillary tonometry (A. Krog, 1927; N. A. Skulsky, 1930); 4) determination of emigration of leukocytes and desquamation of the epithelium of the oral mucosa according to M. A. Yasinovsky (1931); 5) rheography (A. A. Kedrov, 1941); 6) determination of the functional mobility of the receptor apparatus of the oral cavity (P. G. Snyakin, 1942);
7) electroodontodiagnosis (JI. R. Rubin, 1949);
8) determination of tooth mobility (D. A. Entin, 1951 - 1967); 9) masticationography (I. S. Rubinov, 1954); 10) myotonometry, electromyography; 11) capillaroscopy and capillarography of the gums; 12) determination of the resistance of capillaries of the oral mucosa (V.I. Kulazhenko, 1956-1960); 13) phoniatry (B. Boyanov, 1957);
14) permeability test Kavetsky - Bazarnova;.
15) determination of the compliance of soft tissues of the oral cavity using the ENVAK electric vacuum apparatus (V. I. Kulazhenko, 1964); 16) vacuum test for the qualitative composition of peripheral blood (V.I. Kulazhenko).
We have listed objective tests that are used for anatomical and functional diagnostics in patients with dentition defects and other disorders of the dentofacial system. In each specific case, depending on the goals of the study or determining the effectiveness of treatment, a certain method is used to correctly make a clinical diagnosis, draw up a treatment plan and determine the degree of influence of prostheses on supporting tissues. These data represent only part of the information that determines the location of clasps in healthy periodontium. With the same defects in the dentition with the presence of periodontal disease, the location of the clasps and branches changes. Consequently, only by supplementing anatomical data with functional research methods can the optimal design of the prosthesis be determined.
When examining a patient, you should pay attention to local changes in the oral cavity and general condition, which are decisive in the choice of a particular design of clasp dentures.
When examining the oral cavity, attention is paid to the remaining natural teeth - their stability, position, severity of the clinical crown and its shape. All this is important for determining the design of the clasp prosthesis. All teeth must be carefully sealed, the fillings must be polished and must not have retention points. If the crowns of natural teeth are poorly defined, low and do not have an equator, you have to increase the bite by making crowns for all opposing teeth. The stability of the supporting teeth is of great importance. In case of periodontal disease of I, II degrees, the design of the clasp prosthesis must be special - all natural teeth are included in the prosthesis, they have a retaining and supporting function (G. P. Sosnin, 1970; E. I. Gavrilov, 1973; Spreng, 1956; Hehring, 1962 ; Garter, 1965; Kutsch, 1968; Kemeny, 1968). In such cases, the clasp prosthesis, in addition to replacing missing teeth, splints the remaining teeth, combining them into a single functional block. When one or more supporting teeth are loosened, especially in the lower jaw, it is sometimes advisable to make crowns for the loose and stable teeth and solder them together. Crowns should not enter the pathological tooth-gingival pocket, but reach the neck of the tooth; with a pronounced equator and exposed neck, equatorial crowns are indicated. When examining patients in a state of central occlusion, attention is paid to teeth devoid of antagonists (to what extent they change the occlusal curves). In case of a deep or decreasing bite, it is advisable to increase it with a continuous clasp located on the upper front teeth. To assess the condition of the periapical tissues, all abutment teeth that have fillings are subjected to radiography. Teeth with chronic periodontitis, limiting the dentition defect, are not used as supporting teeth. In such cases, it is advisable to transfer the occlusal pad to intact teeth.
Of particular importance for determining the indications for clasp prosthetics is not only the characteristics of dentition defects, the size of crowns and the position of natural teeth, but also the general condition of the body, which to one degree or another can affect the function of supporting tissues. For example, in diabetes, the resistance of the capillaries of the mucous membrane of the prosthetic field decreases. In these cases, the design of the prosthesis must provide a load on the mucous membrane with strict rules for using the prosthesis (G. P. Sosnin, 1960; V. I. Kulazhenko, 1965; E. I. Gavrilov, 1973; Victorin, 1958; B. Boyanov, R Ruskov, Ch. Likov, I. Todorov, E. V. Evtimov, 1965; Taege, 1967, etc.).
Clasp dentures are indicated for partial defects in the dentition and a sufficient number of natural teeth so that chewing pressure can be rationally distributed between the teeth and the mucous membrane of the prosthetic bed. The presence of 1-4, and sometimes even 5 teeth (especially the front ones) does not allow rational distribution of chewing pressure, therefore clasp dentures are not indicated in such cases.
If there are 6-8 or more teeth left on the jaw, there are conditions for rational distribution of chewing pressure. However, the location of natural teeth on the jaws, the number and size of defects limited by them are also essential for determining the design of the prosthesis. Therefore, various classifications of dentition defects have been proposed, for which clasp prosthetics are indicated (E. Kennedy, V. Yu. Kurlyandsky, etc.).
To facilitate the design of a clasp denture, we have developed a simple working classification of partial defects in the dentition, which is based on the number of teeth limiting large defects located on both halves of the jaw. The teeth limiting the defects are supporting ones, and therefore schematically determine the general features of the prosthesis. The final design of the prosthesis can be selected after an objective examination of the supporting tissues and determination of the general condition of the body. Classification of dentition defects according to V.I. Kulazhenko is shown in Fig. 1.
/ Class. The dentition defect is limited to one tooth - a continuous shortened dentition without distal support (according to Kennedy - class II).
// Class. Two defects limited to two teeth - shortened dentition with bilateral defects without distal support (Kennedy class I).
/// Class. Two defects limited to three teeth - bilateral defects limited to three teeth, one defect without distal support (according to Kennedy - class II, subclass I).
IV class. Two defects limited to four teeth - bilateral defects with distal supports (according to Kennedy - class III, subclass I).
If, in addition to the main ones, there are additional defects, these cases constitute a subclass of the main class. The absence of anterior teeth in the presence of lateral teeth is also class II, but with distal support, and therefore the design of the prosthesis will be different.
All proposed classifications characterize only the topography of the dentition. As for the soft tissues, alveolar processes and hard palate, to which the chewing force is transmitted through the base of the prosthesis
Rice. 1. Classification of dental defects according to V. I. Kulazhenko: a - class I; 6 - II class; c - III class; g - IV class.
pressure, then it is important for us to know their functional state.
Using anatomical and functional tests, we can characterize the condition of the mucous membrane and underlying tissues. First of all, we should be interested in the condition of the peripheral vessels, which are subject to systematic compression by the base of the prosthesis when chewing food. Their condition, durability and permeability are influenced by both local and general factors. Local factors include inflammatory processes that reduce the resistance of capillaries and lead to bleeding of the mucous membrane, especially when pressure is applied to it by the base of the prosthesis. Common diseases include diseases that reduce...
resistance of capillaries (diseases of the gastrointestinal tract, capillary toxicosis, hypovitaminosis, chronic blood diseases, diabetes, etc.). Therefore, in addition to anamnestic data, it is necessary to take into account objective functional tests. To determine the size; before prosthetics, it is advisable to determine the resistance of the capillaries. When the resistance of capillaries decreases (chronic, untreatable diseases), a manufactured base with a small area can lead to a number of complications (bleeding of the mucous membrane, inflammation and even ulceration). In such cases, in addition to expanding the base, the period of use of the prosthesis is limited to one day.
Determination of capillary resistance is carried out using a vacuum apparatus for the treatment of periodontal disease. A sterile glass tube with a diameter of 7 mm is applied to the mucous membrane of the edentulous alveolar process (a vacuum of up to 20 mm Hg is created in the system). If after two minutes no hemorrhages form on the mucous membrane, then the functional state of the peripheral vessels is considered normal. If petechiae form earlier than two minutes later, this is regarded as a decrease in capillary resistance. In such cases, we include extended bases in the design of the clasp prosthesis. Using the method of determining the resistance of capillaries, it is possible to characterize the functional state of periodontal tissues of supporting teeth. We have established that long before teeth become loose, the resistance of gum capillaries in the area of their roots decreases (E. P. Barchukov, 1966; E. I. Yantselovsky, 1968; P. K. Drogobetsky, 1971). The method for determining the resistance of gum capillaries in the root area is the same, but the time for the formation of hemorrhages on the mucous membrane is normally 40-60 seconds. If the resistance of the capillaries of the mucous membrane of the prosthetic field is reduced as a result of inflammatory processes, it can be increased by conducting 3-5 sessions of vacuum therapy (every three days on the fourth). In this case, a complex of restorative therapy is prescribed, in combination with thorough oral hygiene.
The durability and effectiveness of prostheses is directly dependent on an objective assessment of the resistance of the capillaries of the mucous membrane and the degree of compliance.
soft tissues of the prosthetic field. The degree of compliance of the soft tissues of the alveolar process is important for the correct design of clasp dentures.
Determination of the compliance of soft tissues of the prosthetic bed. The pliability of the oral mucosa has been studied for over 40 years. Scientists took two paths in their research. Morphological studies on cadaveric material to determine the structure of the oral mucosa in various parts of the prosthetic field were carried out by Lund (1924); Gross (1931); E. I. Gavrichov (1963); V. S. Zolotko (1965). Other authors include Spreng (1949); M. A. Solomonov (1957, 1960); Korber (1957); Hekneby (1961) - studied the compliance of the oral mucosa using the functional method using devices they developed, the operating principle of which is based on recording the degree of immersion of a ball or small washer into the mucous membrane under the influence of a non-dosed force. From our point of view, the fundamental design decisions of the devices do not correspond to the conditions in which the mucous membrane under the prosthesis is located. These devices determine its compliance only with compression, while under the prosthesis the supporting tissues experience pressure under compression (when chewing) and tension (when removing or balancing the prosthesis). When removing the prosthesis and balancing it, the mucous membrane shifts in the direction opposite to the chewing pressure.
For this purpose, in 1964, we designed an electric vacuum apparatus to determine the compliance of mucous membranes to compression and stretching (Fig. 2).
2. Electrovacuum apparatus for determining the pliability of the mucous membrane.
Method for determining the pliability of the oral mucosa. The sensor is wiped with alcohol, its open end is applied to the area of the mucous membrane being examined, pressing it against the mucous membrane until it stops. In this case, the soft tissues are deformed, part of them is pressed into the cylinder and moves the ferrite core in the inductive coil of the sensor. Using the recalculation scale, the degree of pliability of the mucous membrane to compression is determined.
The obtained data is applied to the diagram of a special card or in the medical history, on which we put stamps depicting the contours of the upper and lower jaws, divided into the most characteristic areas in terms of pliability.
Using the above method, we, together with assistants E.I. Yantselovsky, S.S. Berezovsky, E.P. Sollogub and others, examined over 800 patients with partial dentition defects. The obtained data are shown in Fig. 3.
Rice. 3. Compliance of the mucous membrane of the prosthetic field in persons who have not used removable dentures: a - for compression; b - tensile.
In the absence of an electron-vacuum device, you can use special tables, according to which the compliance of the soft tissues of the alveolar process to compression in case of partial defects in the dentition is 0.3-0.8 mm, and the vertical compliance of the periodontium of a healthy tooth is 0.01-0.03 mm , that is, 10-30 times less than the compliance of the mucous membrane (Parfit, 1960). Therefore, in order to uniformly distribute the chewing pressure of the clasp denture on natural teeth and soft tissues of the prosthetic bed, it is necessary to include in the design of the prosthesis such a connection between the support-retaining clasp and the base that would not lead to overload of the supporting teeth. Otherwise, this will lead to functional overload of natural teeth, their loosening and loss. A diagnosis made only on anatomical data cannot fully characterize the tissues on which the clasp prosthesis rests. It must be supplemented with objective functional research methods. The diagnosis must be descriptive and include all anatomical and functional information about the patient. For example: stage I-II periodontal disease, capillary resistance in the area of tooth roots - 20 s, in the area of edentulous alveolar processes - 2 minutes. Compliance of soft tissues of the alveolar process to compression is 0.7 mm. Such a clinical diagnosis reveals and objectively substantiates the design of the clasp prosthesis.