牙科學修復：Introduction to Complete denture（簡版）

1、Introduction to Complete Denture1Complete Denture A full denture is designed to replace the entire dentition and associated structures of the maxillae or mandible. Partial Denture A partial denture is used to replace one or more removed teeth in an arch.Definition2Definition It is a removable applia

2、nce usually composed of artificial teeth set in an acrylic base. 34 Who will wear the complete dentures? Age 50y Incidence 6.81%（65y-74y） Caries & Periapical diseases Periodontitis Trauma Reasons for dentition loss Congenital & developmental problems Tumor（腫瘤）5 Complete denture Implants supported de

3、nture Tooth Tissue Engineering Restoration methods6 Appearance changes （面容改變） Eating problems （進食困難） Pronunciation troubles （發(fā)音障礙） Influence of psychological status （心理影響） Problems after dentition loss78Changes of oral tissues after dentition loss Jaw bones Soft tissues Temporomandibular joint (TMJ)

4、Bone resorption of the residual ridgesChanges of oral tissues after dentition loss9Characteristics of resorption on residual ridges A chronic, irreversible, and progressive process Changes of loading distribution and atrophy of disuse Speed of bone resorption Faster in the first 6 months after teeth

5、 extraction Stable after 2 years Direction of resorption Maxillae upward & inward Upper arch diminution Mandible forward & outward Lower arch enlargemnt Jaw bonesChanges of oral tissues after dentition loss11Influences of resorption on residual ridgesJaw bonesChanges of oral tissues after dentition

6、loss Reasons for dentition loss esp. Periodontitis Time after dentition missing the longer, the worse Bone density spongy bone compact bone Force bearing Mandible Maxilla 3-4 times General health and bone metabolism12Residual ridge form1. Favorable form with satisfied height and width （有足夠高度和寬度，形態(tài)豐滿

7、）2. Knife-edge form （刃狀牙槽嵴，高度足夠但寬度不足）3. Lower or flat form （低平牙槽嵴，高度寬度均不足）4. Serious alveolar-bone-absorption （牙槽骨吸收達基骨） Decreased vertical dimension （垂直距離降低） Atrophy of masticatory muscles （咀嚼肌萎縮） Lips and cheek retraction, increasing facial wrinkles （唇頰內(nèi)陷，皺紋增多） Tongue expansion （舌擴張） Changes of or

8、al mucosa （粘膜改變）Soft tissuesChanges of oral tissues after dentition loss13 Lips and cheek retraction Increasing facial wrinkles Ptosis of labial angle Changes of oral tissues after dentition loss14 Tongue expansionSoft tissuesChanges of oral tissues after dentition loss15 Changes of oral mucosa Mout

9、h floor and vestibular grooves are shallowing.Attachment of frena are becoming relatively higher.The oral mucosa are getting thinner with increased sensitivity. Temporomandibular jointProtraction of mandibleTMJ disordersPain / Joint clickingLong timeChanges of oral tissues after dentition loss16Anat

10、omic landmarks of edentulous patients 無牙頜解剖標志17 Alveolar ridge 牙槽嵴 Oral vestibule 口腔前庭 Oral cavity proper 口腔本部/固有口腔 Oral Anatomy18Edentulous ridgeAttached mucosa 高度角化復層鱗狀上皮Stress-bearing area 19Hard palate覆蓋高度角化附著黏膜 Maxillary labial frenum （上唇系帶） 上頜唇側(cè)正中位置，牙槽嵴唇側(cè)粘膜到上唇粘膜之間的粘膜皺襞，是口輪匝肌在上頜骨的附著處。20Maxilla

11、取印模時患者作唇的自主運動，并行肌功能修整 基托在此區(qū)應形成相應切跡，予以緩沖。 Maxillary buccal frenum （上頰系帶） 位于上頜前磨牙牙根附近，呈扇形，能固定口角，協(xié) 助頰肌將食物移向后方。 區(qū)分前弓區(qū)和后弓區(qū) 基托在此區(qū)應緩沖，形成相應的切跡。21Maxilla Zygomatic process （顴突） 顴突是顴骨下緣的延長，上頜第一磨牙頰側(cè)根方的骨性隆起。22Maxilla 它把加在磨牙上的咀嚼壓力分散到眶外側(cè)緣和顴弓。予以緩沖，避免壓痛排列人工牙時，應把第一磨牙排列在該處 Maxillary tuberosity （上頜結節(jié)） 上頜牙槽嵴兩側(cè)遠端的圓形骨突。2

12、3Maxilla 形成明顯倒凹時，需要考慮外科修整 義齒基托應覆蓋結節(jié)頰面并盡量伸展，以增強固位。 Pterygomaxillary notch （翼上頜切跡） 上頜結節(jié)后緣和蝶骨翼突之間的間隙，表面有粘膜覆蓋， 形成凹陷切跡狀。 是上頜全口義齒兩側(cè)后緣的界限，發(fā)揮封閉作用。Maxilla Incisive papilla（切牙乳頭） 位于上頜腭中縫前端的梨形軟組織小突起，是上頜重要的、穩(wěn)定的標志。25Maxilla 其下為切牙孔，有鼻腭神經(jīng)和血管通過，不能受壓，故基托組織面需適當緩沖。切牙乳突是上頜全口義齒排牙的重要標志！ Palatal rugae （腭皺） 上頜正中線前端硬腭上，左右側(cè)各

13、有34條前后橫行排列的波浪形凸起粘膜。 有輔助發(fā)音的作用。 26Maxilla 義齒基托組織面應貼合，但不能壓迫；磨光面可仿造腭皺形態(tài)。8. Torus palatinus（腭隆突） 20% 形成骨性隆突 多數(shù)人 較平坦 Maxilla位于硬腭中央部分。 其上粘膜薄且缺乏彈性。義齒基托應緩沖。 個別腭隆突過大，需行外科手術切除。9. Palatal fovea （腭小凹） 位于軟硬腭結合處稍后方中線的兩側(cè)，左右各一，為口內(nèi)粘液腺導管的開口。28Maxilla 它是前顫動線的定位標志。上頜全口義齒的后緣應在腭小凹后2mm處。 Vibrating line （顫動線） 位于軟腭與硬腭的交界部位。發(fā)

14、“阿”音時軟腭升高，發(fā)音結束后又復歸原位，故又稱“阿”線(后顫動線)。Maxilla 前后顫動線之間的弓形區(qū)域為上頜全口義齒基托的后緣封閉區(qū)，義齒基托組織面在此區(qū)域向粘膜突起形成后堤。30 Mandibular labial frenum（下唇系帶） 下頜正中唇側(cè)粘膜從牙齦交界處到下唇粘膜之間的粘膜皺襞，是口輪匝肌在下頜骨的附著處。Mandible 它隨唇肌的運動而活動，活動度小于上頜，基托在此區(qū)應形成相應的切跡。 Mandibular buccal frenum （下頰系帶） 刃狀結締組織，起于下頜前磨牙牙齦交界線下，呈扇形，其活動度大，抗力強。31Mandible義齒基托在此區(qū)應形成相應的

15、切跡。 Buccal shelf area（頰棚區(qū)） 又稱頰側(cè)翼緣，位于下頜后弓區(qū)，在下頜頰系帶至咬肌下段前緣之間。Mandible義齒基托可較大范圍伸展，利于固位和承受咬合力。4. Distal buccal angles area（遠中頰角區(qū)） 頰棚區(qū)后方，磨牙后墊的頰側(cè)。咬肌前緣相對應的部位。Mandible 由于咬肌活動的影響，義齒基托在此區(qū)不能過多伸展。5. Retromolar pad （磨牙后墊） 位于下頜最后磨牙牙槽嵴遠端的粘膜軟墊，覆蓋在磨牙后三角上，由疏松的結締組織構成，含黏液腺。Mandible 下頜全口義齒后緣應蓋過磨牙后墊1/2或2/3，起封閉作用。 磨牙后墊的形態(tài)和

16、位置比較穩(wěn)定，作為排人工牙時的解剖標志 垂直向：下頜第一磨牙的He平面與磨牙后墊的1/2處等高；前后向：下頜第二磨牙應位于磨牙后墊前緣；頰舌向：磨牙后墊頰面、舌面向前與下頜尖牙的近中 面形成一個三角形，下頜后牙的舌尖應位于 此三角形內(nèi)。6. Lingual frenum（舌系帶） 連接口底與舌腹的粘膜皺襞，位于口底中線部，活動度較大。 Mandible義齒基托應形成相應切跡。7. Sublingual glands（舌下腺） 位于舌系帶兩側(cè)，在下頜骨舌面的舌下腺凹內(nèi)?？呻S下頜舌骨肌的運動上升或下降。Mandible 與此區(qū)相應的義齒舌側(cè)基托邊緣不應過長，否則舌運動時易將下頜全口義齒推起。8.

17、Torus mandibularis （下頜隆突） 位于下頜兩側(cè)前磨牙根部的舌側(cè)，向舌側(cè)隆起，表面覆蓋的粘膜較薄。Mandible 與之相應的組織面應適當緩沖，過分突出時，其下方形成顯著的倒凹，需手術鏟除。9. Mylohyoid ridges（下頜舌骨嵴） 位于下頜骨后部的舌面，從第三磨牙斜向前磨牙區(qū)，由寬變窄。38Mandible 表面覆蓋粘膜較薄，下方有不同程度的倒凹，基托組織面應緩沖。10. Retromylohyoid fossa （下頜舌骨后窩） 下頜舌骨后間隙，是下頜總義齒舌側(cè)后緣的邊界。39Mandible 義齒舌側(cè)基托為S型，進入舌骨后窩的基托部分可抵抗義齒向前脫位。義齒舌側(cè)

18、邊緣應盡量向下向后延長。11. Lingual flange area（舌側(cè)翼緣區(qū)） 是與下頜全口義齒舌側(cè)基托接觸部位的解剖標志，從前向后包括舌系帶、舌下腺、下頜舌骨肌、舌腭肌、翼內(nèi)肌、咽上縮肌。Mandible 舌側(cè)翼緣區(qū)后部是下頜全口義齒固位的重要部位，此區(qū)基托應有足夠的伸展。41Structures of Complete DentureArtificial teethGenerally, acrylic artificial teeth!Denture baseAcrylic baseAcrylic-metal frame base42Surfaces of Complete Dent

19、ure Tissue surface Polishing surface Occlusal surface 與牙槽嵴、上腭等組織密切接觸 與唇、頰、舌側(cè)軟組織和肌肉接觸 形成適當?shù)男泵?切割、碾碎食物 咬合接觸廣泛且平衡43Divisions of Complete Denture Primary stress-bearing area （主承托區(qū)） Secondary stress-bearing area （副承托區(qū)） Border seal area （邊緣封閉區(qū)） Relief area （緩沖區(qū)）Maxilla 唇頰側(cè)止于唇頰粘膜與牙槽嵴粘膜的反折線，避讓開唇頰系帶；上頜后緣止于腭小

20、凹后2mm至兩側(cè)翼上頜切跡的連線。Border seal 唇頰側(cè)止于唇頰粘膜與牙槽嵴粘膜的反折線，避讓開唇頰系帶；下頜舌側(cè)止于口底粘膜與牙槽嵴舌側(cè)粘膜的反折線，避讓開舌系帶；下頜后緣止于磨牙后墊的中1/2或前2/3。Mandible45Neutral zone指導人工牙排列與磨光面塑形Retention and Stability of complete denture Retention of Prosthesis1. Removable partial dentureEmbrace force of claspsLock function of abutmentsAdsorption ca

21、pacity472. Fixed prosthesisFrictional forceAdhesion3. Implant supported dentureOsseointegration（骨整合） 1. Adsorption capacity The attractive force between two objects, including adhesion and cohesion. Contact area between denture base and oral mucosa Adaptation Quality and quantity of salivaRetention

22、of complete denture4849Retention of complete denture2. Interfacial reaction Interfacial surface tension （界面的表面張力） Interfacial viscous tension （界面的黏張力） 3. Atmospheric pressure4. Balance of muscles Anatomic morphology of jaws Characteristics of denture bearing mucosa Quality and quantity of saliva Bor

23、der extension of denture base Border sealInfluence factorsRetention of complete denture50 Anatomic morphology of jaws Position of dental arches Characteristics of denture bearing mucosa Arrangement of artificial teeth and occlusion Maxillomandibular relationship Suitable shape of denture polishing s

24、urfaceStability of complete denture5152Complete DentureFabrication processes Examination，diagnosis and preparing treatment Impression and Cast Maxillomandibular relationship recording Mounting the casts on articulator by face bow transfer Selection and Arrangement of Artificial teeth Try in Final fa

25、brication Insertion and adjustment5354Examination, diagnosis and preparing treatment檢查、診斷和修復前準備55InquiryExamination Patients demands History of dental treatment Physical condition (Age, gender, and generalhealth) Character traits and mental status Social backgroundExtra-oral examination (頜面部檢查)Exami

26、nation and DiagnosisExamination Facial characteristics Lip TMJ & muscles5657Examination and DiagnosisExaminationOral examination (口內(nèi)檢查) Morphology and consistency of the residual ridges Oral mucosa Attachment of frena and muscles Palatal Vault Maxillomandibular relationships Tongue Saliva Existing d

27、entures58拔牙創(chuàng)松軟牙槽嵴2. 黏膜1. 牙槽嵴縫齦瘤骨突、骨刺潰瘍3.系帶和肌肉附著4.腭穹窿5.骨突和倒凹6.上下頜弓的位置關系7.舌的大小和位置8.舊義齒59 頜弓前后位置關系正常頜弓關系上頜前突輕度下頜前突嚴重下頜前突60正 常上頜弓寬于下頜弓下頜弓寬于上頜弓舌腭部 頜弓左右位置關系61有天然牙時的垂直距離垂直距離過大垂直距離過小垂直距離適中 頜弓垂直位置關系Diagnosis and treatment plan Implants supported dentureComplete denture VS.63Preparing treatmentSurgery拔除殘根牙槽嵴低

28、平的手術手術修整牙槽骨突手術修整過高的附麗系帶手術修整增生粘膜下的軟組織 （縫齦瘤、松軟牙槽嵴）前庭溝加深術骨移植人工材料植入單側(cè)牙槽嵴的倒凹，義齒通過旋轉(zhuǎn)方式就位，可很好的增加義齒的固位。雙側(cè)存在倒凹時需通過外科手術修整。64Relining 義齒支持組織的修整（重襯）Occlusion adjustment 舊義齒的咬合調(diào)整Maxillofacial muscle training 頜面部肌肉訓練Preparing treatmentNon-Surgery treatment652. Impression and Cast for theedentulous ridges印模和模型Maki

29、ng accurate impression(1) Anatomic landmarks well be recorded(2) Appropriate border extension (3) Good border molding (4) No voids and wrinklesRequirements67Making accurate impressionBorder extension68印模材料非彈性材料彈性材料水膠體瓊脂藻酸鹽不含水的彈性體聚硫橡膠硅橡膠印模膏氧化鋅丁香酚聚醚橡膠Classification of all impression materialsMaking ac

30、curate impression69(1) Alginate （藻酸鹽） for prelimiary and final impression(2) Rubber based elastic material: silicon （硅橡膠） for preliminary, final impression for border molding(3) Impression compound （印模膏） for preliminary impression and border moldingImpression Materials for edentulous jawMaking accur

31、ate impression Should correspond to denture-bearing tissues Must fit tuberosities and profile of ridge Making accurate impressionEvaluating the Tray71Stock TrayCustom Tray72Making accurate impressionImpression techniques(1) 一次印模法 Poor accuracy!(2) 二次印模法 Technique of secondary impression Anatomic imp

32、ression （解剖式印模） - Static，no pressure Functional impression （功能性印模） - With pressure 1. Preliminary impression 2. Custom tray 3. Border molding 4. Final impressionMaking accurate impressionSecondary impression by using custom tray731. Preliminary Impression An impression made for the purpose of making

33、 a preliminary cast which is used for diagnosis and/or fabrication of a custom impression tray. 74Important first step Should as accurate as possible Select an impression material that has a relatively high viscosity. (alginate , compound)751. Preliminary ImpressionCover all the necessary landmarks

34、of edentulous alveolar ridge2-3 mm of clearance should exist between the tray and ridge to allow space for the impression material. Modified the tray with soft boxing wax if necessarySelection of Stock Tray1. Preliminary ImpressionMaxillary Impressiona. incisive papillab. palatal rugaec. median pala

35、tine raphed. maxillary tuberositye. pterygomaxillary notchf. fovea palatini and vibrating line areag. buccal spaceh. zygomatic processi. residual alveolar ridgej. buccal frenumk. labial frenum 1. Preliminary Impression77Mandible Impression a. labial frenumb. residual alveolar ridgec. retromolar padd

36、. lingual frenume. mylohyoid (interior oblique line)f. external oblique lineg. buccal frenumh. masseteric notch 1. Preliminary Impression78(1) Mark the border with indelible pen(2) Pour artificial stone to get preliminary cast2. Preliminary Cast3. Custom Tray Made from preliminary cast Advantageadap

37、ts to the contours of alveolar ridge with borders approximating the outline of the complete denture 80Step 1. Outline the boarder of the preliminary castStep 2. Block out undercuts3. Custom Tray81Step 3. Apply separating medium to the castStep 4. Adapt custom tray material on the castStep 5. Trim of

38、f excess materialStep 6. Add tray handleStep 7. Self-cure or light-cure Step 8. Adjust and polish4. Border Molding The technique for correctly extending the flanges of a custom impression tray using a soft but slightly viscous impression material that becomes at least semi-rigid as it cools, or polymerizes. Definition To determine the contours, height and width of the borders of the completed dentureObjective5. Final impressionMaking accurate impressionSecondary impression by using compound83Checklist for Final Impression(1) All necessary anatomic landmarks