buhatel dan

COALA DOCTORAL

REZUMATUL TEZEI DE DOCTORAT

Cercetri clinice, radiologice i imagistice asupra cmpului protetic edentat total

Doctorand Dan, Buhel

Conductor de doctorat Floarea, Fildan

ClujNapoca, 2013

CUPRINS

INTRODUCERE 13

STADIUL ACTUAL AL CUNOATERII

1. Cmpul protetic edentat total 17

1.1. Consideraii generale 17

1.2. Cmpul protetic maxilar 17

1.2.1. Zona de sprijin 17

1.2.1.1. Substratul osos 17

1.2.1.2. Substratul mucos 20

1.2.2. Zona de succiune 20

1.2.2.1. Mucoasa pasiv mobil 20

1.2.2.2. Mucoasa mobil 20

1.3. Cmpul protetic mandibular 20

1.3.1. Zona de sprijin 20

1.3.1.1. Substratul osos 20

1.3.1.2. Substratul mucos 21

1.3.2. Zona de succiune 22

1.3.2.1. Mucoasa pasiv mobil 22

1.3.2.2. Mucoasa mobil 22

2. Tulburarea funciilor de baz ale aparatului dento-maxilar la edentatul

total 23

2.1. Tulburri masticatorii 23

2.2. Tulburri fizionomice 24

2.3. Tulburri fonetice 24

2.4. Tulburrile de ordin psihic 25

3. Determinarea dimensiunii verticale a etajului inferior al feei 27

3.1. Consideraii generale 27

3.2. Definiii 27

3.3. Condiii de determinare 28

3.3.1. Poziia pacientului 28

3.3.2. Condiii preprotetice 28

3.3.3. Analiza abloanelor de ocluzie 29

3.4. Metode de determinare a dimensiunii verticale de ocluzie 30

CONTRIBUIA PERSONAL

1. Ipoteza de lucru/obiective 37

2. Metodologie general 37

3. Studiul 1 Analiza suportului muco-osos la edentatul total 39

3.1. Introducere 39

3.2. Ipoteza de lucru/obiective 41

3.3. Material i metod 42

3.4. Rezultate 45

3.5. Discuii 53

3.6. Concluzii 56

4. Studiul 2 - Papila interincisiv indicator al resorbiei maxilarului n

edentaia total 57

4.1. Introducere 57



4.4. Rezultate 64

4.5. Discuii 73

4.6. Concluzii 74

5. Studiul 3 - Verificarea corectitudinii determinrii clinice a dimensiunii

verticale de ocluzie cu ajutorul cefalometriei laterale 77

5.1. Introducere 77



5.4. Rezultate 88

5.5. Discuii 89

5.6. Concluzii 91

6. Studiul 4 - mbuntirea calitii vieii la pacientul edentat total dup

protezare 93

6.1. Introducere 93



6.4. Rezultate 97

6.5. Discuii 104

6.6. Concluzii 108

7. Concluzii generale 109

8. Originalitatea i contribuiile inovative ale tezei 111

ABREVIERI 11

ANEXE 113

REFERINE 123

CUVINTE CHEIE: edentat total, lingura individual, dimensiune vertical de ocluzie,

reabilitare protetic, sntate oro-dentar, tulburri masticatorii,

tulburri fizionomice, tulburri fonetice, tulburri psihice, calitatea vieii

INTRODUCERE

Protetica dentar, ca specializare nou aprut, este considerat un domeniu deosebit de important n

medicina dentar. n cadrul acesteia, edentaia total face obiectul unor ample cercetri clinice.

Aparatul dento-maxilar la edentatul total prezint o serie de modificri de form i structur, cu

repercusiuni asupra suportului protezrii i al funciilor acestuia. Examinarea minuioas, clinic i

paraclinic a tuturor elementelor componente ale cmpului protetic edentat total, creeaz premisele unei

integrri favorabile a pieselor protetice, dar mai ales ne scutesc de eecurile terapeutice ulterioare.

Posibilitile terapeutice propuse azi acestor pacieni difer foate mult. Hotrtor n acest sens sunt

posibilitile materiale ale pacienilor. Medicina dentar actual, n Romnia, se regsete aproape n

totalitate n sectorul privat. Rmne totui o categorie mare de pacieni, ale cror mijloace financiare nu

permit tratamente stomatologice costisitoare. Programul Sanodentaprim, aflat n plin derulare, ne pune n

situaia unor alternative terapeutice clasice. Chiar dac implantologia oral a ctigat cu certitudine n ziua de

azi teren, fiind o component important a tratamentului proprotetic chirurgical, situaia financiar a acestor

pacieni defavorizai conduce ca alternativ terapeutic spre protezarea total clasic. Rezolvarea prin

metode clasice pune la grea ncercare, att rbdarea pacientului dar i pregtirea temeinic a corpului

medical. n ceea ce privete cercetrile clinice, radiologice i imagistice ale cmpului protetic, personal am

urmrit trei direcii:

I. Pornind de la examinarea atent a elementelor cmpului protetic edentat total pentru o reuit n

amprentarea acestora, mi-am propus s vizualizez ''minusurile'' aprute n realizarea clasic, n

laboratorul de tehnic dentar a acestor linguri individuale.

II. A doua direcie urmrit n realizarea protezelor dentare l reprezint determinarea relaiilor

intermaxilare. Acurateea n verificarea corectitudinii determinrii clinice a DVO realizat prin analiza

cefalometric recomand aceast investigaie imagistic ca fiind un bun mijloc de examinare a

relaiilor intermaxilare n cazul pacienilor edentai total neprotezai. Aceste direcii de cercetare m-au

ajutat s cresc calitatea actului terapeutic prin protezare total clasic pentru a oferi i acestor pacieni

bucuria reintegrrii sociale.

III. Cea de-a treia direcie a cercetrilor mele a vizat latura subiectiv a pacienilor inclui n studiu, vis-

a-vis de percepia acestora fa de calitatea vieii lor dup aplicarea protezelor dentare.

Succesul protezrii depinde, deci, de muli factori. Pe lng calitatea cmpului protetic, a actului

medical, a modului n care medicul trateaz fiecare caz n parte, maniera de cooperare medic-pacient,

hotrtoare n reuita tratamentului sunt: personalitatea pacientului, nivelul lui de cultur i inteligen,

starea psihic n legtur cu acceptarea i adaptarea la protezele dentare.

M bucur s constat c rezultatul muncii mele i a colegilor mai tineri, studenii, a fost apreciat de ctre

pacieni, care consider c piesele protetice executate contribuie n foarte mare msur la mbuntirea

calitii vieii. Iat deci, c actul medical bine condus capt valoare n ochii pacienilor, iar respectul i

recunotina fa de medicul de medicin dentar este n cretere.

Pe de alt parte, marea satisfacie profesional generat de cercetrile personale, const n deschiderea

de noi orizonturi n mbuntirea calitii amprentrii i n acurateea determinrii relaiilor intermaxilare,

dou elemente deosebit de importante n calitatea actului terapeutic oferit de protezarea total.

CONTRIBUIA PERSONAL

Ipoteza de lucru/obiective Edentaia total este poate cea mai mutilant stare patologic a sistemului stomatognat, deoarece

perturb toate funciile acestuia avnd consecine asupra ntregului organism. Pentru a putea vorbi de o

reuit n restaurarea protetic a edentatului total trebuie s plecm de la o cunoatere amnunit a

cmpului protetic, respectiv a componentelor, precum i a morfologiei acestuia. Instalarea edentaiei totale

trebuie privit ca nceputul unui proces evolutiv de perturbare a echilibrului fiziologic, generat de

mbtrnirea constant a structurilor anatomice ale ntregului organism, cu implicaii i asupra aparatului

dento-maxilar, aspect ce poate declana un stres permanent care plaseaz mai ales persoanele n vrst ntr-o

stare de labilitate psiho-somatic.

Terapia edentaiei totale a fost, este i va fi mereu o preocupare a specialitilor, fiind considerat ca un

domeniu complex, de o dificultate deosebit, ntruct nu se rezum numai la conceperea i realizarea unor

piese protetice, ci constituie o adevarat terapie specific ce se adreseaz unei infirmiti dintre cele mai

variate.

Obiectivele cercetrii au fost urmtoarele:

pornind de la analiza suportului muco-osos la edentatul total, s realizm linguri individuale ct

mai precise pentru a putea nregistra cu maximum de exactitate suprafaa zonei de sprijin la aceti

pacieni;

de a vizualiza dac exist o corelaie ntre poziia papilei interincisive pe de o parte i lungimea,

limea i adncimea bolii palatine pe de alta;

de a verifica cu ajutorul cefalometriei laterale dac determinarea clinic a dimensiunii verticale de

ocluzie a fost sau nu una corect;

s nregistreze percepia pacienilor edentai total asupra calitii vieii n contextul infirmitii

generate de starea de edentaie, precum i n ce msur aceasta se mbuntete la 6 luni dup

purtarea protezelor dentare.

Metodologie general n studiile ntreprinse pe perioada cercetrii, am inclus pacieni care fac parte din Programul

Sanodentaprim, program care promoveaz Sntatea Oral prin creterea accesabilitii populaiei

defavorizate la serviciile de stomatologie n cadrul parteneriatului dintre UMF Iuliu Haieganu i Primria

Cluj Napoca.

Grupul int se refer la persoane instituionalizate (cmine de btrni, cmine de copii, etc),

pensionari, omeri i tineri pn n 26 ani ce nu realizeaz venituri. Din acest grup int de peste 1400 de

pacieni, intrai n evidena Catedrei de Reabilitate Oral, Sntate Oral i Managementul Cabinetului Dentar

n intervalul aprilie 2010 februarie 2012, am selectat pacienii cu edentaie total bimaxilar.

Numrul pacienilor inclui n loturi pentru fiecare studiu n parte a fost diferit, n funcie de obiectivele

urmrite pe segmentele de cercetare alese.

Fiecrui pacient i s-a ntocmit o fi de observaie, iar apoi acetia au completat / semnat un

consimmnt informat n vederea efecturii unui act medical i cte un consimmnt diferit pentru intrarea

n fiecare studiu.

De asemenea, metodele de lucru utilizate de-a lungul cercetrii difer pentru fiecare studiu n parte, n

funcie de specificul acestuia i vor fi prezentate la capitolele respective.

Studiul 1. Analiza suportului muco-osos la edentatul total

Introducere Aparatul dento-maxilar la edentatul total prezint o serie de modificri de form i structur, cu

repercusiuni asupra suportului protezrii i al funciilor acestuia. Pentru a putea vorbi de o reuit n

restaurarea protetic a edentatului total trebuie s plecm de la o cunoatere amnunit a cmpului protetic,

respectiv a componentelor, precum i a morfologiei acestuia. De asemenea, importante sunt i

particularitile individuale ale fiecrui cmp protetic edentat total.

Material i metod n studiu au fost inclui 52 pacieni diagnosticai cu edentaie total bimaxilar. Pacienii au fost

examiani clinic i apoi au fost amprentai dup tehnica clasic, folosind linguri standard de diverse mrimi n

funcie de dimensiunile cmpurilor protetice, iar ca material de amprent s-a utilizat alginatul. Pe amprentele

preliminare am trasat limitele cmpului protetic cu ajutorul unui marker, dup tehnica cunoscut.

Amprentele numerotate corespunztor fiecrei persoane intrate n studiu au fost scanate la

Departamentul de Ingineria Proiectrii i Robotic al Facultii de Construcii de Maini din cadrul

Universitii Tehnice din Cluj-Napoca pentru a obine modele virtuale 3D, iar ulterior linguri individuale 3D

ideale. Digitizarea amprentelor s-a realizat cu ajutorul unui scaner 3D portabil cu autopoziionare.

Dimensiunile reduse ale amprentelor dentare precum i suprafeele neregulate au necesitat o atenie

deosebit n procesul de digitizare, precum i software i hardware adecvate. Amprentele au fost digitizate cu

ajutorul scanerului laser 3D VIUScan, datele obinute fiind mai apoi prelucrate n Catia V5. Pentru dimensiuni

ale piesei de sub 150 mm3 productorul scanerului garanteaz o precizie de 50 m, precizie de scanare care a

fost atins i n cazul scanrii amprentelor dentare.

Pe fiecare imagine scanat corespunztoare modelului virtual s-a marcat: numrul curent, nume-

prenume, vrsta, sexul pacientului (M-masculin, F-feminin). Prin examinarea clinic i analiza modelului

virtual 3D am urmrit caracteristicile crestelor edentate maxilare privind simetria, nlimea, limea;

caracteristicile bolii palatine (adncime, lungime, lime, form, prezena/absena torusului palatin i

localizarea acestuia), caracteristicile tuberozitilor maxilare (prezena retentivitilor uni, bilaterale,

tuberoziti prezente, neretentive, procidente, absente); caracteristicile crestei mandibulare edentate din

punct de vedere a simetriei, nlimii, limii, direciei fa de planul mediosagital, formei, precum i

caracteristicile tuberculului piriform: direcie fa de creast, volum.

Dup scanare, aceleai amprente au fost turnate pe loc pentru a obine modele preliminarii. Ulterior,

n laboratorul de tehnic dentar, pe modelele astfel obinute s-au confecionat linguri individuale clasice.

Aceste linguri individuale obinute clasic n laborator s-au scanat. Apoi, cele dou imagini 3D, reprezentnd

lingura individual ideal, respectiv lingura individual clasic, s-au comparat, pentru a vizualiza

''minusurile'' aprute n realizarea clasic n laboratorul de tehnic dentar a lingurilor individuale.

Rezultate Analiza suportului muco-osos la edentatul total maxilar a evideniat urmtoarele:

creste edentate cu o nlime medie de 4-6 mm (75% dintre pacienii examinai), cu simetrie

pstrat (80% cazuri), rotunjite (73% cazuri);

bolta palatin cu o lungime cuprins ntre 4,5-4,9 cm (55% dintre cazuri), lime cuprins ntre 4-

4,9 cm (84% dinte cazuri), adncime cuprins ntre 10-14 mm (56% dintre cazuri), fr torus

palatin prezent, cu forma literei U;

tuberozitile maxilare au fost n 95% dintre cazuri prezente, i cel mai frecvent erau retentive

bilateral n 70% din cazuri.

La mandibul, cmpul protetic edentat total a fost caracterizat de creste edentate simetrice (42

cazuri), n forma de U (34 cazuri), iar direcia crestei a fost n 38 de cazuri descendent spre distal.

Crestele edentate au prezentat o nlime medie n 34 de cazuri, respectiv o lime medie n 38 de

cazuri.

Ca urmare a centralizrii datelor, s-a constatat o direcie orizontal a tuberculului piriform n 38 de

cazuri, respectiv o direcie oblic n 14 cazuri.

n ceea ce privete volumul tuberculului piriform n 8 cazuri acesta a fost voluminos, n 32 de cazuri

acesta a avut un volum mediu, iar n 12 cazuri acesta a fost redus ca volum. Dup analiza suportului muco-osos, n partea a doua a studiului, am fcut o analiz a deviaiei care s

pun n eviden, prin instrumente matematice, diferena ntre suprafeele lingurilor individuale clasice i

ideale, scanate i aliniate.

Diferenele semnificative aprute dup interpretarea hrilor de culori au fost evideniate la maxilar n

zona tuberozitilor, iar la mandibul, n zona tubercului piriform.

Studiul 2. Papila interincisiv indicator al resorbiei maxilarului n edentaia

total

Introducere Odat cu pierderea unitilor dentare la edentat procesul alveolar, numit de Beltrami i os dentar,

sufer remanieri, osul de neoformaie umplnd alveola i astfel devine creasta alveolar, sau cum mai apare

n literatur, creasta edentat. Imediat dup pierderea unitilor masticatorii, osul maxilar sufer fenomene

de atrofie i resorbie osoas. Aceste fenomene vor influena negativ stabilitatea viitoarelor piese protetice.

Material i metod n studiu au fost inclui 52 pacieni diagnosticai cu edentaie total.

Am inclus n studiu doar pacienii cooperani i care, n urma examenului clinic prezentau:

arcade dentare n form de U

simetria arcadelor pstrat

Au fost exclui din studiu:

pacienii necooperani

pacienii care au purtat anterior proteze dentare

pacienii care n urma examenului clinic endobucal au prezentat:

alt form a arcadelor dentare dect U

arcade asimetrice

absena bridelor canine

prezena torusului maxilar

n timpul examenului clinic am surprins pe obiectivul aparatului foto poziia papilei interincisive, iar n

finalul examinrii fiecare din cei 52 de pacieni au fost amprentai, n vederea confecionrii modelelor de

studiu. Modelele astfel obinute au fost scanate la Departamentul de Ingineria Proiectrii i Robotic al

Facultii de Construcii de Maini din cadrul Universitii Tehnice din Cluj-Napoca i s-au realizat modele de

studiu 3D.

1. Determinarea clinic i pe fotografie a poziiei papilei interincisive:

posterior (pe versantul palatinal al crestei edentate n zona frontal);

pe mijlocul crestei edentate;

anterior (pe versantul vestibular al crestei edentate frontale).

Studiul modelelor 3D obinute dup scanarea modelelor de studiu a cuprins urmtoarele msurtori:

a. Lungimea bolii palatine (LBP): de la tangent la proeminena maxim de pe versantul vestibular al crestei

edentate n dreptul frenului buzei superioare pn la linia tangent la faa distal a tuberozitilor n

anul retrotuberozitar.

b. Adncimea bolii palatine la nivel molar (ABP): adncime msurat la unirea treimii mijlocii cu treimea

distal a palatului dur.

c. Limea bolii palatine (lBP): limea maxim la unirea treimii mijlocii cu treimea anterioar pe versanii

externi ai crestei edentate.

Rezultate Cei 52 de pacieni luai n studiu (26 femei, 26 barbai), aveau vrste cuprinse ntre 40 i 85 ani.

Variaia poziiei papilei la sexul feminin arat n felul urmtor:

La o vechime a edentaiei cuprins ntre 0 i 2 ani predomin poziia pe mijlocul crestei n 13 cazuri,

poziia posterioar n 5 cazuri. Nu exist nici un caz n care poziia papilei s fie anterior.

La o vechime a edentaiei cuprins ntre 3 i 5 ani predomin poziia pe mijlocul crestei n 3 cazuri.

Nu exist poziie anterioar sau posterioar la nici unul din cazuri la aceast vechime a edentaiei.

La o vechime a edentaiei de peste 5 ani am observat 4 cazuri n care poziia papilei era una

anterioar, respectiv 1 caz n care papila avea o poziie pe mijlocul crestei.

La femei exist o asociere semnificativ statistic ntre poziia papilei i grupele de edentaie, testul

exact al lui Fisher, p=0.0020.05-nesemnificativ statistic.

Indicatorul LBP (lungime bolta palatin) are valori medii n scdere de la primul interval de vechime

pn la ultimul.

Indicatorul lBP (lime bolta palatin) are valori medii n scdere de la primul interval de vechime

pn la ultimul.

Indicatorul ABP (adncime bolta palatin) are valori medii n scdere de la primul interval de vechime

pn la ultimul.

Studiul 3. Verificarea corectitudinii determinrii clinice a dimensiunii verticale

de ocluzie cu ajutorul cefalometriei laterale

Introducere Determinarea dimensiunii verticale de ocluzie este o etap deosebit de important n tratamenntul

edentaiei totale prin proteze dentare. Literatura de specialitate propune astzi o multitudine de tehnici, unele

mai simple, altele mai complexe. Au fost propuse multe metode pentru a determina dimensiunea vertical. Fie

c vorbim de utilizarea poziiei fiziologice de repaus, de deglutiie, de probe fonetice, de msurtori faciale,

nici una din aceste metode nu stabilete o dimensiune vertical matematic corect. Preocuparea multor autori

a fost orientat spre gsirea unor modaliti de pstrare a acestei dimensiuni dinainte de pierderea unitilor

dentare. n acest sens, Swenson propune confecionarea unei mti de acrilat, pstrnd astfel dimensiunile faciale

ale pacienilor. Silverman recomand tatuarea pe mucoasa fix n zona frontal att la maxilar, ct i la mandibul

a dou puncte. Msurarea distanei dintre ele n poziia de R.C. i I.M. va fi nregistrat i pstrat n fia fiecrui

pacient.

Material i metod Material (pacieni)

n studiu au fost inclui 19 pacieni cu vrsta cuprins ntre 60-69 ani, care prezentau edentaie total

bimaxilar, cu o vechime a edentaiei cuprins ntre 0 i 2 ani.

Am inclus n studiu:

pacienii cooperani

pacienii care n urma examenului clinic al extremitii cefalice la inspecie din norma lateral

prezentau un profil drept

pacienii pentru care nu am avut nregistrat i pstrat DVO anterior strii de edentat

(documente preextracionale)

pacienii cu simetrie facial pstrat

Au fost exclui din studiu:

pacienii necooperani

pacienii care au purtat anterior proteze dentare

pacienii care n urma examenului clinic al extremitii cefalice la inspecie din norma lateral

prezentau un profil convex sau concav

pacienii cu malformaii ale masivului facial.

Metoda de lucru

1. Determinarea clinic a dimensiunii verticale de ocluzie

Pacienii au fost aezai pe fotoliul dentar cu trunchiul n poziie vertical i cu capul nesprijinit n

tetier. Totodat am asigurat o atmosfer linitit n cabinet, cutnd s nlturm orice stare de tensiune pe

care pacienii ar fi putut s o aib.

Dimensiunea vertical de ocluzie s-a determinat pornind de la dimensiunea vertical de repaus.

2. A urmat apoi realizarea cefalometriilor laterale pe suport electronic i analiza acestora, urmnd

protocolul de analiz cefalometric. Axiograful computerizat Cadiax, prin softul aferent, are posibilitatea de a

realiza i analiza cefalometric, prin activarea sistemului Cadias.

Rezultate Analiza cefalometriilor laterale pentru pacienii luai n studiu a artat c n doar 7 cazuri DVO

determinat clinic a fost una corect. n 9 cazuri DVO a fost supradimensionat, iar n 3 cazuri s-a constatat c

DVO a fost subdimensionat.

Cefalometriile laterale executate persoanelor de sex masculin arat o determinare corect a DVO n 5

cazuri. Supraevaluarea clinic s-a produs n 4 cazuri, iar subdimensionarea apare n 3 cazuri.

La sexul frumos n schimb DVO clinic a fost stabilit corect n 2 cazuri, iar n 5 cazuri DVO a fost

supradimensionat clinic.

Studiul 4. mbuntirea calitii vieii la pacientul edentat total dup protezare

Introducere n 1998, OMS definete calitatea vieii astfel: calitatea vieii este dat de percepia indivizilor asupra

situaiilor lor sociale n contextul sistemelor de valori culturale n care triesc, i n dependen de propriile

lor trebuine, standarde i aspiraii. O definiie mai complex este dat de I. Mrginean n 2002. Domnia sa,

definea calitatea vieii prin ansamblul elementelor care se refer la situaia fizic, economic, social,

cultural, politic, de sntate etc. n care triesc oamenii, coninutul i natura activitilor pe care le

desfoar, caracteristicile relaiilor i proceselor sociale la care particip, bunurile i serviciile la care au

acces, modelele de consum adoptate, modul i stilul de via, evaluarea mprejurrilor i rezultatelor

activitilor care corespund ateptrilor populaiei, precum i strile subiective de satisfacie i insatisfacie,

fericire, frustare, etc. Totui, declaraiile celor investigai evideniaz o mare importan acordat sntii n

aprecierea fcut de ei, chiar dac aceast apreciere este de cele mai multe ori subiectiv.

Material i metod n studiu au fost inclui 120 pacieni, diagnosticai cu edentaie total bimaxilar. Am inclus n studiu

doar pacienii cooperani i care la examenul clinic prezentau edentaie total bimaxilar, neprotezat. Au

fost exclui din studiu pacienii necooperani precum i pacienii care au purtat anterior proteze dentare.

Pacienii edentai total bimaxilar au completat 2 chestionare identice alctuite din 23 itemi. Ambele

chestionare urmresc s surprind percepia pacienilor cu privire la tulburrile masticatorii, fonatorii,

fizionomice i psihice induse de starea de edentaie, modul n care aceste aspecte:

influeneaz starea de sntate oro-dentar

influeneaz calitatea vieii

contribuie la modificarea n sens negativ a imaginii i a stimei de sine

influeneaz viaa social, viaa profesional

determin apariia unor comportamente evitative (pacienii nu vorbesc n public, nu mnnc dect

n familie, etc)

pot fi corectate prin tratament de specialitate, prin purtarea pieselor protetice.

Primul chestionar a fost completat de ctre pacieni anterior confecionrii protezelor dentare i conine

datele personale ale fiecrui repondent, precum i intervalul scurs (n luni) de la pierderea ultimelor uniti

dentare, iar cel de-al doilea chestionar a fost oferit spre completare la 6 luni dup confecionarea, aplicarea

protezelor i finalizarea etapelor de retu efectuate la nivelul pieselor protetice.

Rezultate Absena unitilor dentare determin n cele mai multe cazuri o imposibil secionare a alimentelor i o

triturare deficitar a acestora. Astfel, majoritatea pacienilor chestionai ntmpin reale dificulti n actul

masticator (83-foarte multe, 37-multe).

Dup protezare, raportul se modific substanial: 74 persoane din totalul de 120 chestionate

semnaleaz dificulti puine n actul masticator sau chiar nesemnificative - 9 cazuri. Sunt, totui, pacieni

care semnaleaz dificulti n actul masticator i dup aplicarea protezelor dentare i efectuarea retuurilor

necesare (33 - multe i doar 4 persoane - f multe).

Situaia oro-dentar a pacienilor intrai n studiul anterior protezrii, impunea preponderent

consumul de alimente lichide, precum i a celor moi-pstoase. Ulterior, la 6 luni dup aplicarea pieselor

protetice, consistena alimentelor ingerate s-a modificat treptat, pacienii chestionai fcnd meniunea c

ingereaz, pe lng alimente moi pstoase, i alimente solide (33 cazuri).

Ca urmare a dificultilor pe care pacienii le ntmpin n actul masticator, pacienii chestionai au fost

nevoii s nghit alimentele fr a le tritura suficient (foarte des - 33 cazuri, respectiv des - 87 cazuri). Odat

cu intrarea n uz a protelor dentare, 5 pacieni chestionai rspund c n rare cazuri sunt nevoii s nghit

mncarea nemestecat, iar 114 reusesc s rectige plcerea de a efectua actul masticator. O persoan nu a

raspuns la aceast ntrebare dup aplicarea protezelor dentare.

Dup extracia ultimelor uniti dentare, treptat, fizionomia feei s-a modificat n ru la nivelul

obrajilor i buzelor foarte mult-29 cazuri, respectiv mult-91 cazuri. Dup aplicarea protezelor dentare

aspectul fizionomic al feei s-a mbuntit ca percepie mult -84 cazuri, foarte mult-36 cazuri.

Treptat, dup pierderea unitilor dentare, 66 dintre pacienii chestionai apreciaz c fizionomia feei

este n foarte mare msur afectat, n timp ce 54 dintre pacieni conider c faciesul este mbtrnit n mare

msur. Purtarea protezelor dentare confer pacienilor un aspect ntinerit n foarte mare msur - 80 cazuri,

n mare msur - 36 cazuri. La aceeai ntrebare, doi pacieni percep ntinerirea facial n mic msur, n

timp ce ali doi pacieni nu percep modificri semnificative n ceea ce privete aspectul ntinerit al

extremitii faciale.

Tulburrile de vorbire i pronunie, odat cu pierderea dinilor, sunt percepute ca fiind multe - 95

cazuri, respectiv foarte multe - 25 cazuri. Dificultile de vorbire i pronunie s-au mbuntit mult - 76

cazuri i foarte mult - 44 cazuri la 6 luni dup aplicarea pieselor protetice.

Pierderea unitilor dentare a contribuit la modificarea n sens negativ a imaginii i a stimei de sine n

22 cazuri - foarte mult, mult - 91 cazuri i puin n 7 cazuri. Prin purtarea protezelor dentare pacienii i-au

recptat ncrederea n propria persoan, fcnd meniunea c piesele protetice le-au modificat n sens

pozitiv imaginea (26 cazuri - foarte mult, mult - 90 cazuri i puin n 4 cazuri).

n ce privete viaa social i inseria n grupul de prieteni, acestea sunt afectate odat cu pierderea

unitilor dentare foarte mult - 36 cazuri, respectiv mult - 84 cazuri. Purtarea protezelor dentare l face pe

pacientul purttor al acestor piese protetice un participant activ la viaa social, mbuntindu-i-o (foarte

mult - 39 cazuri, respectiv mult - 81 cazuri).

Viaa de cuplu, anterior protezrii, a fost afectat: foarte mult - 31 cazuri, mult - 30 cazuri, puin - 44

cazuri i nesemnificativ - 15 cazuri. Ulterior, ca urmare a purtrii protezelor dentare, acest aspect s-a

mbuntit foarte mult - 32 cazuri, mult - 49 cazuri, puin- 21 cazuri, nesemnificativ - 18 cazuri.

Starea de sntate oro-dentar, dup pierderea unitilor dentare, este perceput ca fiind precar - 104

cazuri, respectiv satisfctoare - 16 cazuri. Dup protezare, starea de sntate oro-dentar este apreciat ca

fiind foarte bun - 5 cazuri, bun - 107 cazuri i satisfctoare - 8 cazuri.

Subiecii chestionai apreciaz n ansamblu calitatea vieii dup pierderea unitilor dentare ca fiind

precar - 106 cazuri i n 14 cazuri ca fiind satisfctoare. Calitatea vieii dup aplicarea pieselor protetice

este perceput ca fiind foarte bun - 2 cazuri, bun - 110 cazuri i satisfctoare - 8 cazuri.

Pacienii chestionai anterior protezrii consider c tratamentul stomatologic va contibui la

mbuntirea calitii vieii n foarte mare msur - 38 cazuri, respectiv n mare msur - 82 cazuri.

Rezultatul muncii noastre a fost apreciat de ctre pacienii care au afirmat c piesele protetice au contribuit la

mbuntirea calitii vieii: foarte mult - 74 cazuri, respectiv mult - 46 cazuri.

CONCLUZII GENERALE

1. Cunoaterea i examinarea amnunit a elementelor morfo-structurale ale cmpului protetic

mandibular edentat total ajut practicianul n stabilirea cu exactitate a zonei de sprijin i de succiune.

2. Analiza suportului muco-osos ofer o bun perspectiv asupra prognosticului pentru fiecare caz n

parte.

3. Analiza suportului muco-osos prin rezultatele obinute constituie un material didactic util pentru a

pune n eviden marea variabilitate a cmpurilor protetice examinate.

4. Compararea scanrilor celor dou linguri individuale clasice, respectiv 3D arat necesitatea imperioas

de realizare a unor linguri individuale ideale.

5. Realizarea lingurilor individuale ideale 3D ofer premisele unei amprentri finale de mare acuratee.

6. Papila interincisiv poate fi considerat un indicator incert al resorbiei maxilare n cazul pacienilor

edentai total.

7. Limea bolii palatine (lBP) poate fi considerat marker al resorbiei osoase maxilare, la ntreg lotul

studiat, acest indicator scade ca valoare medie odat cu creterea vechimii edentaiei totale.

8. Adncimea bolii palatine (ABP) este un indicator al resorbiei osoase maxilare, valorile acestui

indicator scznd odat cu creterea vechimii edentaiei.

9. Lungimea bolii palatine (LBP) poate fi considerat, de asemenea, indicator al resorbiei maxilare.

10. Acurateea n verificarea corectitudinii determinrii clinice a DVO realizat prin analiza cefalometric

recomand aceast investigaie imagistic ca fiind un bun mijloc de examinare a relaiilor intermaxilare

n cazul pacienilor edentai total neprotezai.

11. Analiza cefalometric elimin erorile umane i criteriile subiective ale medicului n stabilirea corect a

DVO.

12. Analiza cefalometric este o metod obiectiv n determinarea DVO.

13. Analiza cefalometric trebuie s fie utilizat n faza clinic de determinare a relaiilor intermaxilare la

edentatul total neprotezat.

14. Hotrtoare n reuita tratamentului sunt personalitatea pacientului, nivelul lui de cultur i

inteligen, starea psihic n legatur cu acceptarea i adaptarea la protezele dentare.

15. Niciodat un edentat total protezat prin proteze clasice dentare nu va putea avea capacitatea

masticatorie a unui dentat.

16. Protezele dentare clasice, dac sunt corect confecionate, rspund n mare msur cerinelor

fizionomice.

17. Cu ajutorul tratamentului prin proteze dentare pacientul i rectig stima de sine, putndu-se

reintegra n viaa social.

ORIGINALITATEA SI CONTRIBUTIILE INOVATIVE ALE TEZEI

Cercetarea de fa conine o serie de elemente care-i confer un caracter original i inovativ, prin

aportul adus etapelor clinice de realizare a pieselor protetice.

Studiile din cadrul tezei de doctorat contribuie la perfecionarea celor mai importante faze clinice din

algoritmul terapeutic, influennd pozitiv integrarea protezelor dentare n funcionalitatea aparatului dento-

maxilar.

Compararea scanrilor celor dou linguri individuale clasice, respectiv analiza fiierelor 3D,

evideniaz reale deficiene n confecionarea lingurilor individuale dup tehnica clasic n laboratorul de

tehnic dentar. n urma cercetrii ntreprinse, propun confecionarea unor linguri individuale ideale cu

ajutorul software-ului 3D CATIA V5 pentru a crea premisele unei amprentri funcionale perfecte. Metoda

propus se ncadreaz perfect n utilizarea mijloacelor moderne i inovatoare de tratament care au cunoscut

o dezvoltare important n ultimii ani.

De asemenea, cercetarea a demonstrat c analiza cefalometric este o metod imagistic obiectiv n

stabilirea cu acuratee a corectitudinii determinrii clinice a dimensiunii verticale de ocluzie. Tocmai de aceea

consider c determinarea DVO cu ajutorul analizei cefalometrice ar trebui s fie o etap obligatorie n

tratamentul edentatului total prin protezarea clasic. Buna precizie n determinarea DVO cu ajutorul

cefalometriei laterale constituie astfel un instrument obiectiv n terapia edentaiei totale.

Prin urmare, cercetrile efectuate n cadrul acestei teze doctorale deschid noi perspective spre

mbuntirea etapelor clinice n elaborarea pieselor protetice, cu aplicabilitate n mod curent i pe scar

larg, astfel nct proteza dentar clasic s asigure un status sanogen dentar de excepie.

DOCTORAL SCHOOL

SUMMARY OF THE PHD. THESIS

Clinical, radiological, and imagistic research of the totally endentulous prosthetic field

PhD Student Dan, Buhel

PhD Scientific Coordinator Floarea, Fildan

ClujNapoca, 2013

SUMMARY

INTRODUCTION 13

CURRENT STATE OF KNOWLEDGE

1. The totally edentulous prosthetic field 17

1.1. General considerations 17

1.2. The jaw prosthetic field 17

1.2.1. The support area 17

1.2.1.1. The bone substrate 17

1.2.1.2. The mucous substrate 20

1.2.2. The succion area 20

1.2.2.1. The passive mobile mucosa 20

1.2.2.2. The mobile mucosa 20

1.3. The prothetic field of the jaw 20

1.3.1. The support area 20

1.3.1.1. The bone substrate 20

1.3.1.2. The mucous substrate 21

1.3.2. The succion area 22

1.3.2.1. The passive mobile mucosa 22

1.3.2.2. The mobile mucosa 22

2. Disorder of the main functions of the dento-maxilar apparatus of the TE

TTEedentulous patient

23

2.1. Chewing disorders 23

2.2. Physiognomic disorders 24

2.3. Phonetic disorders 24

2.4. Psychic disorders 25

3. Determining the vertical dimention of the lower floor of the face 27

3.1. General considerations 27

3.2. Definitions 27

3.3. Determining conditions 28

3.3.1. Patient's condition 28

3.3.2. Preprothetical conditions 28

3.3.3. Analysis of the occlusion patterns 29

3.4. Methods of determining the vertical dimention of the occlusion 30

PERSONAL CONTRIBUTION

1. Working hypothesis /objectives 37

2. General methodology 37

3. Study 1 The analysis of the mucous-bone support in the totally edentulous

patient

39

3.1. Introduction 39

3.2. Working hypothesis/Obiectives 41

3.3. Material and method 42

3.4. Results 45

3.5. Discutions 53

3.6. Conclusions 56

4. Study 2 - The interincisive papilla indicator of the jaw's reabsorbtion in

the full edentention

57


4.2. Working hypothesis/objectives 58


4.4. Results 64

4.5. Discutions 73

4.6. Conclusions 74

5. Study 3 - Verification of the correctness of the clinical determination of the

vertical dimention of occlusion by means of the lateral cefalometrics

77




5.4. Results 88

5.5. Discutions 89

5.6. Conclusions 91

6. Study 4 - The improvement of the quality of life in the totally edentulous

patient after prosthesis

93




6.4. Results 97

6.5. Discutions 104

6.6. Conclusions 108

7. General conclusions 109

8. Originalitaty and inovative contributions of the thesis 111

ABREVIATIONS 11

ANNEXED 113

REFERENCES 123

KEYWORDS: totally edentulous, custom tray, vertical dimension of occlusion,

prosthetic rehabilitation, oro-dental health, chewing disorders,

psysionomical disorders, phonetic disorders, psychiatric disorders, quality of life

INTRODUCTION

Dental prosthetics, asa a newly emerging specialty, is considered an extremely important field in dental

medicine. Within this field, totally edentation makes the study of ample clinical research.

The dento-maxillary apparatus in the totally edentulous patient presents a series of modifications in

form and structure, with repercussions over the support of the prosthesis and its function. Careful examination,

clinical and paraclinical of all the composing elements of the totally edentulous prosthetic field creates the

premises of a favorable integration of the prosthetic pieces, but mostly prevent us from ulterior therapeutic

failures.

The therapeutic possibilities proposed to these patients nowadays differ considerably. A decisive factor in

this sense are the material means of the patients. Currently, dental medicine in Romania belongs o the private

sector. A large category of patients remains, however, whose financial means do not allow costly stomatological

treatments. The Sanodentarprim program, currently underway, confronts us with classical therapeutic

alternatives. Even through oral implantology has certainly gained terrain nowadays, being an important

component of the surgical prosthetic treatment, the financial situation of these disvavored patients leads towards

the classical full prosthesis as a therapeutic alternative. Solving the problem through classical methods puts to the

test both the patient's patience and the thorough training of the medical body. As far as clinical, radiological, and

imagistic research of the prothetic fied is concerned, I have personally followed three directions:

I. Starting from the careful examination of the elements of the totally edentulous prosthetic field, in

order to succeed in printing these, I have set out to visualize the "minuses" which have shown up in

the classical approach, in the dental technique laboratories of these individual custom trays.

II. The second direction followed in creating the dental prosthesis is represented by the determination of

intermaxillary relations. The accuracy in verifying the correctness of the clinical determining of DVO,

carried out through the cefalometric analysis recomnds this imagistic investigation as a good means to

examine the intermaxilary relations in the case of totally edentulous patients without prosthesis.

These directions of research have helped me increase the quality of the therapeutic act through

classical total prosthesis in order to offer these patients as well the joy of social reintegration.

III. The third direction of my research has aimed for the subjective side of the patients included in the

stdy, regarding their perception towards the quality of their life after the application of the denatl

prosthesis.

The succcess of the prosthesis depends, thus, on many factors. Besides the quality of the prosthetic field, of

the way in which the doctor treats every individual case, the doctor-patient manner of cooperation, decisive in

the success of the treatment are: the patient's personality, their level of culture and intelligence, the psychological

state regarding accepting and adapting to the dental prosthesis.

I am happy to see that the result of my work and of my younger colleagues, the students, was appreciated

by many patients who consider that the prosthetic pieces executed contribute to a great extent to the

improvement of the quality of life. The well conducted medical act does, hence, gain value in the eyes of the

patients, and their respect and gratitude towards the dental medicine doctor is on the rise.

On the other hand, the great professional satisfaction generated by personal research consists in the

opening of new horizons in the improvement of the quality of imprinting and the accuracy of determining the

intermaxilary relations, two very important elements in the quality of the therapeutic act offered by full

prosthesis.

PERSONAL CONTRIBUTION

Working hypothesis/obiectives Full edentation is perhaps the most mutilating pathological state of the stomatognat system, as it perturbs

all the latter's functions, bearing consequences on the entire body. In order to speak about success in the

prosthetic restoring of the totally edentulous patient, we must start from the thorough knowledge of the

prosthetic field, of itsrespective components, as well as its morphology. The onset of the full edentation must be

regarded as the beginning of an evolutive process of perturbing the physiological balance, generated by the

constant aging of the anatomical structures of the entire organism, with implications over the dento-maxillary

apparatus, an aspect which can set off a permanent state of stress, which put older persons in particular in a state

of psycho-somatic lability.

The therapy of full edentation was, is and will always be a preoccupation of the specialists, being

considered a complex domain, of particular difficulty, as it does not limit itself to the conception and creation of

certain prostehetic pieces alone, but constitutes a true specific therapy which addresses one of the most varied

infirmities.

The objectives of the research were the following:

starting from the analysis of the mucous-bone support in the totally edentulous patient, we should

create individual custom trays, as precise as possible, in order to be able to record, with maximum

exactness the surface of the support are in these patients;

to visualize whether or not there exists a correlation between the position of the interincisive

papilla on the one hand and the length, width, and depth of the pallatal arch, on the other;

to varify with the hep of lateral cefalometrics if the clinical determination of the vertical dimention

of the occlusion was a correct one or not;

to record the perception of the totally edentulous patients of the quality of life in the context of the

infirmity generated by the edentulous state, as well as the extent to which this perception

improves six months after wearing thr dental prosthesis.

General Metodology In the studies carried out during my research, I have included patients who are part of the Sanodentaprim

Program, a program which promotes Oral Health by increasing the disadvantaged population's access to

stomatological services as part of the partnership between UMF Iuliu Haieganu and the Cluj Napoca Town Hall.

The target group refers to institutionalised persons (old persons homes, children's homes, etc), retired

people, unemployed people, and young people under the age of 26 who do not have any income. From this target

group of over 1400 patients, registered with the Faculty of Oral rehabilitation, Oral Health, and the Management

of the Dental Office, during April 2010-February 2012, we have selected patients with bimaxillary full edentation.

The number of patients included in the lots for each particular study was different, depending on the

objectives followed on the chosen segments of research.

Each patient had an observation chart drawn out, and they subsequently filled out/signed an informed

consent towards the performing of a medical act and a different consent form each, for entering each study.

Also, the working methods used throughout the research differ for each particular study, depending on the

latter's specificity, and will be presented in the respective chapters.

Study 1. The analysis of the mucous-bone support of the totally edentulous

patient

Introduction The dento-maxillary apparatus in the totally edentulous patient presents a series of modifications in form

and structure, with repercussions over the support of the prosthesis and its functions. In order to speak about

success in the prosthetic restauration of the totally edentulous patient, we must depart from a detailed

knowledge of the prosthetic field, and its respective components, as well as from its morphology. Also of

importance are the individual particularities of each totally edentulous prosthetic field.

Material and method 52 patients diagnosed with full bimaxillary edentation have been included in the study. The patients have

been examined clinically and were then printed after the classical technique, using standard custom trays of

various sizes depending on the size of the prosthetic fields; alginate was used as printing material. On the

preliminary prints, we have traced the limits of the prosthetic field by means of a marker, after the known

technique.

The prints numbered according to each person who has entered the study were scanned in the

Department of the Engineering of Projection and Robotics of the Faculty of Machine Constructions within the

Technical University in Cluj-Napoca in order to obtain virtual 3D models, and later 3D ideal individual custom

trays. The digitization of prints was realized with the help of a portable 3D scanner with self-positioning. The

reduced dimentions of the dental prints, as well as the irregular surfaces necessitated special attention in the

digitization process, as well as the proper software and hardware. The prints were digitized with the help of the

3D laser scanner VIUScan, the date obtained being then processed in Catia V5. For dimentions of the piece under

150 mm3, the producer of the scanner guarantees a precision of 50 m, a scaning precision which was attained in

the case of scanning dental prints as well.

On each image scanned corresponding with the virtual model, the following were marked: the

current name, surname, name, age sex of the patient. (M-masculin, F-feminin). Through clinical examination

and analysis of the 3D virtual model, we have followed the traits of the maxillary edentulous crests regarding the

symmetry, height, width; the characteristics of the pallatine arch (depth, length, width, shape, presence/absence

of the pallatine torus and its localization), the characteristics of the maxillary tuberosities (the presence of

uni.bilateral retentiveness, tuberosities present, nonretentive, procidentous, absent); the characteristics of the

mandibular edentulous crest from the point of view of the symmetry, height, width, direction towards the

mediosagital plan, shape, as well as the characteristics of the piriform tubercule: direction in relation to the crest,

volume.

After scanning, the same prints were cast on the spot in order to obtain preliminary models.

Subsequently, in the dental technique laboratory, classical individual custom trays were thus made. These

individual custom trays obtained clasically in the laboratory were scanned. Then, the two 3D images,

representing the ideal custom tray, and, respectively, the classical custom tray, were compared, in order to

visualize the "minuses" shown up in the classical realization in the dental technique laboratory of the custom

trays.

Results The analysis of the mucous-bone support in the totally edentulous maxillary patient has highlighted the

following:

edntulous crests with a medium height of 4-6 mm (75% of the examined patients), with

preserved symmetry (80% of the cases), rounded (73% cases);

the pallatine arch with a length between 4,5-4,9 cm (55% of the cases), width between 4-4,9 cm

(84% of the cases), depth between 10-14 mm (56% of the cases), without pallatine torus

present, in the shape of the letter U;

the maxillary tuberosities were present in 95% of the cases, and most frequently were retentive

bilaterally in 70% of the cases.

In the mandibula, the totally edentulous prosthetic field was characterised by symmetrical edented crests

(42 cases), in U shape (34 cases), and the direction of the crest was in 38 cases descendent towards distal.

The edentulous crests presented a medium height in 34 cases, a medium width in 38 of the cases.

As a consequence of centralising the data, a horizontal direction of the piriform tubercule was noted in 38

cases, and an oblique direction in 14 cases, respectively.

Regarding the volume of the piriform tubercule in 8 cases this was voluminous, in 32 cases, it had a

medium volume, and in 12 cases, it was reduced in volume.

After the analysis of the mucous-bone support, in the second part of the study, I performed an analysis of

the deviation which would highlight, through mathematical instruments, the difference between the surfaces of

the individual custom trays, classical and ideal, scanned and aligned.

The significant differences which have shown up after the interpretation of the color maps have been

highlighted at the maxillary in the area of the tuberosities, and in the mandibulla, in the area of the piriform

tubercule.

Study 2. The interincisive pupilla indicator of the reabsorption of the maxillary

in the full edentation

Introduction Along with the loss of dental units in the edentulous patient, the alveolar process, called by Beltrami dental

bone as well, suffers changes, the neoformation bone filling the alveola and thus becomes the alveolary crest, or

as it appears in the literature, the edentulous crest. Immediately after the loss of masticating units, the macillary

bone suffers pheoemenons of atrophy and bone reabsortion. These phenonema will influence negatively the

stability of future proteic pieces.

Material and method 52 pacieni diagnosed with full edentation have been included in the study.

I have included in the study only compliant patients and who, following the treatment, presented:

U shaped dental arcades

the symmetry of the arcade maintained

The following have been excluded from the study:

uncooperative patients

patients who have previously worn dental prosthesis

pacients who following the endobuca clinical exam have presented:

another shape of the dental arcades than U

asymmetrical arcades

the absence of canine brides

the presence of the maxillary torus

During the clinical exam I have captured on the camera lens the position of the interincisive papilla, and

at the end of the examination, each of the 52 patients have been printed, with the purpose of making study

models. The models thus obtained were scanned in the Department of Project Engineering and Robotics of the

Faculty of Machine Construction within the Technical University in Cluj-Napoca, and 3D study models were

created.

1. The clinical determination and on the photograph ofthe interincisive papilla position:

posterior (on the pallatinal side of the edentulous crest in the frontal zone);

in the middle of the crest edentulous;

anterior (on the vestibular side of the frontal edentulous crest).

The study of the 3D models obtained after scanning the study models comprised the following measurements:

a. The length of the pallatine arch (LPA): from the tangent to the maximum prominence on the vestibulary

side of the edentulous crest in line with the upper lip up to the tangent to the distal face of the

tuberosity in the retrotuberose ditch.

b. The depth of the pallatine arch (DPA): depth measured the union of the middle thirs with the distal third

of the hard pallate.

c. The width of the pallatine arch (WPA): the maximum width at the union of the miffle third with the

anterior theird on the external sides of the edentulous crest.

Results The 52 patiente taken into the study (26 women, 26 men) had ages between 40 and 85 years.

The variation of the position of th papilla in the female gender looks ad follows:

When the indentation is 0 to 2 years old, the position in the middle of the crest predominates in 13 cases,

the posterior position in 5 cases. There is no case in which the position of the papilla is anterior.

When the indentation is between 3 and 5 years old, the position in the middle of the crest predominates

in 3 cases. There is no anterior or posterior position in any of the cases when the edentation is this old.

When the edentation is over 5 years old, I have noticed cases in which the position of the papilla was an

anterior one, and one case, respectively, in which the papilla had a position in the middle of the crest.

In women, there is a significant association between the position of the papilla and the edentulous groups,

Fisher's exact test, p=0.002

measurements, none of these methods establishes a mathematically correct vertical dimension. Many author's

preoccupation was oriented towards finding certain ways of keeping these dimensions before the loss of dental

units. Thus, Swenson proposes the confectioning of an acryllic mask, as such maintaining the facial dimentions of

the patients. Silverman recommends tatooing on the fixed mucosa in the frontal area both in the maxillary, and

the mandibula, of two points. The measurement of the distance between them in the position of R.C. and I.M. will

be registered and kept in each patient's chart.

Material and method Material (pacients)

In the study, 19 patients have been included, aged between 60-69 years, who presented full bimaxillary

edentation, the edentation being between 0 and 2 years old.

I have included in the study:

compliant patients

pacients who following the clinical exam of the cefalic extremity at an inspection from the lateral

norm presented a right profile

patients for whom I did not have a registered DVO kept on file prior to the edentulous state

(preextraction documents)

patients with kept facial symmetry

I have excluded from the study:

uncompliant patients

patients who have previously worn dental prosthesis

patients who following the clinical exam of the cefalic extremity upon inspection from the

lateral norm presented a convex or concave profile

patients with malformations of the facial massive

Working method

1. The clinical determination of the vertical dimension of occlusion

The patients were seated on the dental chair with their trunks in a vertical position and with the head

resting against the headrest. At the same time, we provided a quiet atmosphere in the cabinet, seeking to remove

any state of tension the patients might experience.

The vertical dimension of occlusion was determined starting from the vertical rest position.

2. The performing of the lateral cefalometrics followed, on an electronic format, and their analysis,

following the cefalometric analysis protocol. The computerised axiograph Cadix, through the associated softwear,

has the possibility of performing the cefalometric analysis, by activating the Cadias system.

Results The analysis of the lateral cefalometrics for the patients studied has shown that in only seven cases DVO

clinically determined was correct. In 9 cases DVO was overdimensioned, and in 3 cases it was noted that DVO was

underdimensioned.

The lateral cefaometrics executed on male sex persons shows a correct determination of the DVO in 5

cases. The clinical superevaaluation was produced in 4 cases, and the subdimentioning appears in 3 cases.

In the female sex, on the other hand, the clinical DVO was correctly established in 2 cases, and in 5 cases

DVO was clinically overdimentioned.

Study 4. Improving the quality of life in the totally edentulous patient after

prosthesis

Introduction In 1998, OMS defines the quality of life thus: "the quality of life is given by the individuals' perception of

their social situations in the context of the system of cultural values they live in, and in dependence with their

own needs, standards, and aspirations". A more complex definition is given by I. Mrginean in 2002. He defines

the quality of life through "the ensemble of elements which refer to the physical, economic, social, cultural,

political, health situation etc. in which people live, the content and nature of the activities they perform, the

characteristics of the relations and social processes in they participate, the goods and services they have access to,

the consumption models adopted, the way of life and lifestyle, the evaluation of circumstances and the results of

the activities which correspond the the expectations of the population, as well as the subjective states of

satisfaction and insatisfaction, happiness, frustration,etc. Still, the statements of those investigated highlight the

great importance awarded to health in their considerations, even though this appreciation is subjective most of

the times.

Material and method 120 patients diagnosed with bimaxillary full edentation have been included in the study. I have included in

the study only compliant patients and who, upon the clinical examination, presented bimaxillary full edentation

without prosthesis. I have excluded from the study uncompliant patients as well as patients who have previously

worn dental prosthesis.

The totally bimaxillary edentulous patients have filled out 2 identical questionnaires made up of 23 items.

Both questionnaires aim to glean the patients' perception regarding chewing disorders, as well as sounding,

physiognomical, and psychological disorders induced by edentulous state, the way in which these aspects:

influence the oro-dental state of health

influence the quality of life

contribute to the modification in a negative sense of the self image and self image

influence the social life, professional life

determines the apparition of avoiding behavior (patients do not speak in public, only eat in the

family, etc)

can be corrected through specialized treatment, by wearing prosthetic pieces.

The first questionnaire was filled by the patients prior to the making of dental prosthesis and contains the

personal information of every person answering, as well as the interval (in months) bewteen the loss of the last

denatl units, and the second questionnaire was offered for completion 6 months after the making, the application

of the prosthesis and the finalising of the touch-up stages performed at the level of the prosthetic pieces.

Results The absence of dental units determines in most cases the impossibility to section foods and a deficient

chewing of the latter. Thus, the majority of patients questionned encounter real difficulties in the chewing act (83-

very many, 37-many).

After the application of the prosthesis, the raport changes substantially: 74 persons out of a total of 120

questionned signal few difficulties in the chewing act or even insignificant ones --9 cases. There are, however,

patients, who signal difficulties in the chewing act even after the application of dental prosthesis and the

performance of the necessary touch-ups (33 - many and just 4 persons - very many).

The oro-dental situation of the patient who have enetered the study prior to the application of the

prosthesis demanded the preponderent consumption of liquid foods, as well as that of soft-pasty ones.

Subsequently, six months after the application of the prosthetic pieces, the consistency of the foods ingested has

changed gradually, the patients questionned noting that they ingest, alongside soft pasty foods, solid foodds as

well (33 cases).

As a consequence of the difficulties the patients encounter in the chewing act, the patients questionned

were obliged to swallow the foods without sufficiently chewing them (very often --33 cases, 87 cases, often,

respectively). Once the dental prosthesis used, 5 patients questionned answer that in rare cases are they obliged

to swallow the food unchewed, and 114 manage to regain the pleasure of chewing. One person did not answer

this question after the application of the denatl prosthesis.

After the extraction of the last dental units, gradually, the physiognomy of the face has changed for the

worse, at the level of the chheks and lips very much --29 cases, much --91 cases. After the application of the denatl

prosthesis, the psysiognomic aspect o the face has improved as perceived a lot --84 cases, a significant lot --36

cases.

Gradually, after the loss of the dental units, 66 patients questionned note that the psysiognomy of the face

is affected to a great extent, while 54 of the patients consider that the face has aged to a great extent. Wearing

dental prosthesis confers a youthful aspect to patients to a very large extent -80 cases, to a large extent -36 cases.

To the same question, two patients perceive facial rejuvenation to a little extent, while teo other patients do not

perceive semnificant changes regarding the rejuvenated aspect of the facial extremity.

The speaking and pronounciation disorders, alongside the loss of teeth, are perceived as many - 95 cases,

and very many, respectively - 25 cases. The difficulties in speaking and pronounciation have improved a lot - 76

cases and and greatly- 44 cases 6 months after the application of dental prosthesis.

The loss of dental units has contributed to the modification in the negative sense of the image and self-

esteem in 22 cases --to a very large extent, a large extent -91 cases, and little in 7 cases. By wearing dental

prosthesis, the patients have regained confidence in their own person, making the mention that the prosthetic

pieces have modified their image in a positive sense (26 cases --to a very great extent, to a great extent - 90 cases

and to a little extent in 4 cases).

As far as the social life and insertion in the group of friends is concerned, these are affected with the loss of

dental units to a very great extent -36 cases, to a great extent --84 cases. Wearing dental prosthesis makes the

patient wearing these prosthetic pieces an active participant in social life, improving it (to a very great extent -39

cases, to a great extent --81 cases).

Couple life, prior to prosthesis, was affected: to a very large extent --31 cases, to a large extent --30 cases,

to a little extent --44 cases, and insignificantly --15 cases. Subsequently, as a consequence of wearing denatl

prosthesis, this aspect was improved to a very large extent -32 cases, to a large extent -49 cases, to a little extent --

21 cases, insignificantly -18 cases.

The oro-denatl state of health, after the loss of dental units, is perceived as being precarious --104 cases,

respectively satisfactory --16 cases. After the prosthesis, the oro-dental state of health is rated as very good --5

cases, good -107 cases, and satisfactory --8 cases.

The subjects questionned appreciate the overall quality of life after the loss of dental units as being

precarious -106 cases and in 14 cases as being satisfactory. The quality of life after the application of the

prosthetic pieces is perceived as being very good 2 cases, good-110 cases and satisfactory - 8 cases.

The patients questionned previous to the application of the prosthesis consider that the stomatological

treatment will contribute to the improvement of the quality of life to a very large extent - 38 cases, respectively to

a large extent - 82 cases. The results of our work was appreciated by the patients who have affirmed that the

prosthetic pieces have contributed to the improvement of the quality of life: to a very great extent -74 cases, to a

great extent, respectively -46 cases.

GENERAL CONCLUSIONS

1. Knowledege of and thorough examination of the morfo-structual elements of the totally edentulous

prosthetic field help the patient in establishing exactly the support area and the succion area.

2. The analysis of the mucous-bone support offers a good perspective of the prognosis for each particular

case.

3. Through the results obtained, the analysis of the mucous-bone support constitutes a useful didactic

material in order to emphasize the great variability of the prosthetic fields examined.

4. Comparing the scans of the two custom trays, classical and 3D, respectively, shows the imperative

necessity of creating ideal custom trays.

5. The creation of the ideal 3D custom trays offers the premises of a final printing of great accuracy.

6. The interincisive papilla can be considered an uncertain indicator of the maxillary reabsorption in the

case of totally edentulous patients.

7. The width of the pallatine arch (WPA) ma be considered a marker of the bone maxillary absorption, in

the entire lot studied, this indicator decreases as a medium value along with the increase of the age of the

total edentation.

8. The depth of the pallatine arch (DPA) is an indicator of the he bone maxillary absorption, the values of

this indicator decreasing along with the increase of the edentation's age.

9. The length of the pallatine arch (LPA) may be considered, as well, an an indicator of the maxillary

absorption.

10. The accuracy in the verification of the clinical determination of DVO realized through the cefalometric

analysis recommends this imagistic investigation as a good means of examining the intermaxillary

relations in the case of totally edentulous patients without prosthesis.

11. The cefalometric analysis eliminates human errors and the subjective criteria of the doctor in the correct

establishment of the DVO.

12. The cefalometric analysis is an objective method in determining DVO.

13. The cefalometric analysis must be used in the clinical phase of determining the intermaxillary relations

in the totally edentulous patient without prosthesis.

14. Crucial in the success of the treatment are the patient's personality, level of culture and intelligence, the

psychological state regarding the acceptance and adaptation to dental prosthesis.

15. A totally edentulous patient with classical prosthesis will never be able to have the chewing capacity of a

dentulous patient.

16. Classical dental prosthesis, if correctly made, respond to a great extent to physiognomical demands.

17. By means of the treatment with dental prosthesis, the patient regains their self-esteem, being able to

become reintegrated in social life.

ORIGINALITY AND INNOVATIVE CONTRIBUTIONS

OF THE THESIS

The current research contains a series of elements which confer upon it an original and innovative

character, by means of the contribution brought to the clinical stages of the realization of the prosthetic pieces.

The studies within the Ph.D. thesis contribute to the perfecting of the most important clinical phases in

the therapeutic algorhythm, bearing a positive influence on the integration of dental prosthesis in the functioning

of the dento-maxillary apparatus.

The comparison of the scans of the two custom trays, the classical one, and the analysis of the 3D files,

highlight real defficiencies in the making of custom trays according to the classical technique in the denatl

technique laboratory. Following the research undertaken, I propose the making of ideal custom trays with the

help of the 3D CATIA V5 software in order to create the premises of perfect functional printing. The method

proposed falls perfectly within the use of modern and innovative means of treatment which have known an

important development in the past years.

Also, the research has demonstrated that the cefalometric analysis is an objective imagistic method in

the establishment with accuracy of the clinical determination of the vertical dimention of the occlusion. This is

precisely why I consider that th determination of DVO with the help of the cefalometric analysis should be a

mandatory stage in the treatment of the totally edentulous patient through classical prosthesis. The good

precision in determining the DVO with the help of lateral cefalometrics thus an objective instrument in the

thereapy of total edentation.

Therefore, the research carried out under the scope of this doctoral research open new perspectives

towards the improvment of the clinical stages in the elaboration of prosthetic pieces, with current and large scale

applicability, so that the classical dental prosthesis can assure an exceptional sanogenic status.

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