Diagnosis and treatment planning in complete denture patients
Diagnosis and Treatment
planning for Complete
SECOND YR P.G
Chief complaint and dental history
Clinical evaluation 2
Success in complete denture
1.The patient’s attitude to dentures and
his ability and willingness to learn to use
2. The condition of the mouth.
3. The skill of the clinician.
4. The technical assistance available.
Examination: Scrutiny or investigation
for the purpose of making a diagnosis or
Diagnosis: is the examination of the physical
state, evaluation of the mental or psychological
makeup, and understanding the needs of each
patient to ensure a predictable result.
The determination of the nature of a disease
Diagnosis is the act or process of deciding
the nature, location and cause of a diseased
condition by examination and careful
Treatment plan: is the sequence of procedures
planned for the treatment of a patient after
Means developing a course of action that
encompasses the ramification and sequelae of
treatment to serve the patient needs
Prognosis: A forecast as to the probable result of a
disease or a course of therapy.
To forecast the likelihood of a successful outcome
to prosthetic treatment
- D J Neil
To gain the necessary information about the
patient, the clinician should:
– Conduct a thorough examination
– Listen to what the patient has to say
– Be alert to things patient may leave unsaid
– Record details of information in a logical sequence
Diagnostic procedure can be broadly
Appearance and presentation
– Dead fish handshake
– Normal firm
– Vicelike handshake
– Sweaty,clammy and cold hands
Kranti,Meena et al
Psychological considerations for edentulous patients
Insight into patients motor skills and systemic diseases
Stooped shoulder-Spinal changes
Tremor of head-Parkinson disease
Dragging of one leg-Stroke
Damage to brain and spinal cord,
Whether patient is able to move alone or
• The best mental attitude for denture acceptance
• Rational, sensible, calm and composed in
• Confident, easy going and cooperative.
• Overcomes conflicts and organizes his time
and habits in an orderly manner.
• Eliminates frustrations and learns to adjust
• He may require extreme care, effort and
patience on clinician’s part.
• Methodical, precise and accurate and at
times makes several demands.
• Once satisfied, an exacting patient may
become the practitioner’s greatest
• Presents a questionable or unfavourable
• Exhibits little concern if any; he is
uninterested and lacks motivation.
• Pays no attention to instructions, will not
cooperate and is prone to blame the dentist
for poor dental health.
• An education program in dental conditions
and dental treatment is the recommended
• Emotionally unstable, excitable,
excessively apprehensive and
• This patient must be made aware that
his/her problem is primarily systemic and
that many of his symptoms are not result
• Prognosis is poor.
Simon Gamer et al
“M. M. House mental classification revisited: Intersection of particular
patient types and particular dentist’s needs”
J Prosthet Dent 2003;89:297-302
Reasons that the House
classification requires reevaluation
Some of the terminology is antiquated, falling out of
use, or no longer carries the same meaning within
psychiatry eg: hysterical
House classification pertains to the patient in isolation.
House provided little attention to how the patient’s
reactions and behaviors are codetermined by the
treatment and behavior of the dentist.
Based on 2 factors:
the level and quality of the engagement or
involvement of the patient toward the dentist
(including such issues as domination, submission, and
idealization and devaluation of the dentist) and
the level of willingness to submit (trust) to the dentist.
Gamer et al 2003
FACTORS PRODUCING ADAPTIVE RESPONSE
Confidence in the dentist
Previous favorable experiences
Good physical health and coordination
Good learning capacity and cooperative
Awareness to the limitations of a complete denture
Lack of trust in the dentist
Previous negative experience
Inadequate tissue tolerance and muscle
Disapproval to dentures by people who are important
to the patient
SENILE AGED SYNDROME
SATISFIED OLD DENTURE WEARERS
GERIATRIC PATIENTS WHO DO NOT WANT
ALAN MACK’S CLASSIFICATION
Endomorph-Care free type
REASONABLE OR REALISTIC
UNREASONABLE OR UNREALISTIC
The patient should be questioned regarding his or
her chief complaint such as-
Inability to chew
History of presenting illness/
Duration and sequence of the edentulous
Gives information about bone resorption
patterns and progression, as well as the
timing of tooth loss.
Reasons for loss of teeth:
Previous Denture Experience:
The patient should be questioned regarding the
number & types of previous dentures
Patients should be made to comment on the
reasons for replacement and should be educated
regarding the realistic limitations.
Existing Or Current Dentures:
• The patient should be questioned about the length
of time for which the dentures have been worn.
• Careful clinical observation may provide valuable
information about denture experience
• patient should be asked about the esthetics and
function of existing dentures
The existing denture should be checked for tooth
shade,mold and material .
contours,vertical dimension of occlusion and
orientation of the occlusal plane.
Characterization or staining,comfort of the patient.
Motivation to clean dentures must be assessed.
Ashok.K et al
Journal of Orofacial sciences-2010
Diabetes, tuberculosis, blood dyscrasias etc
should be under medical control.
Diabetes: An uncontrolled diabetic or poorly
controlled diabetics may pose problems of:
(i) Bacterial, viral and fungal infections – including
Poor wound healing,increased bone
Appointments should be short and should not
interfere with meal times.
Tissues need functional rest so patients should be
advised less denture wear.
Frequent relining and rebasing may be required.
Ashok .K et al
Journal of Orofacial Sciences-2010
Deep fissures in the tongue; the mucosa of
check; round, undermined ulcers that are very
painful and firm nodules.
Efficient dentures are necessary as diet is
important in treatment.
Oral hygiene is important
. Blood dyscrasias:
proper history should be taken
blood tests/ consultation prior to treatment
care to be taken while planning for pre
these patients get easily bruised
Cardio vascular diseases:
Prophylactic antibiotic coverage for all
dental procedures .
– Convenient morning, short appointment.
– Premedication with diazepam 5-10 mg to
– Nitroglycerine tablets to be made available
in dental office
Diseases of joints:
Under the age of 45, men and women
are affected in the ratio of 2 : 1.
When terminal joints of fingers are arthritic it is
difficult to insert & clean dentures.
Osteoarthritis of TMJ presents problem in CD
construction as mandibular movements are painful
and jaw relation records are difficult to record and
Occlusal correction must be made often
because of subsequent changes in joints.
Special impression trays necessary due to
limited access from reduced ability to open
Diseases of skin:
Pemphigus - extremely painful.
Constant use of dentures is
contraindicated - primarily indicated for
Vesicles and bullae on the mucous
membrane as well as on skin.
Patients with Bell’s palsy and Parkinson’s disease
etc. can be given prosthetic treatment.
Denture retention, maxillo-mandibular relation
records and supporting musculature pose denture
The base of complete dentures should be
metal or should be reinforced with metal as
acrylic base may fracture ,increasing the
risk of aspiration or dislodgement into the
Novel aspects of Epilepsy,2011
Radiation treated patients
Patients treated by radiation of head and neck tend
to develop problems like
iii) Loss of taste
iv) Constricture of muscles (trismus)
v) Secondary infections (Candidiasis)
If prognosis is favorable,but still the tissues have a
bronze color and lack tonus-delay denture
Watch for tissue necrosis.
Use on a limited time basis-depending on the
reaction of the tissues.
Generally seen as osteoarthritis,mental
tongue,tendency to gag,vague areas of pain.
Allergies and Angioneurotic edema
H/o of allergy -drugs or denture materials
Edematous swelling of lips, cheek etc after contact
with an antigen like acrylic / metal.
Emergency treatment: 0.3 – 0.5 ml epinephrine
1:1000 1M, support respiration / obtain medical
Extra oral examination
The head and neck region is examined for the
presence of any pathological condition relating
to non dental or systemic condition
Face and neck palpated to check for enlarged
nodes or masses.
Put forward by House & Loop, Frush &Fisher &
Williams claims that the shape of upper Central
Incisor bears a definite relation with the shape of
Gross asymmetries are recorded.
Can be due to:
– Congenital defects
– Hemifacial atrophy
– Unilateral condylar ankylosis and hyperplasia.
Muscle tone (According to House)
• Class I: The patient exhibits normal tone and
placement of the muscles of mastication and facial
• Class II: The patient displays approximate normal
function but slightly impaired muscle tone.
• Class III: The patient exhibits greatly impaired
muscle tone and function.
• . 66
Skin colour also indicates the presence of underlying
– Pallor may indicate anaemia
– Ruddy complexion: sign of polycythemia or neoplasm.
– Bronzed skin occurs in Addison’s disease.
– Lemon-yellow complexion of jaundice
Lips are examined in relation to
Lack of proper lip support - collapsed
appearance and wrinkling.
A rolled-in vermilion border - inadequate lip
Lips should be examined - cracking
fissures at corners and ulceration.
Candidal infection, vitamin deficiency,
incomplete or over closure, either due to
existing dentures / edentulous, or
A thin lip presents special problems as a slight
change in labiolingual tooth position alters the lip
A thick lip gives more freedom to the dentist in
Good prosthodontic treatment bears a direct
relation to the temporomandibular articulation
since occlusion is one of the most important parts
of the treatment of complete dentures.
Patient presenting with one / more of the
following symptoms are considered to be
suffering from TMJ disorder.
(1) Pain and tenderness in muscles of
mastication and TMJ.
(2) Sounds during condylar movements
(3) Limitations of mandibular movements
- Unhealthy TMJ complicates jaw relation records.
- Centric relation depends on structural and functional
harmony of osseous structures, intra articular tissue
and capsular ligaments.
- Difficulty to give correct & repeatable centric relation.
- Occlusal corrections often needed.
• Patients who are capable to articulate speech with
existing dentures usually have no problems
producing articulate speech with new dentures.
• Speech is classified as : “normal” or “affected”.
Sometimes speech aids in classification of a
-Rapid, jerky speech-hysterical patient
Forcefulness and abrupt speech,demanding-
Monotone ,lack of interest,absence of enthusiasm-
Color of mucosa ranges from healthy pink to fiery
systemic disease or
Mucosa thickness: (Classification by
Arch size: (According to House)
The size of the maxilla and mandible
ultimately will determine the amount of
basal seat available for denture
The greater the size, greater the
support, larger the contact surface,
greater the retention.
Also, arch size provides a quick
estimate of the tooth size required.
Class 1: Large ( best for retention
Class 2: Medium (good retention and
stability but not ideal)
Class 3: Small (difficult to achieve
good retention and stability)
Arch form (according to House)
Class 1: Square
Class 2: Tapered
Class 3: Ovoid
The opposing arch may or may not have the same
If the arch form is not the same in both the arches
some problems in tooth arrangement can be
The arch form influences support of denture by
offsetting rotational movement of denture base.
Ridge form(arch contour)
cross-sectional contour as a whole arch.
The ridge form affects the retention and stability.
Its height resists lateral displacement, and the
parallelism of its sides maintains the seal for a
considerable distance to resist vertical
Maxillary ridge form is classified as:
(According to House)
Class 1: U shaped
Class 2: V-shaped
Class 3: Flat residual ridge
Mandibular ridge form
Class 1: Inverted U shaped (parallel walls
from medium to tall with broad crest)
Class 2: Inverted U shaped (short with flat
Class 3: Unfavorable
Short inverted V
Tall, thin inverted V
Atwood & Howels classification
Order I: pre-exraction
Order II: post extraction
Order III: high- well rounded
Order IV: knife- edged
Order V: low well rounded
Order VI: Depressed
Ridge defects, such as exostoses, may
pose problems for complete denture
patients or may warrant pre-prosthetic
Benign bony enlargements
Found at midline of hard palate or on lingual
aspect of mandible mostly in premolar region.
Small ones may be accommodated
by relief of denture base.
Large enough to interfere with denture design are
Ridge resorption can cause denture to settle over
torus palatinus causing rocking of prosthesis and
A torus in midline of maxilla can be relieved but if
it fills palate to occlusal level, or extends beyond
vibrating line, it should be removed / reduced in
Mandibular tori :
Occur just above floor of mouth.
Difficult to provide relief without breaking border
seal of denture.
Surgical removal is necessary for successful
Class I: Tori absent or minimal in size. Do not
interfere with denture construction
Class II: Tori of moderate size. Pose mild
difficulties in denture construction. Surgery
Class III: Tori large, compromise the
fabrication and function of dentures. Require
surgical recontouring or removal.
Space between the maxillary and the mandibular
arches. Normally it should be 20mm.
Excessive amount of space due to resorption
results in poor stability and retention.
Reduced interarch distance will make teeth setting
and free way space maintenance difficult.
Laney Smith described ridge relationship as the
antero-posterior position of the mandibular ridge
relative to the maxillary residual ridge when the
jaws are in centric relation and separated by the
distance they will be separated by the prosthesis.
Lateral throat form:
Ewell Niel defined lateral throat form as the
contour of the hard lingual surfaces of the
mandibular ridge in the molar area and the velum
like tissue distal to the mylohyoid ridge in the
retromylohoid fossa as it functions under the
influence of tongue.
With the index finger passively
contacting the curved wall of mucosa in
the retromolar fossa with the tongue at
rest, patient is instructed to protrude the
Class I: 0.5 inch of space
exists between mylohyoid
ridge & floor of mouth.
Class II: Less than 0.5 inch
Class III: Mylohyoid fold is
at the same level as
Retention of lower denture
KDJ - Vol.33, No. 1, January 2010
Lateral throat form- design of a measuring instrument
Sadhvi K.V., Chandrasekharan Nair K., Jayakar Shetty
Palatal throat form (Classification according
Class I: it is horizontal & and makes 10o
angle to the hard palate &most
Class II: soft palate makes a 45o angle to
the hard palate
Class III: soft palate makes a 70o angle to
the hard palate.
Milsap C H
“ The posterior palatal seal area for complete dentures”
DCNA 1964; 1: 663-73.
U Shaped: It is most favorable for retention
and lateral stability
V Shaped: It is less favorable for retention
because slightest movement of denture base
will cause the seal to be broken with a
resultant loss of retention
Flat palatal vault: Is unfavorable. Usually
accompanied by resorbed ridges
Palatal sensitivity: (According to
Gag reflex is a normal defense mechanism
designed to prevent foreign bodies from entering
Can be caused by
(1) Systemic disorders
(2) Psychological factors
(3) Extra and intra oral physiologic factors
(4) Iatrogenic factors.
(1) oral examination
(2) medical history
Class I: normal
Class II: subnormal (hyposensitive)
Class III: supernormal
Border attachments: (According to
Class I: attachments are high in maxilla or low in
mandible with relation to ridge crest (0.5 inches or
more between the level of attachment and the crest
of the ridge).
Class II: attachment height in relation to the crest of
the ridge is between 0.25 and 0.5 inches.
Class III: attachment height is less than 0.25 inches
from the ridge crest.
according to House)
Class I: High in the maxilla or low in the mandible
with respect to the crest of the ridge
Class II: Medium
Class III: Freni encroach on the crest of the ridge
may interfere with the denture seal. Surgical
correction may be required
Amount and Consistency of saliva
affects denture construction and
thin, serous or
Dry mouth-increased potential for
Excessive saliva -complicates denture
construction, especially impression making123
Saliva can be classified as: (House)
Class I: Normal quality and quantity of
saliva. Cohesive and adhesive
qualities of saliva are normal.
Class II: Excessive; contains much
Class III: Xerostomia; remaining saliva
Tongue size: (Classification according to
Class I: Normal in size, development and function.
Class II: Teeth have been absent long enough to
permit a change in the form and function of the
Class III: Excessively large tongue. All teeth have
been absent for an extended period of time-
abnormal development of the size of the tongue.
The large tongue completely
- fills floor of mouth and
- Covers alveolar ridges
- Making of impression difficult
- Denture stability difficult to attain because
dentures move with movement of tongue
A small tongue on the other hand facilitates
impression making but might jeopardize the
In 1949 Wright classified tongue position as
Class I: Normal
• The tongue fills the floor of the mouth and is
confined by the mandibular teeth.
• The lateral borders rest on the occlusal surfaces of
the posterior teeth and the apex rests on the incisal
edges of the anterior teeth.
Class II: Retracted
• The tongue is retracted. The floor of the
mouth pulled downward is exposed back to
the molar area.
• The lateral borders are raised above the
occlusal plane and the apex is pulled down
into the floor of the mouth.
Class III: Retracted
• The tongue is very tense and pulled
backward and upward.
• The apex is pulled back into the body of
the tongue and almost disappears.
• The lateral borders rest above the
mandibular occlusal plane.
• Pre-extraction photographs, radiographs,
casts and facial measurements may prove
helpful in denture therapy.
• These adjuncts may be used to recreate
anterior esthetics and facial support and
aid in evaluation of vertical dimension of
It is an essential part of diagnosis and treatment
planning in patients seeking prosthodontic care.
Panoramic radiographs offer an advantage over
periapical radiographs as they are:
(2) Reduce patient exposure to radiation
(3) Image the entire maxilla and mandible
Interpretation of panoramic radiograph
should follow a 5-step analysis as outlined
Step I: Screening the jaw for
Defects in structure and reactive new bone
Bone enlargements / expansion
Displacement of jaw parts
Unerrupted teeth / retained root fragments
Radiolucencies and radiopacities, rarefaction or
Well-defined or ill-defined lesions
Step 2: Appearance of lesion, physical bony changes
including location, size, shape, number and
radiographic pattern is elaborated.
Step 3: Radiographic findings correlated with
clinical, historical and lab findings.
Step 4: Differential diagnosis is done.
Step 5: Rate of growth of lesion estimated
- Slow growing shows sclerosis,
expansion and displacement of
- Fast growing shows gross bone
destruction and lack of
Wical and Swoope described a useful system of
Class I: Mild resorption – Loss of 1/3 of original
Class II: moderate – loss of 1/3rd to 2/3rd of original
Class III: Severe – Loss of 2/3rd or more of original
Studies of residual ridge resorption
J Prosthet Dent 1974
Defined as the forecast as to the probable result of a
disease or a course of therapy.
After all the intra oral and general physical and dental
conditions have been recorded and radiographs, casts
and other visual aids are at hand, they can be
interpreted and diagnosis arrived at.
It is the process of matching
possible treatment options with
patient needs and systematically
arranging the treatment in order of
priority but in keeping with a logical
or technically necessary sequence.
Enables patient to
Addresses patient’s needs
Lists specific treatment
Specifies logical sequence
– Elimination of infection
– Elimination of pathology
– Preprosthetic surgery
– Tissue conditioning
– Nutritional counseling
Elimination of Infection:
Sources of infection like infected necrotic
ulcers, periodontally weak teeth, and nonvital
teeth should be removed.
Infective conditions like candidiasis, herpetic
stomatitis, and denture stomatitis should be
treated and cured before the commencement
Elimination of pathology
Pathologies like cysts and tumors of the jaws
should be removed or treated.
Some pathologies may involve the entire
bone. In such cases, after surgery, an
obturator may have to be placed along with
the complete denture.
Enhance the success of the denture.
Some of the common preprosthetic
Frenectomy, Excision of denture
granulomas, Excision of flabby tissue,
Reduction of enlarged tuberosity,
The patient should be requested to stop wearing the
previous denture for at least 72 hours before
Should be taught to massage the oral mucosa
Denture relining material should be applied on the
tissue side of the denture to avoid denture
Patients showing deficiency of particular minerals
and vitamins should be advised a proper balanced
Patients with vitamin B2 deficiency will show
angular cheilitis. Prophylactic vitamin A therapy
is given for xerostomic patients.
Nutritional counseling is also done for patients
showing age-related changes such as osteoporosis.
Developed by American college of
4 diagnostic criteria
– Mandibular bone height
– Maxillomandibular relationship
– Maxillary residual ridge morphology
– Muscle attachments
Class I (ideal or minimally
Residual mandibular bone height of
permitting normal tooth articulation and
an ideal ridge relationship
Maxillary ridge morphology
Muscle attachments conducive
Class II (moderately compromised)
Residual mandibular height- 16-20mm
Maxillomandibular relationship- normal
tooth articulation and appropriate ridge
Maxillary residual ridge morphology
Muscle attachments that exert limited
Class III (substantially
Residual mandibular height – 11-15mm.
Limited interarch space
Maxillary residual ridge morphology
providing minimal resistance
Muscle attachment results in
compromised denture stability and
Class IV ( severely
Residual mandibular height – 10mm or
An angle class I ,II or III relation with
compromised interarch space
Maxillary residual ridge morphology
provides no resistance
Muscle attachment that significantly
compromises denture base.
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