Diagnosis and treatment plan of complete denture Dr. Dwij Kothari PG Darshan Dental College and Hospital Udaipur

1. 1
If we wait until we are ready, we will
be waiting for the rest of our life

2. DIAGNOSIS AND TREATMENT
PLANNING OF COMPLETE
DENTURE
2
Presented by – Dwij M. Kothari
1st year P.G.
Darshan Dental College & Hospital

3. CONTENTS:
 Introduction
 Definition
 General introduction to the patient
 Principles of perception & Diagnostic procedure
 Oral – Systemic interactions
 Physical examination
 Extraoral
 Intraoral
 Radiographic examination
3

4.  Temporomandibular disorders and orofacial pain
 Pretreatment records
 Preprosthetic surgery
 Treatment planning
 Conclusion
 References.
4

5. INTRODUCTION:
 When people reach middle age they suffer from a variety of
infirmities to which younger bodies are not victim.
 Many of these illnesses were once thought to be inevitable
consequences of old age, but now it is known that certain of
them, such as nutritional deficiencies and tooth loss, are
coincidental rather than incidental to increased age.
 Aging is a variable process.
 Elders create a need which must be met by the health
professions and many of these patients need complete
dentures. 5

6.  Successful complete denture therapy begins with a
thorough assessment of the patient’s physical and
psychological condition and determining a treatment that
will deliver a functional complete denture that will
satisfy the expectations of the patient.
6

7. DEFINITIONS:
7

8. 8
• Prosthodontics is the dental specialty pertaining to the
diagnosis, treatment planning, rehabilitation and maintenance of
the oral function, comfort, appearance and health of patients with
clinical conditions associated with missing or deficient teeth
and/or maxillofacial tissues using biocompatible substitutes.
According to GPT – 8TH ED. -
PROSTHODONTICS

9. DIAGNOSIS :-
According to HEART WELL
Diagnosis is the act or process of deciding the nature of
the diseased condition by examination
A careful investigation of facts to determine the nature
of a thing
The determination of the nature, location and causes of
a disease.
9

10.  According to BOUCHER
Diagnosis consists of planned observations to determine
and evaluate the existing conditions, which lead to
decision making based on the conditions observed.
10
• According to GPT – 8TH ED.
The determination of the nature of a disease.

11. 11
Treatment plan :-
According to SHELDON WINKLER
Treatment planning means developing a course of
action that encompasses the ramifications and sequelae of
treatment to serve the patient’s needs.
According to GPT- 8th ed. –
The sequence of procedures planned for the treatment of a
patient after diagnosis.

12.  In short, DIAGNOSIS & TREATMENT PLAN can be
summarized as:
 Recognizing the problem
 Formulating the plan
 Carrying out the necessary examination
 Finally, interpreting the result.
12

13. 13

14. GENERAL INTRODUCTION
TO THE PATIENT:
 First appointment  most important time
Fact finding
Development of mutual trust & understanding
 Familiar with the overall condition of the patient.
14

15.  New patients + patients with previous experience 
complete history taking & thorough examinations in
which perceptive abilities of the dentist play an
important role.
15

16. PRINCIPLES OF
PERCEPTION:
 Detection: noticing something
 Discrimination: distinguish which we have noticed from
something else.
 Recognition
 Identification
 Judgement
16

17. DIAGNOSTIC
PROCEDURES
 Preferably carried out in two appointments:
THE FIRST APPOINTMENT:
 Acquainted with the patient
 Beginning of evaluation of the process involved in
diagnosis & treatment plan
17

18.  Obtain essential information from the patient:
18•Radiographic survey •Diagnostic casts
•Thorough history

19.  Since success & failure of treatment depends greatly
on mutual confidence & rapport between the dentist &
patient, the first appointment is extremely important.
 THE SECOND APPOINTMENT
 The dentist discusses the proposed treatment plan
 The sequence in which the treatment will be carried out
19

20. A THOROUGH HISTORY SHOULD INCLUDE:
 Personal Data:
 Name
 Age
 Sex
 Race
 Occupation
 Cosmetic index: Class I- High cosmetic index
Class II - Moderate cosmetic index
Class III- Low cosmetic index
 Personality (House ).
20

21.  Medical History
 General health
 Pathology
 Dental History
 Chief complaint
 Expectation
 Edentulism
 Previous denture/s.
 Existing or current dentures
 Pre extraction records
 Clinical evaluation 21

22. THE HOUSE CLASSIFICATION
 Proposed by Dr. Milus M. House
 General classification of patient’s mental attitude
 They can be classified as:
 Philosophic
 Exacting
 Indifferent
 Critical
 Skeptical
 Hysterical
22

23. PHILOSOPHIC:
 Willing to accept the dentist’s judgement without
question.
 Best mental attitude for denture acceptance.
 Motivation is generalized.
 Ideal attitude for successful treatment, provided the
biomechanical factors are favourable.
23

24. EXACTING:
 All good attributes of philosophic patient.
 Require extreme care, effort and patience on the part of
the dentist.
 Immaculate appearance and dress.
 Methodical, precise and accurate and at times make
severe demands.
 Want written guarantees or remakes at no additional cost.
 Like each step of the procedure to be explained.
 If intelligent and understanding  they are the best
or else extra hours must be spent, prior to treatment, in
patient education until an understanding is reached. 24

25. HYSTERICAL:
 Submit to treatment as a last resort, have negative
attitude, often poor health, unfounded complaints.
 Emotionally unstable, excitable, apprehensive and
hypertensive.
 Unrealistic expectations.(demand equals to natural teeth)
 Prognosis is often unfavorable.
 Additional professional help (psychiatric) is required
prior to and during treatment.
25

26. INDIFFERENT:
 Questionable or unfavorable prognosis.
 Little concern for their teeth or oral health.
 Without dentures or worn out dentures for years.
 Seek treatment because of the insistence of family.
 Pay no attention to instructions, are uncooperative &
give up easily if problems are encountered with their new
teeth.
 Donot value the efforts or skills of the dentist.
 Require more time for instruction on value and use of
their dentures.
26

27. CRITICAL:
 Find fault with everything that is done for them.
 Never happy with their previous dentist.
 Failure to recognize this category of patients may cause
immense problems for the inexperienced dentist.
 Exercise firm control over these patients
 Dentist must direct all the treatment & decisions
 Advise medical consultation.
27

28. SKEPTICAL:
 Have had bad results with previous treatment.
 Are doubtful if anyone can help them.
 Often in poor health.
 Unfavorable oral conditions.
 Conduct a thorough examination taking more time than
usual, since care and attention to detail at this time will
help the patient to develop confidence in the dentist.
28

29. 29
New M.M. HOUSE Classification
MM HOUSE MENTAL CLASSIFICATION REVISITED : INTERSECTION OF PARTICULAR PATIENT
TYPES & PARTICULAR DENTIST’S NEEDS(J Prosthet Dent 2003;89:297-302.) SIMON
GAMER,TUCH,GARCIA

30. 30
O’Shea et al characterized the ideal dental patient as
compliant, sophisticated, and responsive.
Winkler described 4 traits that characterize the ideal
patient’s response: (1) realizes the need for the prosthetic
treatment, (2) wants the prosthesis, (3) accepts the prosthesis,
and (4) attempts to use the prosthesis.
This patient corresponds to House’s philosophical- mind patient.
Koper characterized and typed patients who
have difficulty in adapting to complete dentures as problem
patients, difficult denture patients, or difficult denture birds.
Other classifications :
(J Prosthet Dent 2003;89:297-302.)

31. PATIENT MADE RECENTLY
EDENTULOUS:
 Completely unaware of difficulties
 Assume to continue same eating habits as with their
natural teeth
 Patient education is of paramount importance and
must begin with the second examination appointment
and continue throughout the entire treatment sequence.
31

32.  Expect their new teeth to last for a life time  not
possible as changes occur in the basal seat causing
position of dentures to change i.r.t. their foundation & to
each other.
 “Green Ridge”
 Tooth sockets do not completely fill with new bone
 Socket edges not rounded off as desired
 Bony spicules remain from extraction site
 Bony undercuts with a thin mucosal covering.
32

33.  Alveolar ridges recently made edentulous  subject
to large, rapid changes during the first year.
 The dentist must inform the patient of these potential
changes before beginning, to avoid problems later on.
33

34. PATIENT EDENTULOUS FOR A LONG
TIME:
 The problems they present are more difficult to treat
especially if they have been previous denture wearers.
 These problems must be recognized before adequate
treatment procedures are planned
 Most important among this group are the difficult
denture wearers  Personality characteristics should be
assessed.
34

35. OBSERVATION OF THE PATIENT:
 Begins when the patient enters the dental clinic.
 Aspects to be observed
 Motor skills
 Facial features
 Attitude and adaptive response.
35
Sheldon Winkler – Essentials of complete denture prosthodontics.

36. 36
(I) MOTOR SKILLS:
 CVA, Bell’s Palsy, nerve blocks for
trigeminal neuralgia  hemiplagia and
dyskinesia.
 Facial tremors/spasms indicate Parkinson’s
disease, nervous habits or possibly drug
induced tardive dyskinesia.
 Psychotropic drug therapy may show
Uncontrollable chewing movements
Licking and smacking of lips
Uncoordinated tongue movements
Sheldon Winkler – Essentials of complete denture prosthodontics.

37.  Twitching of the nose
 Puffing of cheek
 These complications often result in prosthetic failure.
DIAGNOSIS:
 Check fluency and quality of patient’s speech
 Best judged during casual conversation
37
Sheldon Winkler – Essentials of complete denture prosthodontics.

38. (II) FACIAL FEATURES:
Dentist must note
 Length of face
 Labial fullness
 Apparent support of lips
38
Sheldon Winkler – Essentials of complete denture prosthodontics.

39.  Observe for hollowness/puffiness in
Philtrum
Nasolabial fold
Labiomental groove
39
Sheldon Winkler – Essentials of complete denture prosthodontics.

40.  Texture of skin  determines the tone for anterior teeth
setup
 Rough textured skin deserves a more rugged tooth
arrangement than smooth, light coloured skin.
40
Sheldon Winkler – Essentials of complete denture prosthodontics.

41.  Size of oral cavity, activity of lips and width of vermilion
border  directly related to degree of tooth display.
 Profile view indicates position of maxilla to mandible 
first indication of patient’s occlusal classification.
41
Sheldon Winkler – Essentials of complete denture prosthodontics.

42. (III) ATTITUDE & LEVEL OF EXPECTATION:
 Factors producing adaptive response to complete
dentures:
 Acceptance of & confidence in dentist
 Previous favorable experience & capacity to cope
favorably with change
 Favorable physical conditions
 Realistic expectation of the patient
 Good learning capacity
 Desire to please the doctor
42
Sheldon Winkler – Essentials of complete denture prosthodontics.

43. o Factors that produce a maladaptive response to complete
dentures
 Lack of trust in the dentist
 Poor dentist-patient communication
 Negative previous experience
 Unrealistic expectations on the part of the patient
 Resistance to change
 Inadequate tissue tolerance
43
Sheldon Winkler – Essentials of complete denture prosthodontics.

44. MEDICAL HISTORY
44

45. MEDICAL HISTORY:
 Patients today have a more complex health history than
ever before.
 More likely to involve the dentist in medicolegal
challenge.
 Therefore a complete medical history is an extremely
important part of the patient’s overall diagnosis and
treatment planning.
45

46. (I) SYSTEMIC STATUS OF THE PATIENT:
 DEBILITATING DISEASES
 They must be kept under medical control
Eg. Diabetes, Blood Dyscrasias and TB
 Require
 Extra instruction in oral hygiene, eating habits & tissue rest
 Physician consultation
 Frequent recall appointments to check the status of
underlying bone and thus occlusion
46

47. 47
DIABETES
MELLITUS
Includes heterogenic group of disorders all having in common alteration
of glucose tolerance or impaired lipid & carbohydrate metabolism.
Type I – IDDM (autoimmune, destruction of b- cells of pancreas , 5- 10
% cases. In adoloscence)
Type II – NIDDM (insulin defeciency, 85-90% cases, genetic cause,
lifestyle disease, elderly people, obesity.)
Symptoms : Polyuria, Polydipsia, Polyphagia.
Oral manifestations : - Hyposalivation, Salivary Gland Dysfunction,
Parotid Enlargement, Taste Alterations, Burning Mouth Sensation &
Fungal Infections
Braz Dent J (1995) 6(2): 131-136 ISSN 0103-6440. Oral Manifestations of Diabetes Mellitus in
Controlled and Uncontrolled Patients.

48. DIAGNOSTIC CRITERIA & MANAGEMENT
 Management -
 Diet control
 Regular exercise
 Oral hypoglycaemic agents
 - Sulfonylurea – Tolbutamide, Gliclazide
 - Biguanides – Metformin
 - Alphaglucoside inhibitors –Acrabose
 Insulin therapy
48
Diagnostic criteria –
Fasting Blood Sugar Level >/=140 mg/dL
Post Prandial - >/= 200 mg/dL
Glycosylated Hb – more than 6-8%
Dent Clin N Am 50 (2006) 591–606

49. PROSTHODONTIC CONSIDERATIONS
 Blood Sugar Level
 Shorter appointments preferably in mornings
 Mucostatic impression technique
 Avoid adrenaline in LA
 Liquid supported dentures
 Use of soft denture liners.
49

50. TUBERCULOSIS
50

51. TUBERCULOSIS
PROSTHODONTIC CONSIDERATIONS
 Spread by aerosolized droplets  high risk to dentist
 Past history of T.B. physician’s consultation  if
culture positive  only emergency treatment provided
 Minimal use of high speed handpieces
 Operating air should be vented out .
 Oral lesions may make use of prosthesis difficult
51

52. DISEASES OF THE JOINTS
 Primary osteoarthritis:
 Familial disease
 More common in females
 “Heberdens nodes” involving terminal joints of fingers 
difficult for patient to insert & clean dentures
52

53.  Osteoarthritis of TMJ:
 Painful mandibular movements  difficulty in
construction of dentures
 Special impression trays  accommodate reduced
mouth opening
 Difficulty in recording jaw relations
 Occlusal corrections have to be made often
53

54. OSTEOPOROSIS
 Osteoporosis is a systemic disease in the elderly.
Osteoporosis shows a decrease in the skeletal mass
without alteration in the chemical composition of bone.
 Loss of the spongy spicules of bone that support the
weight bearing parts of the skeleton can be seen in
radiographs of regions of the skeleton that bear heavy
loads, such as the vertebral column, epiphysis of long
bones, the mandible and the fingers.
54

55. 55
Osteoporosis is common in aging individuals, especially post
menopausal women when the estrogenic blood level is low.
In elderly men and women, osteoporosis is caused by a
variety of factors such as calcium loss, calcium deficiency,
hormonal deficiency, change in protein nutrition and
decreased physical activity.
Progressive loss of alveolar bone may be a manifestation of
osteoporosis

56.  CARDIOVASCULAR DISEASES
 Includes ischemic heart disease(anginas), arterial
hypertension, arrhythmias, myocardial infarction &
chronic heart failure.
 Consultation with patients cardiologist is indicated
 Surgical procedure of any nature maybe contraindicated
 Short appointments with pre- medication
56

57. 57
Oral manifestation of cardiovascular disease.
Not specific.
Consequences of pharmacologic treatment, rather type of heart disease.
Most frequent cardiovascular drugs & their related manifestations are :
•ACE inhibitors : - Erythema Multiforme, Xerostomia, Loss Of Taste,
Pharyngitis, Burning Sensation & Ulcers.
•B- blockers : Xerostomia, Paresthesia.
•Calcium antagonists (nifedipine) : Gingival Hyperplasia, Sialorrhea
•Diuretics : Xerostomia, Parotid Gland Hypertrophy.
•Nitrates : Alterations Of The Denture Base Materials.
These all affects complete denture treatment .
For eg. Xerostomia - impairs prosthesis retention.
oral mucosa irritation
Adhesion of food to prosthetic materials
(Dent Clin N Am 50 (2006) 483–491 – ischemic heart diseases & their management. James R. Hupp)

58. 58
Prosthetic Management
•Communicate with the patient’s physician.
•Prevent hemorrhage in pt. taking anti-coagulant therapy.
•Reduce patient’s stress and anxiety.
•Morning appointment.
•Short wait in waiting room.
•Reassurance & peaceful environment.

59. 59
•Avoid surgical procedures if possible.
•If not, perform it under proper antibiotics coverage.
•Postpone procedures for at least 6 months if not very
necessary.
•Do not treat patient with coronary bypass until at least
2 weeks after operation.
•Always ready with emergency kit & services for an
immediate control.

60. 60
HYPERTENSION
Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients
with Hypertension.Bruce Bavitz
Adult classification:
Classification Systolic BP Diastolic BP
Normal 120 80
Prehypertension 120–139 or 80–89
Stage I hypertension 140–159 or 90–99
Stage II hypertension 160 or 100

61. 61
Oral side effects of antihypertensive medicines
Drug Oral adverse side effects
• Diuretics Dry mouth, lichenoid reaction
• Beta blockers Dry mouth, taste changes, lichenoid reaction
• ACE inhibitors Loss of taste, dry mouth, ulceration, angioedema
• Calcium channel blockers Gingival enlargement, dry mouth,
altered taste
• Alpha blockers Dry mouth
• Direct-acting vasodilators Facial flushing, possible increased risk
of gingival bleeding and infection
• Central-acting agents Dry mouth, taste changes, parotid pain
• Angiotensin 2 antagonists Dry mouth, angioedema, sinusitis, taste loss
Dent Clin N Am 50 (2006) 547–562 Dental Management of Patients with Hypertension.Bruce Bavitz

62.  ORAL MALIGNANCIES:
 Most often detected by the dentist
 Treatment of choice = eradication of lesion by surgery or
radiotherapy.
 Prosthodontic treatment therein is best handled by a
maxillofacial prosthodontist.
62

63.  Radiation therapist must be consulted  if tissues lack
tonus & have a bronze colour denture construction
should be delayed.
 Observe for signs of radiation necrosis
 Dentures should be used on a limited basis
63

64.  DISEASES OF SKIN
 May have oral manifestations Eg.
Pemphigus & lichen planus
 Oral mucosa is very painful
 Medical treatment may or may not give
comfort
 Constant use of dentures is
contraindicated  their use is primarily
for mental comfort
64

65. 65
White patch : - it may be :-
• Leukoplakia(non scrapable, habit associated)
• Frictional keratosis – seen only on ridges.
• Lichen planus – wickham striae.
• Candidiasis – scrapable

66. ORAL SUBMUCOUS FIBROSIS
 An insidious chronic disease affecting any part of the
oral cavity & sometimes pharynx ,although occasionally
preceded by &/or associated with vesicle formation. It is
always associated with juxta epithelial inflamatory
reaction followed by fibro-elastic changes of lamina
propria, with epithelial atrophy leading to stiffness of
oral mucosa & causing trismus & inability to eat.
66

67. ETIOLOGY
 Chronic irritation- chillies, tobacco, lime, arecanut
 Nutritional deficiency
 Defective iron metabolism
 Bacterial infections
 Collagen disorders
 Immunological disorders
 Genetic susceptibility
 Altered salivary composition
67

68. MANAGEMENT
 Restriction of habit
 Medicinal therapy –
 Supportive treatment
 Steroids – local , systemic
 Hyaluronidase
 Vitamine E
 Oral physiotherapy- Mouth opening, Ballooning of
mouth, Forceful mouth opening with mouth gag
68
Surgical treatment
Indications – marked trismus, neoplastic change
• Surgical treatments –conventional, laser, cryosurgery

69. PROSTHODONTIC CONSIDERATIONS
 Difficulty in impression making  due to restricted
mouth opening
 Solution – use of sectional impression trays
69
Journal of Prosthodontics 2010: 19; 299-302

70.  Difficulty during border molding d/t restricted movement
of tongue
 Difficulty in insertion & removal of dentures
 Solution – use of sectional dentures
70
Journal of Prosthodontics 2010: 19; 299-302

71. VESCICULO-BULLOUS LESIONS
 Vesciculo-bullous lesions which may have intra oral
manifestations are –
 Pemphigus
 Pemphigoid
 Erythema multiformae
 Management –
 Topical / systemic steroids
 Immuno-suppresive therapy
71

72.  Prosthodontic consideration –
 Difficulty in wearing removable prosthesis
 Increased chances of trauma due to prosthesis
72

73. CANDIDA ASSOCIATED LESION
[DENTURE STOMATITIS]
[CHRONIC ATROPHIC CANDIDIASIS]
 Site – usually under CD & RPD
 Appearance patchy distribution often associated with
speckled curd like white lesion
 Symptoms  soreness & dryness of mouth
 Signs  palatal tissue  bright red, edematous &
granular
73

74.  Red patches  erythematous or speckled sharply
outlined & restricted to the tissue actually in contact with
the denture
 Multiple pinpoint foci of hyperemia involving maxilla
74

75. TREATMENT
 Removal of the cause
 Replacement of denture or relining or applying
mycostatin
 Denture – cleaned thoroughly & regularly & should be
left out of the mouth at night in hypochlorite solution
 Anti-fungal treatment
75

76. ANGULAR CHELITIS
[PERLECHE,ANGULAR CHEILOSIS]
Causes
 Micro-organisms – mainly candida albicans
 Mechanical factors – over closure of jaws
- edentulous patient
- prosthesis with decreased vertical dimension
 Nutritional deficiency
 Atopic/ seborrhoic dermatitis
 Hypersalivation
76

77. CLINICAL FEATURES
 Dry & burning sensation at corners of mouth
 Rough triangular area of edema & erythema
 Wrinkled & maserated epithelium,deep fissures appear
ulcerated  do not bleed
77

78. MANAGEMENT
 Removal of cause
 Nutritional supplement
 Antifungal treatment –Miconazole
 Restore correct vertical dimension
78

79. HERPES
 Recurrent intra oral herpes
 Herpes zoster
 Prosthodontic considerations
 Use of prosthesis  uncomfortable
 Care taken to avoid herpetic whitlow
79

80. HIV AIDS
 Acquired immuno deficiency syndrome
 Epidemic disease
 Associated with wide range of oral
lesions like
 Oral candidiasis
 Oral hairy luekoplakia
 Kaposis sarcoma
 NUG & NUP
 Recurent aphthous ulcerations
80

81.  Many of the dental treatments are contraindicated in HIV
patients
 The treatment plan depends on the overall systemic
health of the patient
 Precautions for prevention of transmission
81

82.  NEUROLOGICAL
DISORDERS:
Eg. Bells palsy
Parkinson’s disease
Added Problems:
 Denture retention
 Maxillo-mandibular relation
records
 Supporting musculature
82

83. 83
BELL’S PALSY
JPD vol35, Issue 2, February 1976, Pages 192-201.Prosthetic support for unilateral
facial paralysis. Larsen & carter
Bell's palsy is a disorder of the nerve that controls movement of the muscles
in the face.
Damage to this nerve causes weakness or paralysis of these muscles.
Cause: Not clear. May be due to Herpes zoster infection
The face will feel stiff or pulled to one side, and may look different. Other
symptoms can include:
•Difficulty eating and drinking; food falls out of one side of the mouth
•Drooling due to lack of control over the muscles of the face
•Drooping of the face, such as the eyelid or corner of the mouth
•Hard to close one eye

84. 84
Dr. Suresh s. & Dr. Vipul asopa : Prosthodontic management of complete edentulous
patients with neuromuscular disorders - Case reports. JADR Jan 2011 : 2(1); 67-72.
Symptoms:
•Problems smiling, grimacing, or making facial expressions
•Twitching or weakness of the muscles in the face
•Dry eye or mouth
•Loss of sense of taste
•Sound that is louder in one ear (hyperacusis)

85. 85
•Prosthodontics considerations :
•Proper training on insertion & removal of dentures.
•Non- anatomic teeth.
•Heat strength metal reinforced denture bases
•Upright positions with head supported for making impressions.
•Repeated JR’s.
•Record neutral zone
•Denture hygiene instructions.
•Regular follow-up.
Dr. Suresh s. & Dr. Vipul asopa : Prosthodontic management of complete edentulous
patients with neuromuscular disorders - Case reports. JADR Jan 2011 : 2(1); 67-72.

86. 86
Dr. James Parkinson in 1817.
Parkinson's disease is a disorder of the brain that leads to
shaking (tremors) and difficulty with walking, movement,
and coordination.
Occurs mostly above 50 yr. of age.
Cause – destruction of dopamine producing brain cells
which control muscular movement.
Parkinson’s disease (shaking palsy)
Symptoms
•Automatic movements (such as blinking) slow or stop
•Constipation
•Difficulty swallowing & Drooling
•Impaired balance and walking
•Lack of expression in the face (mask-like appearance)
•Muscle aches and pains
•Movement problems.
•Confusions, dementia, hallucinations, memory loss etc.

87. 87
Gen Dent. 2008 May-Jun;56(4):e12-6.Complete denture prosthodontics for a patient with Parkinson's disease
using the neutral zone concept: a clinical report. Makzoume JE
Prosthodontic management :
•Neutral zone technique.
•If xerostomia is also present, then use of salivary substitutes
recommended.

88.  MENOPAUSE:
 Bone changes: generalized osteoporosis
 Mental disturbances: mild irritability to complete
nervous breakdown
 Oral symptoms: hot flushes, burning tongue, burning
palate and vague area pains.
 Tranquilizers and psychotherapy may help.
 Patient should be made aware of these conditions and
their possible effect during the period of denture
adjustment. 88

89.  Seasonal attacks  routine dental treatment – when
frequency of attacks is lowest
 Patients on steroids  additional dose may be required
to avoid serious reaction to dental stress
 Avoid inhalation anaesthetics or analgesics
89
MANAGEMENT
 Dietary calcium
 Estrogen therapy
 Regular exercise

90. 90
ADDITIONAL TESTS &
MEDICAL CONSULTATION
 Routine blood test.
 Blood sugar.
 Urine sugar.
 Referral to family physician.
 Specialist consultation.

91. PHYSICAL EXAMINATION
91

92.  Clinical Evaluation
92
Square Square
tapering
Tapering Ovoid
 Facial form according to House & Loop

93.  Facial profile according to Angle
93
Class I
Normal
Class III
Prognathic
Class II
Retrognathic

94.  Muscle tone according to House
o Class I :Normal muscle tone(immediate denture pt.)
o Class II: Slightly impaired muscle tone(following loss of all natural
teeth)
o Class III: Greatly impaired muscle tone & function
 Muscle Development according to House
o Class I: Heavy
o Class II: Medium
o Class III: Light
 Complexion (helps in shade selection)
o Hair
o Eye (pale anemic look)
o Skin( underlying disease)
o Nasolabial fold (normal 110 deg., wrinkles ) 94

95. Cracking, fissuring at corner & ulceration: indicative of
vitamin B-complex deficiency, candida infection,
overclosure of existing denture or neoplasm.
Lip contour - adequately supported or
unsupported(collapsed or wrinkled appearance)
Lip thickness
Lip length- long , medium and short.
Lip mobility – normal(classI)
reduced mobility(classII)
paralysis.(class III)
LIP EXAMINATION:
95

96. 96
Lip thickness – thick or thin
•Thick – gives more freedom in teeth setting.
•Thin – any change in labiolingual position can alter fullness,
support or drape of thin lip.
Lip length – long or short.
Measured from - base of the nose to vermillion border of lip
(ideal = 25 mm). or with index finger tip ,from incisive papilla
to upper lip.
•Long – will hide denture base & most of the tooh (maximum
facial expression is required for display of tooth).
•Short – any expression will expose most of the tooth or even
denture base.

97. LIPS CAN BE CLASSIFIED INTO 4 TYPES
1. Competent lips – lips are in slight contact
when the musculature is relaxed
2. Incompetent lips – morphologically short lips
which do not form a lip seal in a relaxed state
3. Potentially incompetent lips – normal lips , fail
to form lip seal
4. Everted lips – hypertrophied lips with weak
muscular tonocity 97
S.I. bhalajhi – orthodontics art &science, 3rd edition.

98. TEMPOROMANDIBULAR JOINT
 Clicking(disc displacement), crepitations(osetoarthrosis)
 Pain & tenderness on palpation
 Temporomandibular arthralgia
 Impaired mandibular mobility
 Irregularity or deviation on opening & closing of
mandible
 Deflection.
 Locking of mandible.
98

99. 99
Examination includes : Analysis Of Mandibular Movements
Palpation
Auscultation
Two types of examination :- preauricular (8 – 13 mm ahead
of tragus)
intraauricular
Preauricular is performed at 7o’ clock & 12 o’ clock position
Intraauricular is performed only at 12 o‘clock position.

100.  Neuromuscular Evaluation
 Speech- normal or affected.
 Coordination :-
 Class I: Excellent
 Class II: fair
 Class III: poor
 Arch Size
 Class I: Large (best for retention & stability)
 Class II: Medium (good retention & stability but not ideal)
 Class III: Small (difficult to achieve good retention and
stability) 100

101.  Determines the amount of basal seat available for
denture foundation.
 Greater the size, more the support
 Greater the contact surface, greater the retention.
 Discrepancy in size of the maxilla and mandible can
present a problem of stability in the smaller arch.
101

102. ARCH FORM
102
Class I
Square
Class II
Tapering
Class III
Ovoid

103. 103
BORDER ATTACHMENTS (HOUSE) :-
Class I – Attachements are high in maxilla or low in mandible with relation to
ridge crest (0.5 inches or more between level of attachment and crest of
ridge)
Class II – Attachements height is 0.25 to 0.50 inches.
Class III - < 0.25 inches from ridge crest.
FRENUM ATTACHMENTS (HOUSE):-same as border attachements
Class I – high in maxilla or low in mandible i.r.t. ridge crest.
Class II – medium
Class III – freni encroach on the crest of the ridge and may interfere with
denture seal. Surgical correction may be required (frenotomy or frenectomy)

104. RIDGE FORM:
104
Class I
Class II
ClassIII
Square
V-shaped
Flat Short
Inverted
Flat
Inverted U-shaped
Inverted
W
Tall
Inverted
Maxillary Mandibular

105. RIDGE CONTOUR:
 Type I: High, well rounded bone profile
+ve resistance
 Type II: Narrow, knife edge ridge
-ve resistance
 Type III: Rounded but lowered residual ridge
-ve resistance
 Type IV: Terminal stage
-ve resistance 105

106. RIDGE RELATIONSHIP ACCORDING TO ANGLE
 GPT8 - The positional relation of the mandibular ridge &
maxillary ridge.
106
Class – I Parallel Class – II Divergent Mandibular
Class – III Divergent Maxillary & Mandibular

107. RIDGE RELATIONSHIP ACCORDING TO SMITH
 It can be described as the Anteroposterior position of the mandibular residual
ridge relative to the maxillary residual ridge when the jaws are in centric
relation.
107

108. HARD PALATE:
 U-shaped palatal vault; most favourable for retention &
lateral stability.
 V-shaped vault: less favourable for retention.
 Flat palatal vault: also unfavourable.
108

109. SOFT PALATE:
 Classified according to configurations based on the
degree of flexure the soft palate makes with the hard
palate and the width of the seal area.
 Class I: Horizontal & demonstrating little muscular
movement. Most favourable condition as it allows for
more tissue coverage for posterior palatal seal. Forms a
10o angle.
 Class II: Turns downward forming a 45o angle to hard
palate. Potential tissue coverage is less than for class I.
 Class III: Turns downward sharply at 70o angle just
posterior to hard palate. Least favourable soft tissue
form. 109
Sheldon Winkler – Essentials of complete denture prosthodontics.

110.  V- shaped vault: associated with Class III soft palate
 Flat palatal vault: usually associated with Class I or Class
II soft palate.
110
Sheldon Winkler – Essentials of complete denture prosthodontics.

111.  Most ideal is a high ridge with a flat crest and parallel or
nearly parallel sides  maximum support & stability.
 Knife edge ridges or ridges with multiple bony spicules
offer the poorest prognosis  incapable of with standing
much occlusal force.
 Best determined by careful palpation.
111

112. PALATAL THROAT FORM: HOUSE
 CLASS – I
 Large and normal in form
 Immovable band of resilient tissue 5-12 mm distal to a distal edge of
the tuberosities
 CLASS – II
 Medium size and normal in form
 Relatively immovable resilient band of tissue 3-5 mm distal to distal
edge of the tuberosities
 CLASS – III
 Usually accompanies a small maxilla
 Curtain of soft tissue turns down abruptly 3-5 mm anterior
to distal edge of the tuberosities
112

113. GAG REFLEX:
 Normal defense mechanism developed by the body
to prevent foreign bodies from entering the trachea.
 Can be caused by:
 Systemic disorders,
 Psychological factors,
 Extraoral & intraoral physiological factors
 Iatrogenic factors.
 Controlled by glossopharyngeal nerve.
113
Sheldon Winkler – Essentials of complete denture prosthodontics.

114. MANAGEMENT OF GAG REFLEX:
 Clinical techniques, pharmacological measures,
psychological intervention.
 Identify the existence of gag reflex with a thorough
conversation with the patient.
 Careful handling of impression procedure and constant
reassurance of the patient will suffice.
 In severe cases, a specialist maybe needed to treat the
problem at a psychological level.
114
Sheldon Winkler – Essentials of complete denture prosthodontics.

115. PALATAL SENSITIVITY : HOUSE
 Class I: Normal
 Class II: Subnormal (Hyposensitive)
 Class III: Supernormal (Hypersensitive)
 Mucosal Thickness according to House
 Class I: Normal uniform density (1 mm)
 Class II: Thin investing membrane
 Soft tissues have mucous membranes twice the normal thickness.
 Class III: Thick investing membrane(redundant tissue,
tissue treatment)
115

116.  Mucosa condition according to House
 Class I: Healthy
 Class II: Irritated
 Class III: Pathologic
116

117. Class I
Class II
Class III
LATERAL THROAT FORM [MANDIBULAR] : NEIL
117
Lateral throat form is classified according to the extent of anterior movement
of the retromylohyoid curtain as the tongue is extended anteriorly beyond the
vermilion border of the lip.

118. SALIVA :
Class I: Normal(cohesive & adhesive)
Class II: Excessive(mucus)
Class III: Xerostomia(remaining mucinous.)
 Flow – regular or irregular.
 Quality – thin serous, mucinous, mixed.
 Quantity – normal, excessive, scanty.
 Contact – competent & incompetent.
Deficient saliva: retention of denture will be affected.
Excess of saliva: complicates impression making.
118

119.  Thick mucous saliva makes dentures more difficult to
wear. It will push out denture by accumulating beneath
the denture.
 Mixture of both Thin serous & Thick mucous saliva is
the best to work with.
119

120. COLOUR OF MUCOSA:
 Ranges healthy pink to angry red.
 Redness indicative of inflammation: related to ill fitting
denture, underlying infection, systemic disease or
chronic smoking.
 Pigmented spots or lesions.
 White patches  keratotic areas caused by denture
irritation.
120

121. TONGUE:
 If patient has been without teeth for a long time: tongue
becomes enlarged & powerful. This will create a
problem in impression making & may contribute to
denture instability.
 A small tongue: may jeopardize lingual seal.
 Tongue position is very important to the prognosis of the
mandibular denture. 121

122. 122
According to House : -
Class I – normal in size, development, & function.
Class II – teeth have been absent for long time
.permits change in form & function.
Class III – excessively large tongue.all teeth have
been absent for a long time, allowing for abnormal
development of the size of the tongue.

123. WRIGHT CLASSIFIED TONGUE POSITIONS AS
FOLLOWS:
 Class I: Tongue lies in the floor of the mouth with the tip
forward & slightly below the incisal edges of mandibular
anterior teeth. Most favourable prognosis.
 Class II: Tongue is flattened and broadened but the tip is in the
normal position.
 Class III: Tongue is tensed, retracted & depressed into the
floor of the mouth with the tip curled upward, downward or
assimilated into the body of the tongue. Least favourable
prognosis.
123

124. EXAMINATION OF EXISTING DENTURES
 Mucosa examined for pathological changes
 As per the study conducted by ostlund in 1953 it was reported
that in 77 % of the denture wearing patients there will be
presence histological changes even though mucosa appears
clinically normal.
 Evaluation of
 Denture cleanliness
 CR & CO premature contacts, sliding
 Vertical dimension
 Denture extensions
 Type of teeth
 Retention , stability
 Esthetics
 phonetics 124

125. RADIOGRAPHIC EXAMINATION
125

126. RADIOGRAPHIC EXAMINATION
 The interpretation of the panoramic radiograph should
follow a five step analysis:
1. Screen jaws for defect in structure and bony enlargement,
2. displacement of jaw parts,
3. unerupted teeth or retained root fragments,
4. foreign bodies,
5. radiolucencies as well as radio opacities.
 TMJ can be screened and findings correlated with history
and clinical examination.
126

127.  Describe the appearance of the lesion as well as any
bony changes adjoining the lesion
 Correlate the radiographic findings with the clinical,
historical and laboratory findings.
 Perform a differential diagnosis which includes all the
diseases that could explain the findings.
 Estimate the growth of the lesion by the appearance of
the jaw structures adjoining the lesion.
127

128.  Panoramic radiographs also aid in determining the
amount of ridge resorption.
 Wical & Swoope advocated measuring the distance from
the inferior border of the mandible to the inferior margin
of the mental foramen and then multiplying it by 3, the
resultant product is a reliable estimate of the original
alveolar ridge crest height.
128
.
Studies of residual ridge resorption. I. Use of panoramic radiographs for evaluation and
classification of mandibular resorption. J Prosthet Dent. 1974 Jul;32(1):7-12
Wical KE, Swoope CC

129.  Class I: Mild resorption, is a loss of upto one third of the
orignal vertical height.
 Class II: Moderate resorption, is a loss from one third to
two thirds of vertical height.
 Class III: Severe resorption, is a loss of two thirds or
more of vertical height.
129

130. 130
Radiographs is useful in the following instances : -
1. Bone pathosis, cysts, tumors.
2. Retained roots or teeth.
3. Bony fractures.
4. Soft tissue thickness.
5. Extent of bone resorption.
6. Thickness of body of mandible.
7. To locate mandibular canal & it’s proximity to ridge crest.
8. To locate maxillary sinuses.
9. To plan surgeries.
10. Remaining bone density and quality.
11. As treatment records.
12. For patient education.

131. TMJ DISORDER
131

132.  Temporomandibular Disorders (TMD)
 It represents a constellation of painful symptoms in the
jaw muscles and TMJs.
 Patient with TMDs commonly complain of pain in the
muscles of mastication, most frequently the masseter and
temporal muscles).
132

133. CLASSIFICATION
Group Disorder
Group I Muscle disorders
Ia Myofacial pain
Ib Myofacial pain with limited opening
Group II Disc displacement
IIa Disc displacement with reduction
IIb Disc displacement with reduction, with limited opening
IIc Disc displacement with reduction, without limited opening
Group III Arthralgia, arthritis, arthrosis
III a Arthralgia
III b Osteoarthritis of the TMJ
III c Osteoarthrosis of the TMJ 133

134. JAW DISABILITY CHECKLIST
 What activities does your present jaw problem prevent or limit
you from doing:
 Chewing
 Drinking
 Exercising
 Eating hard foods
 Eating soft foods
 Smiling/laughining
 Cleaning teeth or face
 Yawning
 Swallowing
 Talking
 Keeping your usual facial appearance
134

135. CLINICAL CONSIDERATIONS FOR DETERMINING
THE PROBABILITY OF A TMD
Consider
ations
High Low
Pain •Constant ache / tightness
•Sharp pain with jaw use
•Sharp, electric, burning, paroxysmal,
intermittent, spontaneous pain.
•Sharp pain with jaw use
Muscles Masticatory muscles or TMJ Site not necessarily in muscles or TMJs
Jaw use Aggravated by jaw use No definitive change with jaw use
Clinical •Pain reproduced with palpation
•Reduced range of mandibular motion
•Painful clicks or grinding in TMJs
•Jaw catches or locks
•Associated ear, neck, tension – type
headaches
May be associated with paresthesia,
dysesthesia or other neurologic signs
135

136. PROSTHODONTICS AND TMDS
 Alteration of TMJ anatomy, including disc displacements
and bony degeneration, may influence occlusal stability.
 Thus, prior to prosthodontic treatment, it is prudent to
provide clinical and radiographic evaluation of the TMJs.
 If clinical examination reveals crepitus and radiographic
evidence of bony alterations of the condyle or articular
eminence, the following steps may be considered prior to
prosthetic treatment:
1. CT scan of temporomandibular joints – it allows accurate
assess of the degree of degeneration of affected joints but
clinician can not predict whether the degeneration is active. 136

137. 2. Scintigraphy . To assess the extent of active
metabolic degeneration, aTc 99m bone scan may be
requested.
 If uptake is identified in TMJs, postpone prosthetic
treatment.
 If treatment proceeds in actively degenerating joints,
occlusal stability certainly cannot be predicted and
treatment failure may occur.
3. Diagnostic stabilization appliance
137

138. PRE TREATMENT RECORDS
138

139. PRETREATMENT
RECORDS:
 Diagnostic casts:
 Helps dentists avoid a potential problem
 Time consuming
 Aid in determining the inter ridge space, ridge relationships,
ridge shape and form that cannot be adequately determined
by clinical examination alone.
139

140.  Pre extraction records:
 Old diagnostic casts: determining both size, position &
arrangement of teeth.
 Old radiographs: determining tooth size & bony change.
 Photographs: relay information regarding tooth size,
position & display during facial expressions. Forms an
effective tool in achieving proper esthetics & patient
satisfaction.
140

141. PREPROSTHETIC SURGERY
141

142. REDUNDANT TISSUE:
 Excess amount of flabby tissue: cause denture base to
shift & move as force is applied, due to instability of
denture foundation.
 Surgical excision may improve the condition before
impression making.
142

143. HYPERPLASTIC TISSUE:
 When present under ill fitting dentures it may present as
an epulis fissuratum, papillary hyperplasia or
hyperplastic folds.
 Patient should be instructed to rest the tissues by not
wearing the existing denture.
 Proper oral hygiene and tissue massage.
 Existing denture should be refitted with a tissue
conditioning or temporary relining material. Occlusion
should be improved if possible.
 Last resort is surgical correction.
143

144. BONY UNDERCUT:
 Frequently found on both maxillary & mandibular
ridges.
 Usually pose no problem in denture insertion.
 Rule should be selective relief of denture rather than
surgical reduction.
 On mandibular ridge, the only undercut that can pose a
real problem is a prominent sharp mylohyoid ridge.
144

145. 145
. DEFECTS
Exostose or divots.
Preprosthetic surgeries may be
required

146. TORI:
 Torus palatinus & lingual tori frequently present.
 Torus palatinus: range from a small prominence in the
midline to one that covers the entire hard palate.
 Adequate relief must be planned.
 Lingual tori: interfere with denture construction & unless
very small should be surgically removed.
146

147. 147
Classification : -
Class I - Tori absent or minimal in size. Donot interfere with denture
construction.
Class II – Moderate size. Mild difficulties in denture construction
and use. Surgery not required.
Class III – Large in size. Compromise fabrication & function of
dentures. Requires surgical recontouring or removal.

148. FLOOR OF THE MOUTH:
 Near the ridge crest or when magnitude of movement is
great, retention and stability of the denture
 Sublingual gland & mylohyoid areas are concern where
floor of the mouth is high  cannot be selectively
displaced by the denture flange, the prognosis of the
mandibular denture will be poor.
 Retromylohyoid space maybe partially or totally
obliterated by tongue movement.
148

149. TREATMENT PLANNING:
 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.
 Must have a parallel process of developing a prognosis.
 Driven by the diagnosis but must take other factors such
as prognosis, patient health and attitudes into account.
149

150. WHY TREATMENT PLAN?
150
Treatment Plans
Addresses patient needs
Lists specific treatment
Specific logical sequence
Informed consent
Treatment
Time
Fees
Enables dentist to
Estimate
•Operating time
•Laboratory time
•Calender time
•Fees
Enables patient to
Delivered care
•Patient specific
Patient
receive
Dentist delivers
Enables
dentist
to

151.  Treatment planning determines the patients problems by
way of a thorough case history as previously described
 Thus making selection of the treatment option that is
most ideally indicated for the particular case at hand.
 By placing a primer on determining patient problems, it
also places a primer on the various treatment options that
are best suited for those particular conditions.
151

152. 152
Steps in t/t planning :-
•Tissue conditioning (finger massage, soft reline)
•Pre-prosthetic surgery (if any)
•Articulator (no, manufacturer, control settings)
•Tooth selection.
•Denture base materials.
•Denture base shade.
•Characterization.

153. PATIENT EDUCATION
 Use the treatment plan as an educational tool to raise the
patient’s level of understanding.
 Essential element in patient care and should start with the
initial contact with the patient.
 It is defined as an initial and continuing activity integral
to, and supportive of the treatment plan.
153

154. PURPOSES:
 Appraise the patient of their dental health & it’s
significance.
 Give the patient understanding of the significance of
edentulism.
 Harmonize the patient’s expectations with reality of
treatment potential.
 Explain the nature and use of prosthesis.
 Identify alternative treatment & their consequences.
154

155. 155
Occasionally, a patient might not agree to suggested treatment
plan, due to various reasons.
1. Surgery.
2. Time.
3. Expense.
4. Demand or requests.(within limits)
The alternate treatment plan may be less than ideal, but is
often necessary for various reasons. However, we must still
try to achieve the best possible result.
ALTERNATE TREATMENT PLAN

156. 156
REFUSAL OF TREATMENT
It is the duty of the Prosthodontist to respect the patients
wishes and include it in treatment plan whenever possible.
Sometimes, however, a patient’s demand may be unreasonable
or against professional judgement or ethics.
In such case, the dentist may refuse treatment or refer him
to another dentist for a second opinion

157. 157
Definition- A forecast as to the probable result of a
disease or a course of therapy.(GPT 8)
•After considering all the factors of the case, an
experienced dentist should be able to predict the degree of
success that can be expected.
•It includes realization by the patient of what can & cannot
be achieved.
•Ultimately leads to more realistic expectations & less
frustration & disappointment
Prognosis

158. 158
FEES AND INFORMED
CONSENT
•Diagnosis and treatment planning also helps the dentist decide the
fees that is fair to both the dentist and the patient.
•Once the patient has fully understood and agreed on the treatment
(including the fees), he/ she must sign a written consent.
•A signed consent is essential to prevent later misunderstanding.

159. A PRIMER ON TREATMENT OPTIONS
159

160. ADJUNCTIVE CARE
 Elimination of infection
 Elimination of pathoses
 Surgical improvement of denture support & space
 Tissue conditioning
 Nutritional counselling
160

161. PROSTHODONTIC CARE
 Edentulous Patient
 Complete denture
 Immediate or conventional
 Definite or interim
 Tooth, implant or tissue supported.
161

162.  Thus it is seen that diagnosis and treatment planning help
both the dentist as well as the patient understand the:
 Diagnostic procedures
 Diagnostic results
 Treatment plan
 Use of prosthesis
 Continuing care
 Fees
162

163. CONCLUSION:
 All the facts must be known before they can be
correlated in such a way that decision can be made. Only
then can treatment plans be developed to best serve the
needs of each individual patient.
 For the patient to be happier the dentist should not only
require the skills of complete denture construction but
also the skills to treat a patient’s aspirations &
expectations.
163

164. REFERENCES :
 William R. Laney: Diagnosis and treatment in prosthodontics,
2nd edition
 Boucher’s: Prosthodontic treatment for edentulous patients,
10th &12th edn.
 Winkler: Essentials of complete denture prosthdontics, 2nd
edn.
 J.J. Sharry: Complete denture prosthodontics, 3rd edn.
 Rahn & Heartwell: Textbook of complete denture, 5th edn.
164

165.  Sheldon Winkler – Essentials of complete denture
prosthodontics.
 Bernard levin – impressions for complete denture.
 Fenn- Clinical denture prosthetics, 3rd edn.
 S.I. bhalajhi – orthodontics art &science, 3rd edition.
 JADR Vol II:Issue I: Jan, 2011.Prosthodontic
management of complete edentulous patients with
neuromuscular disorders - Case reports. Dr. Suresh s. &
Dr. Vipul asopa
165

166. 166
•The dental clinics of North America, Jan 1996;40(1)
•The Dental Clinics of North America, Apr 1977;21(2)
•Radiographic examination of edentulous mouths, JPD
1990;64:180-182.
•Arthur Grieder : Psychological aspects of prosthodontics, JPD
1973;30:736-744
•Wical K.E. & Swoope C.C. : Studies of residual ridge resorption.
Part I Use of panoramic radiographs for evaluation and
classification of mandibular resorption. JPD 1974;32:7-12
•James R. Hupp : Ischemic Heart Diseases & Their
Management. Dent Clin N Am 2006 :50 (4); 483–491
•Bruce Bavitz : Dental Management Of Patients With
Hypertension. Dent Clin N Am 2006 : 50 (4); 547–562