DIAGNOSIS AND TREATMENT PLANNING

FOR EDENTULOUS OR POTENTIALLY

EDENTULOUS PATIENTS

Presented by: Rajsandeep

Guided by: Dr. Nidhi Duggal

Contents
1. Introduction
2. Patient rapport
3. Diagnosis
4. Visual observations
5. Radiographs
6. Panoramic radiography
7. Intraoral radiography
8. Palpation
9. Measurements
10.Diagnostic casts
11.Stepwise diagnosis
12.Chief complaint
13.Social information
14.Diabetes
15.Nutritional disorders
16.Diseases of joints
17.Scleroderma
18.Cardiac and pulmonary disorders
19.CVA
20.Bone disorders
21.Diseases of skin
22.Neurological dosorders
23.Malignancies and radiotherapy
24.Drug history
25.Mental health
26.Dental health
27.Patient expectations and attitudes
28.Extra oral examination
29.Intra oral examinaion
30.Treatment planning
31.Patient education
32.Treatment options for patients already wearing dentures
33.Prognosis
34.conclusions

INTRODUCTION
The complete denture more than any other dental
treatment depends for its success not only on the oral
cavity of the patient but also on his /her general health
and attitude. Complete denture rehabilitation involves
treating the patient and not just the oral cavity. Hence,
the physical and psychological status of the patient
along with oral health should be thoroughly assessed.
A successful complete denture therapy begins with a
thorough assessment of the patients physical and
psychological condition and determining a treatment
that will deliver a functional complete denture that will
satisfy the expectations of the patient which might need
to be modified in certain cases.

PATIENT RAPPORT
The initial contact with the patient is
most important and sets the tone for
the future interaction of the patient
with the dentist.
If the patient has a treatment history
in the present practice, both dentist
and patient have advantage of prior
knowledge.

DIAGNOSIS
It is the use of scientific or clinical methods to
establish the cause and nature of a persons
illness.
According to GPT it is the determination of the
nature of disease.
This is done by evaluating the history of the
disease process, the signs and symptoms, the
laboratory data, and specific tests such as
radiography.
The value of establishing a diagnosis is to provide
a logical basis for treatment and prognosis.

Various means of establishing a

diagnosis
An experienced clinician uses a
variety of tools for coming to a
diagnosis.
The final diagnosis and prognosis is
reached only after careful
examination of the patient visually,
written and verbal interaction with
the patient, palpation, studying of
diagnostic casts and making
radiographic evaluation.

Visual observations
The gradient between task and ambient lighting
should not be too great.
The task light should not produce glare to avoid
high contrast shadows.
The visual acuity decreases with age and higher
levels of lighting are required.
Color balance is important for not only shade
selection but also for evaluation of soft tissue.
Through visual perception, typical tasks to be
identified are detection, discrimination,
recognition, identification and judgment

Use of visual aids

1. Mouth mirror: gives comfortable viewing angles and also
helps focus light on the desired areas.
2. Magnification: hand lenses and loupes are used. Loupes
also have the advantage of giving a comfortable viewing
distance and some also give a comfortable viewing
angle using fiberoptics.
3. Still photography.
4. Intraoral videography gives well illuminated and
magnified images for immediate viewing and storage.
5. Still digital photography help in treatment planning as
the images are easily stored and retrieved for viewing
and when taken at the initial subsequent visits help in
evaluating treatment progression.

Radiography
These are important aids in detecting submucosal conditions.
These may be foreign bodies, retained roots, unerupted teeth,
various pathoses of developmental, inflammatory or
neoplastic in origin.
They aid in evaluating the quantity and quality of bone around
teeth and in edentulous areas.
They also provide information regarding bone surrounding the
apices of pulpless teeth.
The location of the mental foramen and the mandibular canal
can also be judged.
Sharp spicules of bone, spiny ridges and the thickness of the
submucosa affect decisions about the types of impressions
and the denture base design to be used.

Panoramic radiography
These incorporate inaccuracies as a result
of their tomographic principle and the
magnification is of the order of 25%.
Therefore the clinician has to have a
knowledge of the normal structures as they
appear on the panoramic projection.
These allow the clinician to have a broad
view of the supporting structures.
Suspicious areas are then examined using
intraoral radiography.

Intraoral radiography
Since the film used is small it can be placed
close to the tooth and therefore has less
magnification and since the film is placed
flat the distortion is also less.
They give more accurate details of a
smaller area. They are used to study
suspicious areas seen in larger projections.
Digital radiography has the advantage of
easy storage and retrieval and less
radiation exposure to the patient.

Palpation
It is referred to as the third eye of the clinician.
For submucosal structures it complements
radiographic examination. It will reveal textural
differences and unusual contours.
Displaceable structures, discontinuities and
enlargements are detected.
Sharp residual ridges, mylohyoid ridges are
typically tender.
Tenderness in apparently normal areas should
be investigated radiographically.

 Both primary and secondary bone support areas should be

palpated. The sides of the residual ridge should be
palpated along with the crest.
Irregularities and patient reactions are noted.
The floor of the mouth is examined using bimanual
palpation.
The patency of the wharton duct and production of saliva
is detected by the expression of saliva as the duct and
gland are gently squeezed.
For examining the tongue the patient is asked to protrude
the tongue onto a gauze which helps the dentist to hold
the tongue while using a mirror to examine it. The tongue
is palpated from the left to the right and the target areas
are the lateral borders and the vallate papillae.
The intraoral findings are corroborated with extraoral
palpation and are used to explore other structures such as
the TMJ and associated muscles

Measurements
The most commonly used extraoral measurents are the
VDO and the VDR which are often made using arbitrary
marks on the nose and chin however for future
references the menton and the columella of the nose are
used.
Other extraoral mearurements usually relate to the
selection of teeth. Eg. the ratio of the interpupillary line
on a photograph and that measured on the patient can
be used to calculate the size of the natural teeth by
dividing their size on the photograph by the ratio.
Intraoral measurements are made using probes, dividers
and boley gauges. these are helpful in monitoring various
mucosal lesion and in fabrication of custom trays.

Diagnostic casts
They allow for an evaluation of anatomy and relations in
the absence of the patient.
The mounting of casts on an articulator allows for a
dynamic evaluation of interarch relations.
A facebow can be used to relate the casts to an
approximate hinge axis.
We will look for arch size, symmetry, interarch space, arch
concentricity, anteroposterior jaw relationships and lateral
relations especially if a posterior crossbite occlusion is
indicated.
Undercuts might be seen with the naked eye or surveyed..
Displacement of tissues from a previous denture might be
more obvious on a dry cast than in the mouth.

Stepwise diagnosis
1.
.
.
.
.
.
2.
.
.
3.

History
Social information
Medical history
Mental health
Dental health
Dental history
Clinical examination
Intra oral
Extra oral
Any other investigations and diagnostic aids

Chief complaint
According to DeVan, the dentist should meet the mind of the patient before he
meets the mouth of the patient.
The chief complaint should be written in patients own words, patient should be
questioned regarding his chief complaint
History of the present complaint It is important to ascertain full details of any
complaint. If, for example, the complaint is of pain in relation to a denture, the
location, character and timing of the pain should be determined; relieving and
aggravating factors should also be recorded.
It is important to ascertain the relationship of the time of onset of the symptoms with
the time that the present set of dentures were fi tted. If a denture is loose, it is
important to enquire when the looseness was first noticed. If the denture has been
worn satisfactorily for several years before trouble developed, this indicates that
the dentures were initially satisfactory and that subsequent changes such as
resorption of the residual ridges or wear of the occlusal surfaces are responsible for
the problem. In this situation it is essential in addition to identifying the cause of
the complaint to note the good features of the denture, as it is usually sensible to
replicate these in the replacement dentures.
On the other hand, if the looseness was present from the time the denture was
fitted, the cause may be attributed to a basic design fault in the denture, to
unfavourable anatomical factors or perhaps to the inability of the patient to adapt
to dentures. Until an examination is made, it is not possible to distinguish between
these causes.

Social information
Addressing by name gains patients confidence.
Age : Age influences denture success. Tissues of the
older patients are less resilient and the oralmucosa
and Submucosa are thinner. Repair potential of
tissues are altered.
Frush and Fisher suggested guidelines for selection
and arrangement of anterior teeth based on age, sex
and personality.
Some age related diseases of interest are
Congenital cleft lip and palate, Acute rheumatic
fever, Scleroderma, Rheumatoid
arthritis,Hypertension, Diabetes ,Climacteric etc.

 Sex : Generally appearance is of high priority for women and men are
more concerned with comfort and function. Women during menopause can
be difficult to treat due to psychological problems, dry mouth, burning
sensation in the mouth and general vague pain.
For female patients the teeth must have softer anatomic features and
incisal edges must follow a curve which suggests softness. A more
masculine appearance is achieved by a more square or cuboidal tooth
form.
Some of the sex related disorder which have significant role in complete
denture therapy are Heamophilia, Osteomalacia, Iron deficiency anemia.
Occupation : A patients job and social standings often determine the
value he or she places on oral health, as well as the esthetics and other
qualities desired in denture. Tooth position is very important for a musician
who plays a wind instrument. Some occupational habits like nail biting of
tailors and cobblers may cause attrition of anterior teeth. Occupations like
public speakers, teachers and singers are more particular about the
phonetics with their new dentures.
Address : Helps in future communication, knowledge of patients social
status and setting up of appointments.
Out Patient Number : Helps to maintain the statistical analysis and
hospital data.

Medical History :
Provides important insights regarding patients
dental prognosis.
A patient in good general health is generally
able to accept and adjust to a complete
denture better than one who is in poor health.
Systemic factors that may affect complete
denture treatment include; anemia, arthritis,
Bell's palsy carcinomas, diabetes, nicotinic
stomatitis, Paget's disease, Parkinson's disease,
and therapies that cause xerostomia and
infectious diseases.

Diabetes mellitus
The following diagnostic features are in evidence in diabetes: a
dry feeling in the mouth; a coated tongue, with swollen edges
and tooth impressions along the borders; fissures on the
tongue; small abscesses throughout the mouth, poor tissue
tone; and a burning and metallic taste in the mouth.
It is associated with poor wound healing, increased bone
resorption, muscle atrophy and decreased salivation.
Appointments should be short and not interfere with meals
time.
Minimal pressure impression techniques should be used ,care
should be taken in teeth selection and type of occlusion.
The tissues need functional rest so patients should be advised
of less denture wear.
Frequent relining and rebasing of dentures may be required

Nutritional Disorders
Avitaminosis lowers the defense mechanism of
the body and mucosal structures,
Various type of anemia present the following
generalized symptoms: changes in the mucous
membrane; pallor of the tongue and lips; burning,
smooth, glossy tongue; and usually pain in the
tongue and supporting areas.
such painful conditions make the denture use
impossible without medical treatment.
patients have fragile mucosa so the dentures
should be as smooth as possible. Constant use of
prosthesis should be discouraged for these
patients

Diseases of the joints

The oral aspects of arthritis are usually seen in the temporomandibular
joint. These are limited movement and opening, generalized pain
throughout the side of the face, abnormal chewing procedures, and
changing occlusal relations.
Osteoarthritis :
When terminal joints of fingers are arthritic it is difficult for the patient
to insert and clean the dentures.
When it affects TMJ the mouth opening will be restricted and painful
movements of the jaw necessitates the use of special impression trays.
it becomes increasingly difficult for the patient to clean dentures
adequately. The patient can be helped by increasing the thickness of
the brush handle so that it can be gripped without discomfort, by
providing brushes which can be attached to a washbasin and by
recommending an effective cleansing solution which reduces the
reliance on mechanical means of plaque removal.

Scleroderma
Lips become rigid and the aperture narrows,
and presents mask like facial expression.
Restricted mandibular movements are seen.
Management includes improving the mouth
opening by stretching exercises and
sectional trays for impression making.
Dentures can be designed with midline
hinge, so that they are collapsible and can
be easily inserted and removed.

Cardiovascular and pulmonary

diseases
Cardiovascular conditions include hypertension, angina pectoris,
myocardial infarction, previous cardiac bypass surgery, Congestive
heart failure, presence of cardiac pacemaker and infective
endocarditis.
Proper care and treatment planning are necessary for such patients.
Hypertension: Morning dental appointments were once suggested for
hypertensive patients, however recent evidences indicate that blood
pressure levels generally increases around awakening and peaks at
mid morning, therefore afternoon dental appointments maybe
preferred.
Bronchial asthma : The asthmatic patients should be questioned about
concerned precipitating factors, frequency and severity of attack,
medications used and response to medications
Congestive heart failure, chronic bronchitis and emphysema
Elderly patients with these conditions are likely to become breathless
if the dental chair is tipped back into the supine position.

Cerebro-vascular accident
The occurrence of a stroke may result in
unilateral paralysis of the facial muscles,
making it more difficult for the patient to
control dentures, especially the lower
denture.
patient may also have difficulty clearing
food which has lodged in the buccal sulcus.
Speech may be affected, making it difficult
for the patient to communicate with the
dentist.

Bone disorders
the disorders of interest include
osteosclerosis, osteomalacia and
Osteoporosis.
osteoporosis can lead to a hunched
posture, or kyphosis, which requires
the dentist to ensure that work is
undertaken with the patient in the
sitting position with the head and
neck adequately supported.

Diseases of the skin

Skin diseases like pemphigus have oral
manifestations which may vary from ulcers to
bullae, Pemhigus is the most often fatal of the
dermatologic diseases.
Orally it presents vesicles and bullae on the
mucous membrane as well as on the skin. When
the vesicles rupture, they leave eroded areas
and ulcerations, and the resulting condition
causes discomfort and pain.
Other dermatological diseases include lichen
planus, pemphigoid, DLE.

Neurological disorders
Diseases like epilepsy, Bells palsy, Parkinsons disease can influence
the denture retention, jaw relation records and impression making
procedures.
Use of anxiety reduction protocol and stress levels should be
minimized.
Bell's palsy is a toxic, infective, thermal, or mechanical over
stimulation of the facial nerve, which results in facial asymmetry, lack
of muscular control on the affected side, failure of the eyelid to close
normally on the affected side, excessive tearing on the paralyzed side,
drooping of the corner of the mouth, and emission of saliva.
Parkinsons disease, as well as other tremors that are likely to occur in
the elderly, can adversely affect the precise control of the mandible,
making it more difficult to obtain an accurate recording of the jaw
relationship. Parkinsonism can also cause difficulty in swallowing,
leading to pronounced dribbling, which can be very distressing for the
patient.

Oral malignancies and radiation

therapy
High dose radiation therapy results in hypovascularity,
reduction in wound healing capacity and stress bearing
capacity of the tissues.
Saliva may become extremely viscous or non existent
depending on the dose of radiation.
Xerostomia may cause a decrease in the normal salivary
cleansing mechanisms.
Sialogogues and use of denture adhesives may have to be
considered.
Here posterior occlusion should be such that there is
reduced stress.
A waiting period should elapse between the end of radiation
therapy and beginning of complete denture construction.

Drug history
The dentist should know the medications a patien is taking. Some drugs have a direct effect on the
oral environment.
side effects that occur due to various medications are - Xerostomia, changes in the oral microflora,
Sialorrhea, dysphagia, postural or orthostatic hypotension, behavioural changes or confusion etc.
should be taken care during prosthesis fabrication.
The commonest drugs prescribed for elderly people, in descending order of frequency, are
diuretics, analgesics, hypnotics, sedatives, anxiolytics, antirheumatics and betablockers. Many of
these drugs have side effects that are relevant to the dentist about to undertake prosthetic
treatment.
Xerostomia is produced by certain antidepressants, diuretics, antihypertensives and
antipsychotics, some drugs having a more profound effect on secretion than others. Lack of saliva
adversely affects the retention of dentures, increases the possibility of oral infection and, through
the absence of lubrication, can result in generalised soreness or even a burning sensation.
Certain drugs, such as steroid inhalers used in the treatment of asthma, immunosuppressive drugs
and broad-spectrum antibiotics used over a long period, can alter the oral flora thus predisposing
to candida infection.
Tardive dyskinesia is a condition characterised by spasmodic movements of the oral, lingual and
facial muscles. These uncontrollable movements can make it extremely difficult, or even
impossible, to provide stable dentures. The condition is brought on by extensive use of drugs such
as antipsychotics and tricyclic antidepressants. It will occur in 2040% of patients who have been
taking the drugs for longer than 6 months. In approximately 40% of sufferers the condition is not
reversible, even if the drug therapy is stopped.
Endocrine injections and thyroid, estrogenic, and androgenic compounds often cause an extremely
sore mouth for the edentulous patient.

Mental health
Psychiatric disorders
Depression is the most common mental disorder in later life.
This condition can result in poor appetite and weight loss, and
can adversely affect motivation and self-care.
It is not a normal consequence of ageing and is treatable.
With regard to prosthetic treatment, the condition may reduce
the patients ability to make an effort to accommodate to new
dentures.
Dementia is found in 56% of people over the age of 65 and in
20% of those over 80 years old and can result in conditions
such as intellectual impairment, a poor memory (particularly
for recent events), poor concentration and a reduced level of
self-care. The situation can deteriorate to such a level that
dentures, particularly the lower, cannot be worn.

Psychological changes
Advancing age leads to certain inevitable changes that must be
taken into account when treating the elderly patient.
For example, the patient finds it more difficult to perform tasks that
depend upon rapid movements. Such tasks may well include the
need to suddenly control a denture that has become destabilized
during normal function.
It should also be realized that elderly people take rather longer to
learn to perform new tasks or to remember new information which
is not put over clearly or which may not appear to be immediately
relevant Elderly people are less able to accept new situations, be
they a change in denture shape, a new dentist or even the
appointment time for treatment.
It will be appreciated that the clinician must take many aspects of
the life of the patient into account when investigating a complaint.

House classified patients depending on their mental attitude

as philosophical, exacting, indifferent and hysterical.
1.Philosophical patient:
The best mental attitude for denture acceptance is the
philosophical type.
This patient is rational, sensible, calm and composed in
different situations.
His motivation is generalized as he desires dentures for the
maintenance of health and appearance and feels that
having teeth replaced is a normal, acceptable procedure.
2.Exacting patient:
The exacting type may have all of the good attributed to
the philosophical patient; however, he may require extreme
care, effort and patience on the part of the dentist.
This patient is methodical, precise, accurate and at times
makes severe demands. He likes each step in the procedure
explained in detail.

1. Indifferent patient
. The indifferent type of patient presents a questionable
or unfavorable prognosis.
. This patient evidences little if any concern; he is
apathetic, uninterested and lacks motivation.
. The indifferent patient pays no attention to
instructions, will not cooperate and is prone to blame
the dentist for poor dental health.
2. Hysterical patient
. The hysterical type is emotionally unstable, excitable,
excessively apprehensive.
. The prognosis is often unfavorable and additional
professional help (psychiatric) is required prior to and
during treatment.
. This patient is primarily systemic and many of his
symptoms are not the result of dentures

Dental health

Understanding of the etiology of the loss of teeth helps estimate the patients appreciation of
dentistry.
When obtaining a patients dental history, it is necessary to ascertain:
1. When the natural teeth were extracted
2. The reasons for the extractions
3. The occurrence of any surgical complications
4. How many dentures have been worn subsequently
5. the degree of success or failure with the dentures.
This history can provide important information on:
(1)The rate of bone resorption. The history of tooth loss provides a basis on which to make an
assessment of the current rate of bone resorption. If extractions were carried out in the
previous few months, resorption will still be continuing at a rapid rate, so that if dentures are
provided at this time they will soon become loose and require rebasing. The patient should
therefore be warned of this likelihood. If, however, the teeth were extracted several years ago,
the alveolar bone will have reached a relatively stable state and the life of a replacement
denture will be considerably extended.
(2)Retained roots. If there is a history of difficult extractions, it is advisable to obtain radiographs
in order to check for the presence and location of retained roots.
(3)The adaptive capability of the patient. Clues can be obtained to the adaptive capability of the
patient. For example, if three sets of dentures have been worn successfully over a period of 15
years, it may be assumed that adaptation has been satisfactory, whereas if the same number
have been provided over the last 2 or 3 years and each has been troublesome, adaptation will
be suspect. However, it is vitally important not to jump to conclusions and to put the blame on
the patient until one is satisfied that the complaint cannot be related to defects in the design
of previous dentures It is thus wise practice to ask the patient to bring all available sets of
dentures when attending for the initial assessment, as inspection of them can yield valuable
clues and increase the accuracy of the diagnosis.

 Patients who have lost teeth in an accident are usually more

unhappy about their edentulous state than those who lost
their teeth due to neglect.
The amount of bone loss would be more for the patient with a
long history of progressive periodontal disease than for the
patient with a history of caries.
Questioning should also include the general order of teeth
loss.
If all the posterior teeth were extracted prior to the anterior
teeth a habit of eating with front teeth may lead to
unstabilized effect on full dentures.
Past dental experiences good or bad might influence the
patients attitude towards and his expectations from the
dentist.

Patients Expectations And Attitudes

The reason the patient seeks prosthetic
treatment is of critical importance.
His or her expectations must be
evaluated to determine if they are
realistic and attainable.
The practitioner must be cognizant of
patients personality classification and
should not make unrealistic promises
regarding treatment outcomes.

The importance of older

dentures
Most edentulous people over the age of 65 are wearing dentures that
are more than 10 years old and, as a result, mucosal changes are
present in between 44% and 63% of cases.
The need for treatment, based on clinical judgement, suggests that
40% of 5-year-old dentures and 80% of 10-year-old dentures should be
replaced.
Need can be measured in a variety of ways:
Normative need is the need defined by expert or professional opinion.
Felt need is the patients subjective desire.
Expressed need is recorded when the felt need is activated through
the patient seeking treatment.
Elderly people are likely to consider that treatment is required as a result
of experiencing pain, difficulty in chewing, a deteriorating appearance,
or because the existing dentures are broken or have been lost.

Extra-oral examination of the

dentures
The dentures are removed from the mouth and a detailed and systematic extra-oral
examination is made of their impression, polished and occlusal surfaces. Any relevant
findings are recorded.
Impression surface
The presence or absence of a post-dam and palatal relief.
Width of borders.
The amount and distribution of plaque, an important cause of denture stomatitis.
Painting disclosing solution on the impression surface will help to visualise the
plaque.
Evidence of adjustments, relines or repairs.
Surface roughness.
Polished surface
Shape and inclination. In essence, is the shape such that it will allow the muscles to
help rather than hinder the control of the denture
Condition and general cleanliness of the denture material.
Occlusal surface
Amount of wear; presence of shiny facets.
Teeth acrylic or porcelain; size, shape and colour.

Intra-oral examination of the dentures Each denture is placed in

the mouth separately and examined for:
stability
retention
border extension.
The dentures are then examined together to assess the:
occlusion
occlusal vertical dimension
appearance
Assessing stability and retention An assessment of stability and
retention can be made by carrying out the following simple tests.
(1)Assessing stability of the upper denture.
(a)The upper denture is seated in the mouth and an attempt made to
rotate it in the horizontal plane. Any resulting lateral movement of
the midline is noted. Some movement is inevitable because of the
compressibility of the mucosa, but a movement of 3 mm or more
either side of the midline is an indication of loss of fi t or the
presence of a fl abby ridge.
(b)A similar conclusion can be drawn if an attempt to rock the denture
across the midline results in clearly detectable movement of the
prosthesis with the centre of the hard palate acting as a fulcrum.

(2) Assessing stability of the lower denture.

(a)The stability of a lower denture can be investigated by seeing if it stays seated
on the ridge when the mouth is slightly open and the tongue is brought
forwards so that its tip lightly contacts the lingual surfaces of the anterior
teeth. An unstable denture will usually be displaced away from the ridge by
the lower lip or by the tongue
(b)The patient is asked to move the tip of the tongue from the corner of one side
of the mouth to the other. Lack of tongue space within the arch of teeth will
readily result in movement of the denture.
(c)A lower denture can be unstable if the occlusal table is extended too far
posteriorly. Finger pressure applied to the lower second molars to check this
should meet with noticeable resistance. An unstable denture will readily slide
anteriorly.
(d)The lower denture is held against the ridge by a fi nger and thumb in the
incisor region and an attempt is made to move it in an antero-posterior
direction. The absence of any resistance to movement posteriorly is highly
suggestive of lack of extension of the denture base over the pear-shaped
pads.

cal examination
Intra
Extra
oral
oral

The clinical examination should proceed in a logical and orderly

sequence so that nothing is overlooked.

Extra Oral Examination

Simply by talking to the patient and making careful observations
at the same time, the dentist may obtain important information
that will help in treatment planning:
(1) Discrepancy between actual and biological ages. Any
discrepancy between the actual age and biological age should be
noted as this can be important in assessing the likely adaptive
capability.
(2) Skeletal relationship. The skeletal relationship of the patient
should be assessed because this will indicate the appropriate
incisal relationship of the planned dentures.
(3) Occlusal vertical dimension. The facial appearance provides
valuable information about the occlusal vertical dimension of
existing dentures. If loss of occlusal vertical dimension is noted,
correction may be required before new dentures are started

 Facial symmetry : Should observe for the symmetry of

the face, whether its bilaterally symmetrical or not
Facial form : Leon Williams claimed classified the form
of the human face in to 3 types Square/Tapering/
Ovoid
Facial Profile : Angle classified facial profile into
Normognathic/Prognathic/Retrognathic. The lateral
surface of the tooth viewed from the mesial aspect
should show a contour similar to that when viewed in
profile.
Complexion : Complexion helps in shade selection of
the teeth.

Lips
Restoration of the lip support and vermillion border width must be considered
during placement of the anterior teeth.
Lip thickness: Can be thick /medium/ thin .In patients with thin lips any slight
change in the labio lingual position of teeth makes an immediate change in the
lip contour
Thick lips give little more room for alteration in the teeth position before obvious
changes occur in lip contour.
Lip length : Lip length plays an important role in esthetics. Can be classified asLong / normal or medium/ short
A long lip reveals very little of the anterior teeth, where as a very short upper lip
leads to display of the denture base. Mold selection and denture characterization
can be critical factors in these cases.
Health of the lips : Angular cheilitis may occur in cases of decreases vertical
dimension. Should observe for fissures, cracks or ulcers at the corners of the
mouth.
Modiolus The muscles of the lips and cheek converge into a thick, mobile hob
region called the modiolus, which is slightly inferior and distal to the corner of the
mouth. This region is supported primarily by the maxillary teeth

Temporo mandibular joint

examination
Temporomandibular joints should be thoroughly examined. The range
of movements and the amount of deviation must be noted.
Any pain on palpation or during mandibular movements must be
observed.
Muscles of mastication must be examined for any tenderness. Joint
sounds like crepitus, clicking or popping sounds must be investigated.
These could be encountered due to severe discrepancy of vertical
dimension of occlusion or due to loss of posterior teeth which causes
the load to shift anteriorly.
A digital examination of the area over the temporomandibular joint
should be made. Place the fingers over each joint/ place in the
external auditory meatus behind the tragus and have the patient
slowly open and close his mouth.
Any pain or tenderness in this area may be indicative of an excessive
increase or decrease in the vertical dimension of occlusion. Crepitus,
clicking, or abnormal movements should be noted.

Influence of muscles
Muscle tone : The tone of the facial tissues may indicate the
limitations to improve the patients facial contours. The
muscle tone of the patient can be classified as
Class 1: the patient exhibits normal tension, tone and
placement of the muscles of mastication and facial
expression. No degenerative changes are apparent , usually
only immediate denture patients have normal muscle tone.
Class 2 : the patient displays approximately normal function
but slightly impaired muscle tone.
Class 3 : the patient exhibits greatly impaired muscle tone
and function.
Muscle development : Classification according to
M.M.House-Class 1 : heavy/Class 2: medium/Class 3: light

Intra-oral examination of the

patient
The broad objectives of this part of the examination are to determine:
Whether there is any pathology in the mouth;
What the prospects are for the new dentures providing a satisfactory level of
comfort and function.
Detecting systemic disease
The mouth has been aptly described as a mirror which reflects the state of health
of the individual. When systemic disease develops, the powerful combination of
microorganisms, normal wear and tear, and moisture and warmth present in the
mouth frequently result in visible changes in the oral tissues before signs of
disease are evident elsewhere in the body.
Investigation of these changes may allow an early diagnosis of the systemic
condition to be made. For example, there may be a change in the population of
papillae on the tongue; this change occurs first on the tip and sides, the areas of
maximum trauma. The filiform papillae are progressively lost so that the fungiform
papillae become more noticeable and produce the appearance of a pebbly
tongue; eventually, the fungiform papillae also disappear and the tongue becomes
smooth .
These changes should lead the dentist to suspect deficiencies such as iron, vitamin
B12 and folic acid. Diagnosis may be confi rmed by the appropriate haematological
investigations.

Mucosa
Normal color of the mucous membrane is coral pink , any
variation must be investigated. Common prosthetic causes of
irritation are - Over extension of the periphery of the denture, ill
fitting dentures, continuous wearing of the denture,. faulty
articulation of the teeth, rubber suction discs, traumatic injury,
allergy, small spicules of alveolar bone etc.
Mucosal Condition: Classification according to M.M.House - Class
1: healthy/Class 2: irritated/Class 3: pathologic
A mucosa of medium thickness and uniform resiliency offer the
most favorable prognosis. If the oral mucosa is excessively thick
stability becomes more of a problem than retention. If the
mucosa is inflamed it should be treated before impression
procedures are started. Thickness of mucosa is classified
according to M.M.House as
Class1: normal or uniform/Class 2: twice the normal/Class 3 :
excessively thick

 Arch Size :
Class 1(large) : The alveolar ridge of adequate height gives support and to
resist lateral movement of the denture.
Class 2 (medium) : The alveolar ridge would have undergone some
resorption
Class 3 (small ) : the alveolar ridge is almost or completely resorbed. There
is no resistance to lateral movement of the denture
Arch Form : Arch form is generally classified as square, tapering, or ovoid.
Class 1 : Square arch form is the best form to prevent rotational movements
Class 2 : The tapering form offers some resistance to movement but to a
lesser degree than the square arch
Class 3 : The ovoid form offers little or no resistance to rotational
movements.
The vault form should be classified as follows
Class 1- Square or gently rounded
Class 2 - Tapered or V shaped
Class 3- Flat
Mandibular ridge form
Class 1- parallel walls & broad crest
Class 2- Inverted U shaped , short with flat crest
Class 3- Unfavourable-inverted W or short inverted V or with undercuts

 High ridge with a flat crest and parallel walls is

ideal which give maximum support and
stability.
The knife edge ridge with multiple bony
spicules offer the poorest prognosis because
they are incapable of withstanding much
occlusal force. Relief has to be provided for this
ridge type in the impression procedures.
The flat ridge also has a poor prognosis
because of the lack of vertical height affords
little resistance to horizontal movement.

 Inter arch space : Classified as

Class 1- Ideal interarch space to accommodate the artificial teeth
Class 2- Excessive interarch space leading to poor stability and retention of
dentures because of increased leverage action.
Class 3- Insufficient interarch space to accommodate artificial teeth, enchances
the stability of the dentures since the occlusal surface of the teeth are close
to the ridge minimizing tilting leverage but decreases retention.
Ridge Parallelism : When teeth are gradually lost the residual ridges will
diverge from each other. If the ridges are not parallel to the occlusal plane,
dentures will slide over the basilar tissues when occlusal forces are applied to
them.
Classified as :
Class 1 - Both ridges are parallel to the occlusal plane
Class 2 - Either the mandibular or maxillary ridge diverging anteriorly
Class 3 - Both ridges diverge anteriorly
Ridge Relationship : Jaw relationship can be
Normal (Angle class1): Anterior segment of the mandibular ridge is directly
below or slightly posterior to the maxillary ridges
Retrognathic mandible (Angle class2) : Anterior segment of the mandibular
ridge is retruded beyond the normal position as related to the maxillary
anterior ridge segment.
Prognathic (Angle class 3): Anterior segment of the mandibular ridge is
protruded beyond the normal position as related to the maxillary anterior
ridge segment.

Lateral Throatform
Neils Classification :
Class1 : Indicates that the anatomical structures will
accommodate a fairly long and wide flange; minimal
or no pressure is exerted on the finger , can be
classified as deep.
Class 2 : It is about half as long and narrow as the
class1 and twice as long as class3. it can be
classified as moderate.
Class 3 : This form has minimum length and thickness
Heavy pressure is placed on the finger. This is
important for ascertaining the border extension in
this area. This form can be classified as shallow

 The patient with the class 1 will be

more comfortable with a fairly thin
posterior border of 1 to2 mm. The
patient with class 2 throat form can
tolerate a posterior border of
moderate thickness. The patient with
the class 3 has little or no area for a
posterior seal, so the posterior
border can be made thicker.

Maxillary Tuberosities
Classified as-normal/Pendulous or bulbous
Large pendulous or bulbous tuberosities
may present a number of problems like
encroachment on the interridge distance.
Sometimes maxillary tuberosities may be
fibrous that hangs pendulously.
They should be surgically reduced as they
contribute to excessive vertical and
horizontal movement seriously jeopardizing
the stability of the denture.

Palate
Shape of The Hard Palate : Classified as flat/rounded/ U shaped / V shaped.
A flat palate resists vertical displacement but easily displaced by lateral or
torquing forces. The rounded and U shaped palate has the best resistance
to vertical and horizontal forces. The V shaped palate is the most difficult
one because any vertical or torquing movement tends to break off the seal
easily.
Relationship of the Soft Palate to the Hard Palate is classified as:
Class 1 : It is horizontal, makes 10 degree angle to the hard palate and
demonstrates little muscular movement. In this case more tissue coverage
is possible for posterior palatal seal
Class 2 : Soft palate makes 45 degree angle to the hard palate
Class 3 : Soft palate makes 70 degree angle to the hard palate.
Shape of the Soft Palate: MM House classified it as
Class 1 : More than 5mm of movable tissue available for post damming.
Ideal for retention
Class 2 : One to five mm of movable tissue available for post damming.
Good retention is usually possible
Class 3 : Less than one mm movable tissue available for post damming.
Retention is usually poor

 Bony Undercuts:
Class1 : bony undercuts are absent
Class2 : small undercuts, the denture can be placed by
altering the path of insertion
Class 3 : prominent bilateral undercuts, must be corrected
surgically.
Tori : A torus palatinus or lingual tori are occasionally
present. Extremely large tori must be removed surgically.
Small or moderate tori can be managed by altering the
impression procedures, since the thin mucosal covering
of these tori cannot tolerate pressure. Adequate relief
must be planned for tori in the impression and the
denture.

Freni
Frenal Attachments: Classification according to
M.M.House
Class 1: high in the maxilla as low in the mandible with
respect to the crest of the ridge
Class 2 : medium
Class 3 : freni encroach on the crest of the ridge and
may interfere with the denture seal , surgical
correction may be required.
Inadequate clearance may result in pain and
ulceration of mucosa or displacement of the denture.
Over clearance may result in a loss of seal and a
loose denture.

Tongue
Classification according to M.M.House:
Class 1 : normal in size, development and function.
Class 2 : teeth have been absent long enough to permit a change in the form
and function of the tongue.
Class 3 : excessively large tongue. All teeth have been absent for an extended
period of time allowing for abnormal development of the size of the tongue.
A small narrow tongue contributes to the ease of impression making , but
jeopardizes the lingual seal for the mandibular denture. A broad thick tongue
always is in the way during impression making, provides an excellent seal for
the denture. An extremely large tongue poses additional problems during
impression making and impairs denture stability.
Tongue Position : Classification according to Wright
Normal or Class1: the tongue fills the floor of the mouth and is confined by the
mandibular teeth.
Retracted or Class2 : the tongue is retraced. The floor of the mouth is pulled
downward is exposed back to the molar area.
Class 3 : the tongue is very tense and pulled back ward and curled upward.

Saliva
Saliva is classified as follows:
Class1 : normal quality and quantity of saliva, cohesive and
adhesive properties of saliva are ideal.
Class 2 : excessive saliva, contains much mucous
Class 3 : xerostomia, remaining saliva is mucinous
Copious thick ropy saliva interferes with impression
procedures and often provokes nausea and increased
hydrostatic pressure leads to loss of retention of maxillary
denture.
Scanty thin saliva interferes with the seal of the dentures
and provides poor protection against scuffing and chafing.

Mylohyoid Ridge :
Should be examined by palpation,
can be sharp or normal.
The mucous membrane over a sharp or
irregular mylohyoid ridge will be easily
traumatized by the denture base, unless
relief is provided in the denture base.
Genial Tubercles :
May be sharp or normal. The genial
tubercles become prominent with
resorption of the ridges.

(3) Assessing retention. Tests of retention are usually only of value in

assessing the upper denture as the physical retention of lower dentures is
normally minimal:
(a)Seat the upper denture and attempt to dislodge it by pulling vertically
downwards with the thumb and first finger on the buccal aspects of the
right and left premolar teeth. Lack of resistance indicates poor retention.
(b)Seat the upper denture and ask the patient to open the mouth until the
incisal separation is 23 cm. If this causes the denture to drop, an error in
either the impression or the polished surface should be suspected.
(4) Border extension. The denture base is assessed for over- and underextension. Underextension of the upper and lower denture buccally, labially
and at the post-dam can be determined by direct vision. Overextension is
present if the denture moves occlusally when the muscles are gently
pulled. Lingual extension is less easy to assess. Anteriorly a mouth mirror
can help, and overextension can be inferred if the lower denture lifts when
the tongue is raised. A fully border moulded alginate wash impression
within the denture can be very informative, indicating either over- or
underextension.
(5) Occlusion. Both dentures are examined together in the mouth and a check
is made on occlusal balance.
(6) Appearance. A further assessment of the appearance of the dentures
should be made. The lips can be retracted and features such as orientation
of the occlusal plane, and the colour, shape and arrangement of the
anterior teeth can be noted.

Investigations
Radiographic Examination : A complete radiographic study
furnishes information as to the presence of retained roots,
foreign bodies, pathologic areas and generalized osteoporosis
in the bony support.
A panoramic radiograph is useful in assessing the amount of
ridge resorption.
Wical and Swoope found that in panoramic radiographs if the
distance from the inferior border of mandible to the lower
border of the mental foramen was measured and multiplied by
three, it gives the actual height of the alveolar ridge crest.
Other Investigations : Blood investigations Blood glucose
levels for diabetics, Hb % of blood for anemic patients is
important for any preprosthetic surgery desired.

Treatment planning
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 logical or technically necessary
sequence.
The adjunctive care in treatment planning includes:
1. Elimination of infection
2. Elimination of pathoses
3. Surgical improvement of denture support and space
4. Tissue conditioning
5. Nutritional counselling

Prosthodontic care
For the patient destined to become edentulous:
1. Removable partial denture
. Conventional
. Interim
. Hybrid complete denture
. Transitional
2. Complete denture
. Immediate or conventional
. Definitive or interim
. Tooth or implant supported
For the edentulous patient soft tissue supported or implant
supported dentures may be given. The implant supported
dentures may be removable or fixed.

WHY TREATMENT PLAN

PATIENT EDUCATION

Management of completely edentulous

patients already wearing complete dentures
Possible treatment options include:
No treatment.
Preparatory treatment such as denture adjustment or a short-term reline
Defi nitive denture modifi cations such as reline, rebase , repair or cleaning.
Replacement dentures.
If replacement dentures are to be made, it is of great value to make a note of
the features in the existing dentures that must be modified in order to
overcome the patients complaint. It is just as important to make a note of
those aspects of the existing design which have proved to be successful and
therefore need to be incorporated into the design of the new dentures.
There are several approaches to designing and constructing complete
dentures. The dentist should make a positive decision at the treatment plan
stage as to which is appropriate for the patient.
(1) Carving record rims. The shape, or design, of the dentures may be
determined by the dentist carving the record rims, so that the upper rim
provides adequate lip support and the lower rim lies in the neutral zone.

(2) Copy dentures. Where dentures have provided satisfactory service for
the patient in the past, it may be advisable to base the design of
replacement dentures on the well-accepted features of the old ones.
Such an approach is particularly appropriate for the treatment of elderly
patients who have a reduced ability to adapt.
(3) Biometric guides. measurements from certain anatomical landmarks
which allow the denture teeth and base to be placed in positions similar
to those formerly occupied by the natural teeth and alveolar bone.
(4) Functional neutral zone impression. When there are particular problems
in achieving stability of a lower denture for example, if there is
abnormal muscular activity or intra-oral anatomy the dentist can record
the neutral zone by getting the patient to mould a soft record rim into a
position of stability between the tongue and cheeks and lips by means of
swallowing and speaking. A lower denture is then produced whose shape
is derived from the neutral zone impression. This clinical technique has
been shown to enhance the tongues retentive ability over a conventional
design

Prognosis
The findings of the history and
examination will enable the dentist
to assess the degree of success the
proposed line of treatment is likely to
achieve. If problems are anticipated,
they should be explained to the
patient before treatment proceeds.
The patient is then
more likely to accept and to cope
with the unavoidable limitations of

Conclusions
Dentists must have a sense of real concern for the
health comfort and welfare of the patients to establish
necessary mutual confidence. A tender loving care
approach towards dental patients should be taken
before treatment is started and continued throughout
the treatment planning and the treatment itself.
Dentists must have a sense of real concern for the
health comfort and welfare of the patients to establish
necessary mutual confidence. A tender loving care
approach towards dental patients should be taken
before treatment is started and continued throughout
the treatment planning and the treatment itself.