Diagnosis

&

treatment planning
in
complete dentures

The patients
expectations
and psychological
situation.

Evaluation of
the existing
dentures

Predictable results

Evaluation of the
patients general
and oral health
conditions &
History.

The factors to be considered : :

1.
2.

3.

4.
5.

Patient assessment & evaluation

Clinical history recording :
- Medical history
- Dental history
Clinical examination of the patient
- Extra oral
- Intra oral
Radiographic examination
Examination of the existing
prostheses

PATIENT ASSESSMENT

NAME

AGE

SEX

Occupation

Gait

Mental attitude

Philosophical

Exacting

Hysterical

Indifferent

- Can also be classified as :

Cooperative
Apprehensive
Uncooperative

CHIEF COMPLAINT
-

Primary reason the patient consults the

dentist .

Stated in patients own words and

perspective .

History of presenting illness

- Elaboration of all circumstances
surrounding the onset and progression
of patients symptoms .
- Emphasize the significant incidents in
chronological order

Clinical history

Medical history/ systemic

status

DIABETES MELLITUS

Poor wound healing

Increased bone resorption
Muscle atrophy
Decreased salivation .

- Appointments should be short.

- Minimal pressure impression technique
should be followed.
- 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

Blood dyscrasias

Anemia

Iron deficiency causes anemia

- Atrophic glossitis ,
- Mucosal pallor,
- Angular cheilitis .

Fragile mucosa ,so the dentures should

be as smooth as possible .

Leukemia
Oral complications of leukemia frequently
include gingival hypertrophy, petechiae, Ecchymosis,
mucosal ulcers, and hemorrhage
Multiple myeloma
-

Swelling of the jaws,

Pain,numbness mobility of teeth,
Pathologic fractures.
Punched out lesions of the skull and jaw .

Joint disorders

Osteoarthritis :
- Difficulty in inserting ,Removal and

Cleaning of dentures.
- If TMJ is involved , mouth opening is
restricted , painful movements of the jaw
necessitates the use of special impression
trays.

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

Cardiovascular Disorders

Hypertension
- Mild to moderate primary hypertension is
usually asymptomatic .
- Severe or later stage hypertension may lead to
the potential cardiovascular, cerebrovascular ,
and renal complications of the disease.

Antihypertensive drugs can often cause sideeffects, such as:

-

Xerostomia,
Gingival overgrowth,
Salivary gland swelling or pain,
Taste sense alteration, and
Paresthesia .

Establish the patient's baseline blood pressure

at the first dental appointment.

Reduce stress and anxiety during dental

treatment.

Do not use local anesthetics with

vasoconstrictors in uncontrolled or poorly
controlled hypertension.

Angina pectoris , Myocardial

infarction , Congestive heart failure ,
Infective endocarditis etc..

. Medical consultation before

treatment
. Premedication.

Pulmonary Diseases

Bronchial
Asthma
- Ask about concerned precipitating factors ,

frequency and severity of attack ,

medications used and response to
medications .

Considerations
Shorter appointments +/- sedation (preferably late

mornings)

Antihistamines .
Avoid aspirin containing drugs .
Minimize use of epinephrine .

Diseases of the skin

-

Diseases like Pemphigus have oral manifestations

which may vary from ulcers to bullae , such
painful conditions make the denture use
impossible without medical treatment.
Constant use of prosthesis should be
discouraged for these patients.

Neurological Disorders

Diseases like epilepsy ,

Bells palsy , Parkinson's disease can
influence the denture retention , jaw
relation records and impression
making procedures.
Use of anxiety reduction protocol
and stress levels should be minimized.

Radiation Therapy

High dose of radiation results in hypo vascularity ,

reduction in wound healing capacity and stress bearing
capacity of the tissues.

Saliva may become extremely viscous or non existing

depending on dose of radiation.

Sialogogues and use of denture adhesives may have to

be considered.
Waiting period should elapse between end of radiation
therapy and beginning of complete denture
construction.

MEDICATIONS

CLIMACTERIC CHANGES

Dental history

Year of edentulous

Reasons for tooth loss

Denture wearing experience

- Pre extraction records.

Clinical Examination

- Extra oral
- Intra oral

Extra oral

FACIAL FORM

Square

Tapering

Ovoid

Square tapering

FACIAL PROFILE

Class I - normal / straight

Class II - Retrognathic

Class III - Prognathic

FACIAL HEIGHT

LOWER

FACIAL HEIGHT

Directly related to vertical

height of dentures .
Important to determine the vertical
jaw relation.
If wearing dentures, height observed
under occlusion
- If face collapsed: loss of vertical
dimension
- Facial tissues stretched: excess VD

Reduced lower facial height

Increased lower facial height

Length of lips

Short .

Long .

Lip Fullness

Inadequate lip support

Adequate lip support

Lip thickness

Thin lips.

Thick lips.

so
a
N

ia
b
a
l

ol
f
l

Texture of the skin

Rough May require rugged teeth.

Wrinkles show reduction in vertical

dimension

All the factors aid in determination

of shade , shape and arrangement of
teeth

MUSCLE TONE
According to House classified asClass I - Normal tension, tone .
Class II - Normal muscle function with
slightly reduced muscle tone .
Class III Decreased muscle tone and
function .

Temporo mandibular Joint

PAIN & TENDERNESS in and around TMJ

and masticatory muscles on palpation, on
chewing .

RANGE OF MANDIBULAR
OPENING/MOVEMENTS impaired
mobility

JOINT SOUNDS clicking ,popping,

crepitus noted during condylar movements

Intra oral

SOFT TISSUE ASSESSMENT

-

MUCOSA
RESIDUAL ALVEOLAR RIDGE
PALATE
FRENAL ATTACHMENTS
- TONGUE
- SALIVA .

Mucosa

Colour
coral pink
- Redness indicates inflammatory change, inaccurate impression
- Pigmented lesions- light to dark brown or blue
- White patches frictional keratosis, cheek biting
- Fordyce's granules

Classified as
Class 1 - Healthy
Class 2 Irritated
Class 3 - Pathologic .

Normal colour of mucosa

Inflamed mucosa

Thickness
A mucosa with medium uniform
thickness and uniform resiliency offer the most
favorable prognosis.

Classified as Class 1
Normal density of mucosal tissue ( 1 mm- ideal
cushion for basal seat) .

Class 2
Soft tissue with mucous membrane twice the
thickness

Class 3
Excessively thick investing membrane filled with
redundant tissue. Requires surgical treatment

Residual Alveolar Ridge

Arch size
CLASS- I
- Large :
ideal retention
and stability .

Class II
-

Medium:
good retention
and stability .

Class III
-

Small :
difficult to
achieve good retention
and stability .

Arch form
- Denture support
- Tooth selection .

SQUARE

- Best form to prevent

lateral movements of
dentures.

TAPERED

- Offers some resistance

to movement of
dentures.

OVOID
- Offers little or no
resistance to movement of
dentures.

Ridge contour
- High ridge with flat crest and parallel sides .

Flat
ridge

Knife edged
ridge / V
shaped

Ridge relation

Class I- Normal

Class II

RetrognathiC

Class III

Prognathic

Parallelism of ridges
-

Class I- Both ridges parallel

to occlusal plane

Class II

- Mandibular ridge
divergent anteriorly .

Class III
- Maxillary ridge diverts
anteriorly/both ridges
divergent .

Inter arch space

Class I

Ideal, 16-18 mm

Class II
Excessive inter arch space

Class III
Reduced
inter arch
space

Hard Palate
Shape of vault examined :
U shaped Ideal for retention and stability with well
defined incline of rugae .

V shaped , high palatal vault

Less retention , peripheral seal easily lost .

Flat
Reduced resistance to lateral and rotatory forces

Soft palate

Important to observe the relation

of soft palate to hard palate.

Called Palatal throat form .

Class I :
Soft palate is horizontal as it
extends posteriorly with
minimal muscular activity .

More than 5mm of movable

tissue available for post
damming.

Ideal for retention.

Class II
Soft palate make a 45
degree angle with hard
palate
1 to 5mm of movable
tissue available for post
damming.
Good retention is usually
possible.

Class III
Most acute contour about
70 degrees .

Less than 1 mm movable

tissue available for post
damming.
Retention is usually poor .

NEILS LATERAL THROAT FORM

Class I :
Large (extends well towards
tissues)

Class II :
Between I and III

Class III :
Small and unfavorable

Palatal sensitivity/Gag
reflex
-

Normal Defense mechanism .

Initiated by systemic disorders, psychological, extra

oral ,intraoral and iatrogenic factors

Management psychological, pharmacological.

- Classified as- normal, hyposensitive, hypersensitive .

BONY UNDERCUTS
-

May be an aid to retention

Cause loss of peripheral seal
Maxilla anterior ridge & lateral to
tuberosities
- Mandibular under mylohyoid
ridge
- If undercuts severe. Require
surgical intervention .

Tori
-

Abnormal bony prominences

Mid palatal in maxilla
Lingual side of mandible. Premolar
region
- Surgical intervention not necessary
unless they are big & interfere
- Require relief due to thin mucosal
covering

Classification of Frenal attachments

Class I

Attachments placed away from crest of the ridge

Atleast 0.5 inches between the attachment and crest

Class II

Distance between crest and attachments is 0.25-0.5 inches

Class III

Less than 0.25 inches of distance between crest and attachments

Tongue
Examination of position , size and coordination .
SIZE
Large Tongue - decreases the stability of denture and hinders
impression making.
Small Tongue - leads to inadequate peripheral seal .
Movement & Coordination :
Good movements for peripheral tracing and
maintaining denture during functional activities .

HOUSE CLASSIFICATION OF TONGUE SIZES

Class I
Normal in size,
development and function
with enough teeth present
to maintain the form .
Class IITeeth absent long enough
to permit change in from
and function of tongue .

Class III
Excessively large
tongue all teeth absent
for an extended period
of time allowing for
abnormal development
of tongue.

WRIGHTS CLASSIFICATION OF TONGUE POSITION

Class I
Normal
(favorable) Tongue
lies in floor of
mouth tip forward
and slightly below
incisal edge of
Most ideal position as floor of
lower incisors .
mouth is at ideal height ,the
lingual flange contacts it and
maintains peripheral seal .

Class II
Tongue flat and broad ,but tip in normal position

Floor of the mouth too low , tendency to overextend the denture

with resultant loss of retention .

Class III
Tongue retracted
and depressed in
floor of mouth with
tip curled upward
or assimilated into
body of tongue .

Saliva
-Viscosity should be determined .
CLASS I : Normal quality and quantity saliva with

ideal cohesive and adhesive properties

CLASS II : Excessive saliva, too much mucus

Class III : Xerostomia, poor retention and tissue

irritation.
- Thick ropy saliva alters seat of denture

Radiographic Examination

Class I resorption pattern

2/3 alveolar bone still present

Class II resorption pattern

1/3 2/3 alveolar bone present

Class III resorption pattern

1/3 or less of mandibular bone

TREATMENT PLANNING
The process of matching possible treatment options with
patient needs and systematically arranging the treatment in
order of priority but in keeping with a logical or
technically necessary sequence

The process requires a broad knowledge of treatment

possibilities and detailed knowledge of patient needs
determined by a careful diagnosis

The consequences of both treatment and no treatment

must be considered .

Treatment planning must have a parallel process of

developing a prognosis .

Treatment planning is driven by the diagnosis but

must take other factors such as prognosis, patient
health and attitudes into account .

Logical sequence of treatment planning

ADJUNCTIVE CARE
-

Elimination of infection
Elimination of pathosis
Pre-prosthetic surgery- to improve denture
support & space
Tissue conditioning
Nutritional counseling .

PROSTHODONTIC CARE
Patients destined to be edentulous ::
REMOVABLE PARTIAL DENTURE :

Conventional
Interim
Hybrid complete denture / RPD
Transitional .

COMPLETE DENTURE :
-

Immediate or conventional denture .

Definitive or interim denture .
Implant or soft tissue supported denture .

Patients already edentulous ::

COMPLETE DENTURE
- Soft tissue supported .
- Implant supported (fixed or removable) .