Examination and diagnosis of complete denture patients

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Examination and diagnosis of complete denture patients

  1. 1. Examination And Diagnosis Of Complete Denture Patients www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. Examination And Diagnosis Of Complete Denture Patients www.indiandentalacademy.com
  4. 4. According to Glossary of Prosthodontic Terms “Examination is defined as scrutiny or investigation for the purpose of making a diagnosis or assessment” The goal in clinical examination is to recognize normal anatomy and physiology, normal variations, and early signs and symptoms of any disease. A through, comprehensive examination also allows modification or possible deferment of treatment when indicated. www.indiandentalacademy.com
  5. 5. Importance of case History Case history taking is important to know if the patient has recently become edentulous or has been edentulous for a long time. A “green ridge” may be bony spicules remaining from the extraction sites or bony undercuts with a thin mucosal covering. The intraoral examination will determine if any surgical correction is necessary, the prosthodontist must realize these possibilities and discuss with the patient. The examination should be carried out meticulously. A systematic recording of case history along with careful examination and evaluation leads to a diagnosis, probable prognosis and the tentative plan. www.indiandentalacademy.com
  6. 6. Prosthodontic Approach to edentulous patients Examination of edentulous patients should be divided into two steps: Getting acquainted: Seat the patient comfortably, don’t hurry, let him talk, one can learn much by listening. Establish rapport with the patient and the spouse or the person accompanying the patient. Develop mutual understanding. Technical analysis: (Do visual and digital oral examination, add x-ray and panorex apparatus). Make diagnostic impressions for visual explanation to the patient, guidance for oral surgeon, note correctable abnormalities and record all adverse factors, make plans for their management. www.indiandentalacademy.com
  7. 7. History taking and examination www.indiandentalacademy.com
  8. 8. Name Obtaining the name of the patient not only helps in maintaining records but also helps in creating a more personal and ambient atmosphere for the patient in the dental clinic. Addressing the patient by his/her name gives a rather personal touch to the dentist patient relationship. Age Age is an indicator of the patient’s ability to wear and use a prosthesis. Through the fourth decade of life, tissues heal rapidly and are resilient. Beyond fifth decade healing is not rapid. Woman facing the physiologic and psychological problems often present as exacting or hysterical patients who are very conscious about esthetics. Men are pre-occupied and present as indifferent patients who are concerned more with comfort or function. www.indiandentalacademy.com
  9. 9. Sex Generally appearance is a higher priority for women than for men. Though younger men are often grow indifferent to their own appearances as they age and are concerned with comfort and function. Occupation A patient’s job & social training often determine the values he or she places on oral health, as well as the esthetics and other qualities desired in a denture. Race Race can be critical factor in the characterization of dentures i.e., choice of denture base shade, denture base stains. www.indiandentalacademy.com
  10. 10. Chief Complaint The questioned regarding his or her chief complaint such as1. Inability to chew 2. Impaired speech 3. Poor appearance 4. Others. patient should be HOPI The duration of the edentulous state is of importance in ascertaining a proper diagnosis and treatment plan for the patient. Also the manner in which there was a loss of teeth helps to understand the patients personal interest in his or her oral hygiene and other habits. www.indiandentalacademy.com
  11. 11. Expectations The reason the patient seeks prosthetic treatment is important. His or her expectations must be determined. These should then be evaluated to determine I they are realistic, practitioner should not make unrealistic promises regarding treatment outcome. Mental Attitude House classified patients as: Philosophical Exacting Indifferent Hysterical www.indiandentalacademy.com
  12. 12. Philosophical Patient The best mental attitude for denture acceptance is the philosophical type. This patient is rational, sensible, calm and composed in difficult situations. The philosophical patient overcomes conflicts and organizes his time and habits in an orderly manner, he eliminates frustrations and learns to adjust rapidly. Exacting Patient The exacting type may have all of the good attributes of the philosophical patient; however he may require extreme care, effort and patience on Prosthodontist’s part. This patient is methodical, precise and accurate and at times makes several demands: if the patient is intelligent and understanding, he can give the best time. www.indiandentalacademy.com
  13. 13. Indifferent Patient The indifferent type of patient presents a questionable or unfavourable prognosis. This patient exhibits little concern if any; he is apathetic and 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. An education program in dental conditions and dental treatment is the recommended treatment plan before denture construction. Hysterical Patient The hysterical type is emotionally unstable, excitable, excessively apprehensive and hypertensive. The prognosis is often unfavorable and additional professional help (psychiatric) is required prior to and during treatment. This patient must be made aware that his/her problem is primarily systemic and that many of his symptoms are not result of dentures. www.indiandentalacademy.com
  14. 14. Dental History Reasons For Loss Of Teeth: The patient should be questioned regarding the cause of teeth loss (e.g. periodontal, caries, congenital, trauma etc) Duration Of Edentulousness The maxillary/mandibular responses to the question proves about bone resorption patterns and progression. Previous Denture Experience, Max/Mand: The patient should be questioned regarding the number & types of previous dentures; patients should be made to comment on the reasons for replacement and should be educated regarding the realistic limitations. A patient with a history of several dentures over a short time is a poor prosthodontic risk. Existing Or Current Dentures: The patient should be questioned about the length of time for which the dentures have been worn. Careful clinical observation may provide valuable information about denture experience, dental care, knowledge, parafunctional habits etc. www.indiandentalacademy.com
  15. 15. Medical History Debilitating diseases A) Diabetes: Oral Manifestations: Dry feeling in mouth, coated tongue with swollen edges, fissures on the tongue, small abscesses throughout the mouth, a faint odour of acetone may be prevalent in advanced cases and should be treated because dentures can be debased by the action of acetone. The patient should have medical control for the dental procedures to start. Non- pressure impression should be used for maximum physiologic compatibility of denture base with supporting tissues. Care should be taken as not to traumatize the tissues because healing in diabetic patients takes a longer duration e.g. diabetic ulcers. If patient has an insulin shock while treating place some sugar in his mouth. Instructions on eating habits and oral hygiene should be given. www.indiandentalacademy.com
  16. 16. B) Anemia: Oral Manifestation: changes in the mucous membrane, Pallor of the tongue and lips, burning, smooth, glossy tongue, usually pain in tongue and supporting areas. The patient should be placed under good medical care. Dentist must achieve good oral hygiene, efficient dentures, i.e, small food table with maximum supporting area to keep supporting tissues from being over stimulated. Careful patient instruction should be given. www.indiandentalacademy.com
  17. 17. C) Tuberculosis: Oral Manifestation: Oral lesions are not common in TB but when present they show long, deep fissures in the tongue; lesions on the mucosa of check; round, undermined ulcers that are very painful and firm nodules. Cautions & Procedure TB: Efficient dentures are necessary as diet is important in treatment.  Mouth hygiene is important as oral infections add to the load of general resistance.  Irritating projections on the dentures must be removed so that they will not erode the skin and start tubercular lesions.  Denture should be checked often for infection.  Dentist should protect himself by using mask, gloves and make a thorough scrub of face. www.indiandentalacademy.com
  18. 18. Diseases of the Joint: Diseases involving the joint particularly osteoarthritis is seen in 37 out of 100 adults approximately. Osteoarthritis of the TMJ presents a problem in complete denture constructions as mandibular movements are painful. Oral Manifestation: Limited movement and opening due to TMJ, generalized pain throughout the side of face, abnormal chewing procedures and changing occlusal relations are seen. In extreme cases, surgery must be indicated & oral surgeon consulted. Osteoarthritis is more prevalent in woman than in men. It becomes difficult in opening of mandible during impression may necessitate special trays and procedures. Occlusal corrections must be made often because of arthritic changes in TMJ. www.indiandentalacademy.com
  19. 19. Cardiovascular Diseases: Consultation with the patient’s cardiologist is indicated for a patient with CVS disease. Denture procedures of any kind may be contra-indicated. Pre-medication may be required before any procedure. www.indiandentalacademy.com
  20. 20. Diseases of the skin Pemphigus: It is the most fatal of the dermatologic diseases. O/M: Vesicles and bullae on the mucous membrane as well as on skin. When the vesicles rupture they leave areas and ulcerations & the resulting condition causes discomfort and pain. Foul odour is usually present in the oral cavity and loss of body weight is apparent. Medical treatment is necessary Supporting tissues are too painful to wear dentures which should be worn only for mastication & mental comfort. Lupus Erythematosis: It is a type of dermatitis and often thought to be lichen planus or leukoplakia, presents dermatitis on the face. Dry and atrophic area, scales over the lesions generally, sharply demarcated white patches, bases that are red with some edema. Dentures can be worn as lesions are not usually on the denture bearing area. Occasionally, some lesions are present on hard palate and need only relief. Good oral hygiene is required & periodic check-up to minimize irritation is required. Polished surfaces of dentures should not irritate the lesions. www.indiandentalacademy.com
  21. 21. Leukoplakia: Term applied to smooth, white, diffuse patches on the membranes of the lips, tongue and cheeks, biopsy is the method of diagnosis. If specimen shows premalignant lesion then the affected area should be removed. If the report says that the patch on the membrane is heaped up keratin, no surgery is required & can be covered with a denture. www.indiandentalacademy.com
  22. 22. Oral Malignancies Most oral malignances are detected by the dentist. Oral lesions that cannot be readily diagnosed should be further studied by biopsy. Eradication of the lesion by surgery or radiation is a must and subsequent prosthodontic treatment is best handled by maxillofacial prosthodontists. Climacteric It is one of the periods in the life of both the male & female when an important change in bodily functions occur. In females, this period is termed as menopause. O/M – Desquamative stomatitis, apthosis (canker sores), herpes labialis (fever blisters), taste-aberrations (bitterness, metallic, saltiness), Xerostomia, burning tongue generalized muscle and joint pain, hot flushes, headaches, etc. www.indiandentalacademy.com
  23. 23. Radiation Recent radiations show bronzing and burning of external layers of the skin at the site or loss of hair at area. I/O diffuse scaring & slightly pale tissues are seen which are firm on examination. If dentures are to be worn, no abrasion or irritation should be present on supporting tissues. It is best not to use dentures at all over radiated tissues. www.indiandentalacademy.com
  24. 24. Nutrition Complete denture prosthesis also depends upon the health and integrity of the denture bearing tissues for successful function and comfort to patient. Careful impaction of the oral tissues and the oral environment is therefore important before making the final diagnosis and prognosis for the prosthesis Patients should also be asked about the vegetarian or non vegetarian status of their diet as this will also emphasis on the amount of forces the patient is accustomed to exert. Habits Information regarding the habits such as smoking, pan chewing etc should be taken. Also, habits such as bruxism can jeopardize the success of the even properly fabricated denture so the patient should be motivated and educated regarding these www.indiandentalacademy.com
  25. 25. The Physical Examination The face and mouth are relatively simple to examine since their component structures are readily accessible to visual inspection, digital palpation, and percussion and Roentgenographic examination. www.indiandentalacademy.com
  26. 26. Extraoral Examination Facial Form: Classification according to House & Loop, Fisher & Williams. a. b. c. d. Square Tapering Ovoid Different combinations. www.indiandentalacademy.com
  27. 27. Facial Profile (Acc. To Angle): The facial profile is examined by viewing the patient from the side. This helps in diagnosing gross deviations in the maxillomandibular relationship. Profile is obtained by joining the two reference lines, line joining the forehead and the deepest point in curvature of upper lip (A). Line joining point A & most anterior point on the chin (B). Based on Relationship of these lines a. Straight/orthognathic: The two lines form a nearly straight line b. Concave/prognathic: The two references lines form an angle with the convexity towards the tissue. This is associated with a prognathic mandible or a retrognathic maxilla as in Class III malocclusions c. Convex/retrognathic: The two lines form an angle with the concavity facing the tissue. This profile occurs as a result of a prognathic maxilla or a retrognathic mandible as seen in Class II malocclusion. www.indiandentalacademy.com
  28. 28. Facial Symmetry: It is examined to determine disproportions in transverse and vertical plane. In most patients, the right and left sides are not identical which is also termed as normal asymmetry. Some degree of asymmetry is accepted as normal whereas gross asymmetries are recorded. Gross asymmetries can be due to: a. Congenital defects b. Hemifacial atrophy c. Unilateral condylar ankylosis and hyperplasia. www.indiandentalacademy.com
  29. 29. Complexion: As all of us are aware that our aim is to achieve a harmonious blending of shape, shade, arrangement and position so that the final result is a “removable restoration that creates an illusions of being what it is not” so as to get an Esthetic denture which is defined as “the cosmetic effect produced by a dental prosthesis which affects the desirable beauty, attractiveness character and dignity of the individual. These shades should be comparable with the patient’s general facial coloration & complexion. a. Pallor may indicate anaemia, hyperthyroidism or nephrosis, systemic disease such as TB. b. Ruddy complexion sign of polycythemia or neoplasm. c. Bronzed skin occurs in Addison’s disease. d. Diffuse, bluish purple color may indicate Vit B2 deficiency. e. Lemon-yellow complexion of jaundice is associated with gallbladder, liver or bile duct disorders. f. Complexion marred by ulcerated lesions may be due to basal cell and squamous cell carcinoma. www.indiandentalacademy.com
  30. 30. Skin color Dark Skin, hair and eye Fair Along with patient’s age Medium Hair Black Brown White Grey Eye Helps in determining the tooth shade. Black Brown Green Grey www.indiandentalacademy.com
  31. 31. Lip support: If tissues around the mouth has wrinkles and rest of the face does not, significant improvement can be done. If present anterior teeth are set lingually, the lip will lack support and plans to bring new teeth forward can be made. The long standing wrinkles do not disappear at once. Lip Thickness: Thin Lips: Patients with thin lips present special problems. Any slight change in the labiolingual tooth position makes a sudden change in lip contour. Even overlapping of teeth may distort the surface of lips. Thick Lips: Variations in the arch form and individual tooth arrangement do not make obvious changes. www.indiandentalacademy.com
  32. 32. Lip Length: Patients with short upper lips will expose all the upper anterior teeth, much of labial flange as well. Care must be taken to select color and form of denture base. Long lip shows less of anterior teeth. Lip Fullness: This is directly related to the support it gets from the mucosa or denture base and the teeth behind it. An existing denture with thick labial flange could make the lip appear to be too full rather than displaced. If the existing dentures have the teeth set to far palatally, the patient may feel that the new and corrected tooth arrangement makes the lip too full. www.indiandentalacademy.com
  33. 33. Lip Mobility: Class I – normal Class II – reduced mobility Class III – paralysis Some stroke patients may have paralysis of half the lip leading to unilateral mouth droop and facial asymmetry and counseling should be done regarding treatment limitations as they might have unrealistic expectations regarding function and esthetics. Lips should be examined for cracking, fissuring at the corners and ulceration. These changes could be caused by Vit B complex deficiency or infections from organisms such as candida albicans. www.indiandentalacademy.com
  34. 34. Muscle Tone: Classification According to House: Class I: The patient exhibits normal tension tone and placement of the muscles of mastication and facial expression. No degenerative changes are apparent. Majority of edentulous patients have experienced some degree of degeneration and usually only immediate denture patients have normal musculature. Class II: The patient displays approximate normal function but slightly impaired muscle tone. Maximum muscle function cannot be used following the loss of all natural teeth. Class III: The patient exhibits greatly impaired muscle tone and function. This is usually coupled with poor health, inefficient dentures, and loss of vertical dimension, wrinkles, decreased biting force www.indiandentalacademy.com and drooping commissures.
  35. 35. EXAMINATION OF THE TEMPOR MANDIBULAR JOINT: Good prosthodontic treatment bears a direct relation to the temporomandibular articulation since occlusion is one of the most important parts of the treatment of complete dentures. The TMJ affects the dentures which further affect the health and function of the joints. CLINICAL EXAMINATION OF THE TEMPOROMANDIBULAR JOINT: The examination should include the auscultation and palpation of the TMJ and the musculature associated with mandibular movements as well as the functional analysis of the mandibular movements. PALPATION: lateral palpation, posterior palpation Lateral Palpation: Exert slight pressure on the condyloid process with the index fingers, palpate both sides simultaneously. Register any tenderness to palpation of joint and any irregularities in condyloid movement during opening and closing maneuvers. The co-ordination of action between the left and right condylar heads should be assessed at the same time. www.indiandentalacademy.com
  36. 36. Posterior palpation: Position the little fingers in the external auditory meatus and palate the posterior surface of the condyle during opening and closing movements of the mandible. Palpation should be carried out in such a way that the condyle displaces the little finger when closing. MOVEMENTS OF THE MANDIBLE Opening movement Closing Protrusive excursion Retrusive Lateral All these are examined as part of the functional analysis. The amount and direction of these actions are recorded during the clinical examinations. Deviations in speed can only be registered with electronic devices e.g. Kinesiograph. The first signs of initial temporomandibular joint problem include deviations of the mandibular opening and closing paths in the sagittal and frontal planes. The characteristic movement deviations include incongruency of the opening and closing and uncoordinated zigzag movements. The ‘C’ and ‘S’ types of deviations are typical signs of functional disturbances. www.indiandentalacademy.com
  37. 37. Intra oral examination Arch size The size of the maxilla and mandible ultimately will determine the amount of basal seat available for denture formation. The greater the size: greater the support, larger the contact surface, greater the retention. If discrepancy is present, in the size of maxilla and mandible, it should be noted. This condition may arise from a developmental source, trauma, and early loss of teeth in one arch with resultant increase in resorption or from a severe Class II or Class III malocclusion. This may lead to a poor relationship of teeth in one arch to the other. Arch form The arch may be (i) square (ii) ovoid or (iii) tapered and opposing arch may or may not have the same form. The form of the arch will influence the support of the denture. If the arch form is not same in both the arches some problems in tooth arrangement can be anticipated. www.indiandentalacademy.com
  38. 38. Residual ridge contour / form Ridge form is characterized traditionally as by its crosssectional contour as a whole arch. i) U shaped ii) V shaped iii) Flat U shaped arch is generally favorable for supporting a denture since it has broad base for occlusal stresses and parallel sides that enhance adhesion and resistance to displacement as well as encourage border seal. V-shaped has a narrow crest that is not conducive to the reception of masticatory stresses without irritation and discomfort. Less favorable for retention because of its sloping sides and has a tendency to progress towards narrowness. The thin sharp mandibular ridge presents difficulty in prosthetic management. www.indiandentalacademy.com
  39. 39. Flat residual ridge is the most difficult for restoration by the prosthodontist. The normal pattern of resorption for maxillary arch is upward and inward as compared to the downward and outward progression of bone loss of the mandibular ridge. (Lack of vertical height produces less resistance to horizontal forces) Jaw relationship thus normally progresses to crossbite situations and complicate the distribution of prosthetic stress to the basal support. www.indiandentalacademy.com
  40. 40. Ridge relation Laney Smith described ridge relationship as the anteroposterior position of the mandibular ridge relative to the maxillary residual ridge when the jaws are in centric relation and separated by the distance they will be separated by the prosthesis. CLASSIFICATION BY ANGLE: Angle Class I (Normal): - Anterior segment of the mandibular ridge is directly below or slightly posterior to the maxillary anterior ridge segment. Angle Class II (Retrognathic): - Anterior segment of the mandibular ridge is retruded beyond the normal position as it relates to the maxillary anterior ridge segment. Angle Class III (Prognathic): - Anterior segment of the mandibular ridge is protruded beyond the normal position as it relates to the maxillary anterior ridge segment. www.indiandentalacademy.com
  41. 41. Ridge parallelism Classification according to Angle Class I – Both ridges are parallel to the occlusal plane Class II – The mandibular ridge is divergent from occlusal plane anteriorly Class III – The maxillary ridge is divergent from the occlusal plane anteriorly and/or both ridges are divergent anteriorly Importance: Ridges that are not parallel to each other will cause movement of the bases when teeth occlude because of an unfavorable direction of forces www.indiandentalacademy.com
  42. 42. Intermaxillary space This is the space between the maxillary and the mandibular arches. Normally it should be 20mm. If the space is less than 20mm it is difficult to obtain stability of the denture base, which is compromised as the teeth are set away from the basal seat. Class I: Ideal interarch space to accommodate the artificial teeth Class II: Excessive interarch space Class III: Insufficient interarch space to accommodate the artificial teeth www.indiandentalacademy.com
  43. 43. MUCOSA: Mucosal displaceability Classification by House Class 1: Normal uniform density of mucosal tissue (approx 1mm thick). Investing membrane is firm but not tense and forms an ideal cushion for the basal seat of the denture Class 2a: Soft tissues have thin investing membrane and are highly susceptible to irritation under pressure Class 2b: Soft tissues have mucous membrane twice the noraml thickness. Class 3: Excessively flabby to the degree that surgical excision is indicated www.indiandentalacademy.com
  44. 44. HARD PALATE SHAPE OF PALATAL VAULT U Shaped: It is most favorable for retention and lateral stability V Shaped: It is less favorable for retention because slightest movement of denture base will cause the seal to be broken with a resultant loss of retention Flat palatal vault: Is unfavorable. Usually accompanied by resorbed ridges and although retention may be satisfactory in a downward direction, any lateral or rotatory forces results in poor resistance and less retention www.indiandentalacademy.com
  45. 45. SOFT PALATE Classification is based upon the angle formed with the hard palate. The more acute angle of the soft palate in relation to the hard palate, the more muscle activity that is necessary for velopharyngeal closure (closing of nasopharynx). More the soft palate is markedly displaced in function, the less can be covered by the denture base. CLASS I: Indicates a soft palate that is rather horizontal as it extends posteriorly with minimal muscle activity. When the vibrating muscle is located, a few mm separate the anterior and posterior vibrating lines allowing for wide posterior palatal seal but not very deep. Considered as most favorable as more tissue surfaces can be covered leading to more retentive denture base. www.indiandentalacademy.com
  46. 46. CLASS III: Indicates the most acute contour in relation to the hard palate, creating marked elevation of the musculature to create velopharyngeal closure. Seen usually in configuration with a high V-shaped palatal vault. As there is greater elevation of the soft palatal musculature in function a few mm separate the vibrating lines and so, smaller area for the posterior palatal seal is there than class I. Along with being smaller, it is also deeper than class I configuration. CLASS II: Designates those palatal contours that lie between class I and class III Position of the patient: The classification of soft palate are determined when the patient is in upright position and the head is held erect. www.indiandentalacademy.com
  47. 47. MAXILLARY TUBEROSITY: Extremely large maxillary tuberosities make it necessary to locate the back end of the occlusal-plane too low, omit some posterior teeth or shorten the denture bases from their correct border extent and contour. Pendulous fibrous maxillary tuberosities are frequently encountered. They occur unilaterally or bilaterally and may interfere with denture construction by excessive encroachment on or obliteration of the interarch space. Surgical treatment is the choice and occasionally maxillary bone must be removed. Absence of maxillary tuberosities and loss of pterygomaxillary notch: Advanced bone resorption or excessive surgical resection of the tuberosity area can lead to absence of one or both tuberosities. This is frequently accompanied with obliteration of the pterygomaxillary notch area which is essential for enhancing for maximum breath to the posterior palatal seal area and the patient should be informed as the maxillary denture will not be as resistant to posterior downward dislodgement when incising takes place. www.indiandentalacademy.com
  48. 48. TONGUE: Smith described two anatomic tongue types: Long, narrow, tapered Short, broad and thick The first type presents fewer problems but while making impression; it might jeopardize lingual border seal. The second fills more of space in the floor of mouth so as to provide posterior denture flange and hence better border seal. Classification of tongue size according to House: CLASS I: Normal in size, development and function, sufficient teeth are present to maintain normal form and function. CLASS II: Teeth have been absent long enough to permit a change in the form and function of the tongue. CLASS III: Excessively large tongue. All teeth have been absent for an extended period of time, allowing for abnormal development of a class www.indiandentalacademy.com III tongue.
  49. 49. FLOOR OF THE MOUTH It presents a wide variation in anatomy and functional relation to the ridge crest. If the floor is near the crest, at rest or the magnitude of movement is great, magnitude of retention and stability is poor. The floor of the mouth in the sublingual gland and mylohyoid areas can be very high and close to the ridge crest at times may spill over the ridge and eliminate alveolingual sulcus. If there tissues cannot be placed selectively by the denture flange than the prognosis of mandibular denture is poor. www.indiandentalacademy.com
  50. 50. LATERAL THROAT FORM Niel described soft palate configuration throat form but distinguished this category from lateral throat form. He defined lateral throat form as the contour of the hard lingual surfaces of the mandibular ridge in the molar area and the velum like tissue distal to the mylohyoid ridge in the retromylohoid fossa as it functions under the influence of tongue. Lateral throat form is classified according to the extent of anterior movement of the retromylohoid curtain as the tongue is extended anteriorly beyond the vermillion border of the lower lip. Examination: With the index finger passively contacting the curved wall of mucosa in the retromolar fossa with the tongue at rest, patient is instructed to protrude the tongue. www.indiandentalacademy.com
  51. 51. Classification Acc to Niel CLASS I: If the lateral throat form changes configuration so as to place heavy pressure on the finger. CLASS III: If the pressure is minimal or no pressure is exerted. CLASS II: Any position of the tissue between these two extremes Overextension in the retromylohyoid areas results in loss of border seal, displacement of denture or soreness that readily radiates to the floor of the mouth, throat and neck www.indiandentalacademy.com
  52. 52. TORI CLASS I: Tori are absent or minimal in size and do not interfere with existing denture. CLASS II: Clinical examination shows several tori of moderate size, often mild difficulties in denture construction and use of surgery not required. CLASS III: Large tori are present. These tori compromise the function of dentures. These tori require surgical removal. www.indiandentalacademy.com
  53. 53. FRENUM ATTACHMENTS Classification according to House: CLASS I: High in the maxilla or low in the mandible with respect to the crest of the ridge CLASS II: Medium CLASS III: Freni encroach on the crest of the ridge may interfere with the denture seal. Surgical correction may be required www.indiandentalacademy.com
  54. 54. Diagnosis The word diagnosis is derived from Greek word dia (thorough) and gnosis (knowledge) and is defined as “to know apart or to distinguish”. For our purposes diagnosis is defined as 1) The act or process of deciding the nature of a diseased condition by examination 2) A careful investigation of the facts to determine the nature of things or 3) The determination of the nature, location and causes of the disease - by Charles Heartwell. According to glossary of prosthodontics – diagnosis is defined as determination of the nature of disease. www.indiandentalacademy.com
  55. 55. The ability to make diagnosis is predicted on several different factors. The knowledge of how to conduct a careful and thorough investigation of a problem is important, but still more important is the knowledge of the system and the problems that might affect it. A correct diagnosis is the basis for the appropriate and adequate treatment of the patient with the problem. The prosthodontist will know the natural history of the problem and the most effective form of therapy. This information in turn then provides the basis for a prognosis. www.indiandentalacademy.com
  56. 56. DIAGNOSTIC AIDS 1. Pre-extraction records Old diagnostics casts are invaluable aids in determining tooth size, position and arrangement. Old radiographs are also helpful in determining tooth size and bony changes. Photographs showing natural teeth can also relay much information regarding tooth size, position etc; and be helpful in achieving proper esthetics and patient’s satisfaction. 2. Radiographic Examination Of Edentulous Patients Radiograph examination of edentulous patients is advisable prior to the construction of dentures. Use of the orthopantomograph for routine examination of prosthetic patients. Such an examination will often reveal the presence of residual roots, unerupted teeth or other abnormalities in patients who are otherwise free from signs or symptoms that might suggest existence of a pathologic condition. www.indiandentalacademy.com
  57. 57. 3. Diagnostics Casts On occasion, ridge relationships, inter-ridge distance or ridge shape and forces cannot be adequately determined by clinical examination alone. It may be necessary to make preliminary impressions and a maxillo mandibular relation record to mount the casts on the articulator. The centric relation and occlusal vertical dimensions records must be viewed around the entire arch. Sufficient space may not be available for both denture bases between the tuberosities of the maxillae and retromolar pad of mandible. www.indiandentalacademy.com
  58. 58. Conclusion As it is rightly said in a Latin proverb “The first step towards cure is to know what the disease is” The acquisition of knowledge is one of man’s greatest accomplishments. Putting that knowledge to use is the fuel that turns the wheel of progress. Research works may develop mathematical models, devise predictive procedures and test them satisfactorily, but the practicing prosthodontic treating the patient at a time will prove the ultimate worth of any suggestive method. So equipped with the knowledge and understanding of examination and diagnosis, we can become skilled hands to intervene during treatment planning. www.indiandentalacademy.com
  59. 59. References 1. The Dental Clinics of North America – Complete dentures 2. Charles M. Heartwell – Syllabus of complete dentures. 3. Boucher’s – Prosthodontic treatment for edentulous patients. Pg: 51. 4. Sheldon Winkler – Essentials of complete denture prosthodontics. Pg: 39. 5. Internet : http//:completedentures/XH229/diagnosis www.indiandentalacademy.com
  60. 60. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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