Diagnosis and treatment planning in complete denture #prosthodontics #cd #complete_denture #case_history #edentulous_patient #edentulous

1. Diagnosis and
treatment
planning in
complete
denture
ABHIRAM A B
IIIRD YEAR

2. CONTENTS
Diagnosis
Patient evaluation
History
Examination
Treatment planning
Prosthodontic diagnostic index (PDI) for complete
edentulism

3. Diagnosis
Diagnosis is the examination
and evaluation of the
physical and psychological
state and understanding the
needs of each patient to
ensure a predictable result.
Diagnosis involves patient
evaluation, history and
examination.

4. Patient
evaluation
This process commences as the patient
walks to the dentist’s chair as well as
during the introductory and history taking
conversation.
Gait
• Stooped shoulders—spinal changes.
• Tremor of head—Parkinson disease,
tranquillizers.
• Dragging of one leg—stroke.
• Staggering—excessive alcohol and
medication, hyperventilation, damage to
brain and spinal cord.

5.  Age
• This refers to the physiologic age and provides information about the
patient’s expectations and care for the dentures.
• A young patient who appears old may indicate disinterest, while an
old patient who appears young indicates willingness to adapt and
look good.

6.  Facial expression
• This provides information
about the mental attitude
and presence of any
disorders.
• Absence of any
expression indicates loss
of muscle tone, trigeminal
neuralgia, plastic surgery
or disorders of central
nervous system.

7.  Complexion
• It is used to select the colour of the
teeth.
• It may also be indicative of the
following conditions:
 Pale—anaemia, lack of nourishment.
 Ruddy—polycythaemia, chronic
alcoholic.
 Bronze—radiation therapy, Addison
disease.
 Bluish-purple—vitamin deficiency,
cyanosis.
 Lemon-yellow—jaundice.

8. Speech
• The fluency and quality of the
speech should be noted, as it will
help in arranging artificial teeth.
• Speech can also be altered due to
the following pathologies:
 Hypernasality—paralysis of
palatal musculature.
 Hoarseness—paralysis of both
vocal cords, excessive smoking.

9.  Breathing pattern
Abnormal breathing patterns may indicate the
following:
• Heavy sighing—emotionally disturbed
• Wheezing—asthma
• Shortness of breath—lung disease, heart failure
• Shallow breathing at rapid rate—pulmonary fibrosis
• Erratic breathing—continuous hyperventilation

10. Mental
attitude
•Dr M.M. House (1950) classified patients as
Class I:
Philosophical
patients
• They desire
treatment for
maintenance of
health and
appearance
and accept the
complete denture
treatment as a
normal procedure.
• They learn to
adjust rapidly.
• These patients
have the best
mental attitude for
acceptance of
the treatment.
Class II: Exacting
patients
• They are very
methodical, precise
and accurate,
making
severe demands.
• They are
comfortable when
each procedure is
explained
and discussed with
them in detail.
• They require
extreme care, effort
and patience on
part of the dentist.
Class III: Indifferent
patients
• These patients are
identified by their
lack of concern and
motivation and
apathetic attitudes.
• They may not pay
any attention to
instructions, will
not cooperate and
are prone to blame
others including the
dentist for their
poor health.
• A patient
education program
me is
recommended
before treatment.
Class IV: Hysterical
patients
• They are
emotionally
unstable, excitable
and apprehensive.
• They may not be
aware that their
symptoms may be
more related
to their systemic
health.
• They often
present
an unfavourable pro
gnosis and
additional psychiatri
c counselling is
required prior to
the treatment.

11. History
A record of all the information
obtained from the patient must
be made and kept for further
study and later use. The health
history is an extremely important
part of the patient’s overall
diagnosis and treatment
planning. It should include the
following:
 General information
 Medical history
 Dental history

12. General
information
oName
• This is important for
documentation and
record maintenance.
• Patients are more
comfortable and
confident when addressed
by their names.
This Photo by Unknown author is licensed under CC BY.

13. oAge
• Younger patients usually show better
healing ability. They also adapt easily
to treatment and a new prosthesis.
• Older patients need more care and
patience on part of the dentist.
• Proper nutritional care is very
important in geriatric patients. This is
an important consideration in the
selection and arrangement of artificial
teeth.

14. oGender
• Generally, appearance is a higher
priority for women.
• Males may be more concerned
about comfort and function of
the dentures.
• Menopause and its associated
hormonal and behavioural
changes are a concern with
women.
• This is also an important
consideration in the selection
and arrangement of artificial
teeth.

15. oOccupation/Social information
• Particulars such as the occupation can help in setting
up a convenient appointment for the treatment
procedure and in tooth selection and arrangement.
• Executives in high stress jobs may exhibit bruxism.
• People who work in places with high physical exertion
and factories where abrasive dust abounds require
rugged teeth which do not wear easily.
• Public speakers and singers may need greater
attention to palatal shape and thickness and perfect
retention.
• Wind instrument players may require special
positioning of anterior teeth.
• Patients in high socioeconomic groups may be more
demanding and critical, while those of low economic
status may show disinterest and poor hygiene
maintenance.

16. oLocation/Address
• Some endemic disorders may be
confined to certain localities.
oHabits
• Pan chewing, smoking, chronic
alcoholism may modify the systemic
status and evoke concerns regarding the
hygiene, maintenance and wear of the
denture.
• Habits like pencil biting and nail biting
may cause denture instability.
• Parafunctional habits like clenching and
bruxism should also be verified as they
affect teeth selection and prognosis.

17. oNutritional history
• It is important to obtain a
record of food intake of
the patient over a 3– 5
days period. This helps in
evaluating the nutritional
status of the patient.
• The ability of the oral
tissues to withstand the
stress of dentures is
greater in a well-
nourished patient.
• Dietary counselling is
necessary in
malnourished patients.

18. Medical history
No prosthodontic procedure should be commenced without evaluating the systemic status
of the individual.
Debilitating diseases
• The most common is diabetes mellitus.
• Patients are at a higher risk of opportunistic infections such as candidiasis and show
delayed wound healing.
• Salivary flow may also be impaired.
• Special emphasis on denture hygiene, recall and maintenance is also necessary for such
patients.
• Tuberculosis is contagious and necessary precautions are required. The therapy is also
long term and the drugs can cause nausea.
• Patient with blood dyscrasia require specific precautions if pre-prosthetic surgery is
contemplated.
• All patients with debilitating disease should be under medical control before commencing
any dental treatment.

19. Diseases of the joints
• Rheumatoid arthritis and osteoarthritis
are common diseases affecting the
joints.
• In the jaw, RA and OA can cause pain,
swelling, and stiffness, making it
difficult to wear dentures comfortably.
• When the temporomandibular joint
(TMJ) is affected, special impression
trays are required due to poor mouth
opening and frequent occlusal
correction may be necessary as jaw
relations are difficult to record due to
painful mandibular movements.

20. Cardiovascular disease
• Patients with stable cardiac problems
under the regular care of a
cardiologist are not contraindicated
for procedures.
• A consultation with the physician is
required if any invasive pre-prosthetic
procedure is contemplated, along
with premedication and stoppage of
anticoagulants.
• Cardiac patients with dentures may
need to take special precautions when
it comes to their dental health. Poor
dental health can lead to infections,
which can affect the heart and
increase the risk of complications for
cardiac patients.

21. Neurological conditions
• Neurological conditions such as Parkinson's
disease, stroke, and multiple sclerosis can
affect oral hygiene and the ability to wear
dentures comfortably.
• Patients need to be educated regarding
these anticipated problems.

22. Oral malignancies
• Construction of CD may be
commenced depending on the tumor
prognosis, the healing of tissues
following the treatment and the
amount of radiation.
• After CD construction, the tissues
should be evaluated constantly for any
evidence of radiation necrosis.
• Patient should be advised to use the
dentures on a limited basis.

23. Epilepsy
• Patient may aspirate or break the denture
during the seizure.
• It will influence the selection of denture base
material and teeth.
• Patient and close relatives may also need to be
educated on quick removal of the dentures
prior to or during seizures.

24. Diseases of the skin
• Dermatological diseases like
pemphigus have painful oral
manifestations like ulcers and
bullae.
• Medical treatment may or may not
provide relief to these patients. The
constant use of dentures in such
patients must be discouraged.

25. • This is an important consideration in women as they could undergo CD
construction during this period.
• The period is characterized by bone changes like osteoporosis, burning mouth
syndrome, mental disturbance ranging from mild irritability to complete nervous
breakdown.
• They may require psychiatric counselling and medication.
• Patient must be made aware of this condition before treatment and the possible
effect on denture adjustment.

26. Medications
• It can be an indication of a systemic
problem or dental treatment may be
modified and influenced by the effect of
the drug.
• Xerostomia is a common side effect of
antihypertensives and antidepressants.
• This can decrease denture retention and
cause increased soreness. Diuretics cause
changes in tissue fluids which affect
retention and stability of dentures.
• Psychotropic drugs can cause
uncontrollable tongue or facial
movements.
• Drugs can also act as synergists or
antagonists to produce undesirable
effects. Hence, the dentist must be aware
of all the patient’s medications

27. Dental history
• Chief complaint
The chief complaint is recorded in patient’s own words. It
should be determined if the complaint is justified and
realistic.
• Patient’s desires and expectations
It is important to find out what the patient expects from
the treatment. Unrealistic expectations will be
detrimental to success of treatment. Patient education
regarding what is possible is very important in such cases.

28. • Past dental history
The following information should be elicited:
1. Reason for tooth loss: If periodontal disease was the reason, more
bone loss is anticipated. It also helps in prognosis.
2. Period and sequence of edentulousness: Longer the period, more
will be the bone loss. By understanding the sequence, bone
resorption pattern can be identified.
3. Previous dental and denture experience: Traumatic experiences will
affect the attitude of the patient towards dental treatment and they
will require more counselling and education. Patient’s experience
with previous dentures will give an insight into their attitude, desire
and expectations.

29. • Current denture
The examination and evaluation of the present prosthesis
gives an insight into the patient’s previous experience, patient
tolerance and aesthetic values. It is evaluated for the
following:
 Extension of denture is evaluated using vestibule,
hamular notch and vibrating line as guides for maxillary
denture; and vestibule, retromolar pad, retromylohyoid
area and buccal shelf as guide for mandibular denture.
 The jaw relation—vertical and horizontal, is checked
using appropriate methods.
 Occlusion is verified for balance and premature contacts.
 Artificial teeth are examined for type and wear or
breakage. Considerable wear in a short time period is
indicative of bruxism.
 Retention and stability.
 Aesthetics.
 Maintenance of the denture is checked which will provide
information about patient’s hygiene, interest and
methods.
 Any previous prosthesis and the reasons for its change
should also be evaluated.

30. • Pre-Extraction records
This will include old diagnostic casts,
radiographs and photographs.
 Old diagnostic casts aid in
determining tooth size, position
and arrangement.
 Old radiographs aid in
determining tooth size and bony
changes.
 Photographs give information
about tooth size, position and
tooth display.

31. • Diagnostic casts
• They confirm and sometimes reveal
new information obtained from
intraoral examination. It may be of
immense benefit to keep the cast
ready during intraoral examination.
• Diagnostic casts should be mounted
on an articulator following a facebow
transfer. This allows for dynamic
evaluation of interarch relations, most
importantly the interarch space
(interridge distance), which is very
essential in determining if space exists
to place artificial teeth.
• Undercuts and their significance can
be evaluated with a dental surveyor.
• Preprosthetic surgeries can be
planned and surgical templates can be
made on the diagnostic cast.

32. Examination
Extraoral examination
• The patient’s head and neck should
be examined for the presence of any
pathologic condition.
• Any nodules and ulcerations on the
face are noted.
• Facial colour and tone, hair texture,
eye clarity, symmetry and
neuromuscular activity should be
noted.
• Face and neck are palpated to check
for enlarged nodes or masses

33. Facial examination
• Face form
Leon William has classified the facial form
based on the approximate shape of the face
as square, tapering, square–tapering and
ovoid
• Facial profile
The facial profile is classified as: • Class I:
Straight profile • Class II: Retrognathic or
convex profile • Class III: Prognathic or
concave profile. This helps in selection and
arrangement of artificial teeth

34. • Color of face, hair and eye
This helps in determining the
tooth shade. Though there is no
scientific evidence to associate
this colour with a particular
tooth shade, a harmonious
relationship of all of these
should exist.

35. Lip examination
• Lip health
• Fissures, cracking or ulcers at the corner of the mouth
indicate vitamin B deficiency, candidiasis and loss of vertical
dimension or neoplasm.
• Lip support
• Lack of proper support can lead to wrinkling. Correct
placement of upper anterior teeth will provide adequate lip
support to eliminate wrinkles around the modiolus.
• Lip thickness
• In patient with thin lips, even a slight change in the
labiolingual tooth position makes an impact on lip fullness
and support. Thick lips can tolerate more alterations in tooth
position without visible changes.
• Lip length
• Length of the lips affects the amount of anterior tooth
exposure and the anterior tooth size. Patients with short
upper lip will expose all the upper anterior teeth and much
of the labial flange of the denture base with any expression.
Long lip will hide most of the tooth and denture base. Short
lips will influence the selection of anterior tooth size and
characterization of denture base.

36. Muscular examination
The musculature surrounding the mouth plays
an important part in the stability of the
prosthesis. The musculature can be classified
according to House as:
 Class 1: Normal muscle function and tone
or patients showing no degeneration. This
is most commonly seen in patients with
recent extractions.
 Class 2: Normal muscle function with
mildly decreased muscle tone.
 Class 3: Decreased muscle tone and
function, seen as drooping commissures,
exaggerated nasolabial fold or loss of
vertical dimension.

37. Temporomandibular joint
The TMJ and associated muscles
should be examined for pain by
palpation or mandibular
movement. Range of opening,
deviation, clicking and crepitus
should be noted. It must be
decided if CD construction will
solve some of the problems
associated with the TMJ and
explained to the patient.

38. Intraoral
examination

39. Mucosa
• The mucosa of the cheeks, lips, floor of the mouth, residual ridge, hard palate
and soft palate is evaluated for colour and thickness and the condition is noted.
Colour
• Redness is a sign of inflammation, which could be due to ill-fitting dentures,
infections, smoking and systemic diseases such as diabetes. It is important to
eliminate the cause and allow the tissues to return to normal before impression
making.
• White patches and brown/blue pigmented spots should be noted. If the cause is
uncertain, a biopsy is indicated.
Thickness
• M.M. House has classified mucosa thickness as follows:
I. Class 1: Normal uniform density of mucosal tissue (approximately 1 mm
thick). Investing membrane is firm but not tense and forms an ideal cushion
for the basal seat of a denture.
II. Class 2: Soft tissues have mucous membranes twice the normal thickness.
III. Class 3: Soft tissues have excessively thick investing membranes . At the very
least, this requires tissue treatment. Such conditions may require surgical
correction.
Condition
• Classified by House as:
• Class I—healthy
• Class II—irritated
• Class III—pathological

40. Residual alveolar ridge
• Residual alveolar ridge should be evaluated for the
following.
Arch size
• Greater the arch size larger is the contact and
support, hence greater is the retention.
• Discrepancy in the size of the maxillary and
mandibular ridges can create problems with denture
stability in the smaller arch due to poor relationship
of the teeth. This discrepancy may be due to
developmental causes, trauma and early loss of
teeth in one of the arches, or from a severe class II
or class III malocclusion.
• Arch Size can be classified as—small, medium and
large

41. Arch form
Influences support and tooth selection.
• If opposing arches do not have the same form, difficulty in tooth arrangement can
be anticipated.
• Arch forms can be classified as—square, tapering or ovoid
Ridge contour
Influences support and stability of the dentures.
• The ideal is a high ridge with a flat crest and nearly parallel sides. This offers
maximum support and stability.
• A flat ridge lacking vertical height affords little resistance to horizontal movement
leading to reduced stability.
• A knife-edged ridge offers the poorest prognosis because it cannot withstand
much occlusal force and can easily become sore.

42. Ridge relation.
Ridge relation is evaluated for the following:
1. Interridge distance
2. Parallelism
3. Positional relation
Bony undercuts
These do not aid in retention but cause loss of border seal and retention; may
be present in both maxillary and mandibular ridges.
• Maxilla—present in anterior ridge and lateral to maxillary tuberosity. These
may be selectively relieved without any surgery. Only if the undercuts are
severe and previous denture attempts have failed, surgery should be
considered.
• Mandible—prominent sharp mylohyoid ridge produces undercut. Surgical
reduction and reattachment may be beneficial.

43. • Muscle and frenal attachments
The location of these attachments in relation to the crest of the ridge
must be verified.
In resorbed ridges, they can be near the crest of the ridge. This
interferes with the border seal compromising retention of the dentures.
In such cases, a surgical correction may be required.
The attachments most often corrected surgically are the maxillary labial
frenum and the mandibular lingual frenum; buccal frena rarely require
surgical repositioning.

44. • Palate
The following are evaluated.
Hard palate
It is classified according to the shape as:
• U-shaped: Provides good retention and
stability
• V-shaped: Provides least retention
• Flat: Provides poor retention and stability

45. Soft palate
• Based on the degree of flexure that the soft
palate makes with the hard palate and the width
of the palatal seal area, the soft palate
configurations may be classified as:
• Class I: Almost horizontal with little movement
making angle of less than 10° with hard palate;
most favourable.
• Class II: Makes a 45° angle with the hard palate.
Tissue coverage is less than class I (3–5 mm).
• Class III: Makes a 70° angle with the hard palate;
least favourable; usually associated with V-
shaped palate

46. Gag reflex
• Gagging is a normal defence mechanism to prevent
foreign objects from entering the trachea.
• An exaggerated gag reflex can compromise
prosthodontic procedures like impression making.
• The cause of this can be systemic, psychological,
physiologic and iatrogenic. The management of such
patients may be clinical, psychological or
pharmacological.
• House classified palatal sensitivity as:
○ Class I: Normal
○ Class II: Hyposensitive
○ Class III: Hypersensitive

47. • Lateral throat form
• The retromolar space can be partially or
totally obliterated by tongue movement.
This area is critical for lingual seal and
lateral stability.
• Neil classified lateral throat form according
to the extent of anterior movement of
retromylohyoid curtain as tongue is
extended anteriorly. Checked by placing a
finger in the area.
• Class I - Deep - Change in configuration,
places heavy pressure on finger
• Class II - Moderate - Any position in
between I & III
• Class III - Shallow - Minimal pressure

48. • Tongue
• Size
The size of the tongue may be normal, enlarged or small. If the patient has
been without teeth for a long time, the tongue can become enlarged,
which causes tongue biting, compromises impression making and also
leads to denture instability. Small tongue compromises a lingual seal.
• Position
Tongue movement, muscular coordination and position control the
dentures during speech, mastication and deglutition.
• Wright has classified tongue positions as:
○ Class I: Tongue lies on the floor of the mouth with the tip forwards
and slightly below the incisal edges of the mandibular anterior
teeth.
○ Class II: Tongue is flattened and broadened but the tip is in normal
position.
○ Class III: Tongue is retracted and depressed into the floor of the
mouth with the tip curled upwards, downwards or assimilated into the
body of the tongue.

49. Tori
• These are bony prominences which may be
present in the palate or lingual alveolar ridge.
• Torus has an extremely thin mucous covering
which can be traumatized during impression
making and by the denture. Adequate relief
must be planned.
• Tori can also act as a fulcrum to rock the
denture and compromise denture stability.
Surgical removal is not indicated unless the
tori are large.

50. • Saliva
• Major salivary glands orifices should be examined to ensure they are open.
The amount and consistency of saliva affects denture retention and
construction.
• Amount of saliva can be classified as:
• • Class I: Normal
• • Class II: Excessive
• • Class III: Xerostomia
In xerostomia, denture will have poor retention and there is increased
potential for soreness as lubricating action of saliva is lost. Excessive saliva will
complicate impression making.
Consistency
It ranges from thin and serous to thick and ropy. Thick ropy saliva prevents
intimate contact between the denture and the tissues and results in dentures.

51. Radiographic
examination
• If some teeth are remaining, periapical and panoramic radiographs
are essential to plan the treatment for immediate dentures, single
complete dentures and overdentures.
• Panoramic radiographs are necessary for the completely
edentulous patients. The aim is to screen the edentulous jaws for
any pathology and determine the amount of ridge resorption.
• The screening gives information about the defects in jaw structure,
root fragments, unerupted teeth or retained roots, foreign bodies,
sclerosis, tumours and cysts and TMJ disorders.
• Amount of bone resorption can be assessed using the method
described by Wical and Swoope. According to this, the original
alveolar ridge crest height is three times the distance from the
inferior border of the mandible to the inferior margin of the mental
foramen.
• The amount of bone resorption is classified as:
○ Class I: Mild resorption—loss of one-third of vertical ridge height.
○ Class II: Moderate resorption—loss of one-third to two-third of
vertical height.
○ Class III: Severe resorption—greater than two-third loss

52. Treatment planning

53. • Mouth preparation
• Mouth preparation involves:
1. Elimination of infection
2. Elimination of pathology
3. Conditioning of tissues
4. Nutritional counselling
5. Preprosthetic surgery.

54. • Prosthodontic treatment
• Patients with some teeth remaining:
1. Interim removable partial dentures
2. Immediate dentures
3. Single complete denture
4. Overdenture.
Completely edentulous patient:
1. Conventional CD
2. Implant supported CD—fixed, removable

55. • PDI for edentulous class I
• patient A patient who presents ideal or minimally compromised complete
edentulism and who can be treated by conventional prosthodontic techniques.
• PDI for edentulous class II patient
• A patient who presents moderately compromised edentulism and continued
physical degradation of the denture supporting anatomy.
• PDI for edentulous class III patient
• A patient who presents substantially compromised complete edentulism
• PDI for edentulous class IV patient
• A patient who presents the most debilitated form of complete edentulism where
surgical reconstruction is usually indicated, and specialized prosthodontic
techniques are required to achieve an acceptable outcome.
Prosthodontic diagnostic index for complete
edentulism

56. conclusion
• Diagnosis and treatment planning are
the most important parameters in the
successful management of a patient. A
major reason for prosthetic failure is
the inadequate and inappropriate
diagnosis and treatment planning.
Therefore, care must be taken to elicit
and record an informative case history
to understand the patients’ needs and
expectations for a successful outcome

57. Thank you