5. complete denture diagnosis.pptx

 The diagnostic record for complete denture
treatment can best be compiled by using a
systematic diagnostic form. From this
information a treatment plan and prognosis
can be developed.
 Each patient must be considered as an
individual. It is possible to categorize patients
and anticipate certain problems, but always
remember that not all patients will fit a
predetermined group.

 Diagnosis_ diagnosis is the examination of the
physical state, evaluation of the mental or
psychological makeup, and understanding the
needs of each patient to ensure the predictable
results.
 Treatment planning_ treatment planning means
developing a course of action that
encompasses the ramification and sequelae of
treatment to serve the patients need. This takes
for granted and exhaustive supply of knowledge
, a realization of what can and cannot be done
for an individual, and an understanding of the
clinical procedures needed

AGE- The age of the patient gives an indication of his ability
to wear and use dentures.
An arbitrary change point is considered to be age 40. patient
younger than 40 are usually adaptable to change; their
tissue heal rapidly and offer resistance. Patients over 40
have tissues that do not heal as quickly and a mental
attitude that may not readily adapt to new situations.
Women in this age group are undergoing menopause and its
associated problems. Men are at their height of their
careers and tend to be busy and impatient.

 Many patient over the age of 60 find it difficult to
adapt to new situations, tissue repair is often slow,
and in many cases there has been extensive
destruction of denture supporting tissues. Problems
can be anticipated with
1. Adaptation to the denture
2. Coordination
3. Bone resorption
4. Tissue sensitivity
5. Healing
6. balanced nutrition

 In general, women are more difficult to please with
the appearance of their dentures than are men.
They are more aware of their face and lips than are
men. Any change in this part of the body is readily
apparent to them. Women during menopause can
be difficult to treat due to psychological problems,
dry mouth, burning sensation in the mouth, and
general vague pain.
 Men tend to be more occupied with their work and
less concerned with their denture. They do expect
comfort and function.

 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.
 The dentist should know what medication a patient is
taking. Some drugs have a direct effect on the oral
environment.
 Endocrine injections and thyroid, estrogen and
androgenic compounds often cause and extremely
sore mouth for edentulous patient.
 Tranquilizers can cause a dry mouth
 Many systemic diseases have a direct or indirect
effect on the patient. In many instances it will be
necessary to consult the patients physician.

 Knowing the patients occupation and social
position helps in determining what the
patient expects from his denture. In general,
the higher the social position, the more
demanding the patient is about the esthetics.

 The ability to accept and adjust to denture is determined largely by the patient’s mental
attitude and feelings about himself, his fellowman and life in general.
 House classified patients as philosophical, exacting, indifferent, and hysterical
 Philosophical: these patients are rational, sensible, calm and composed in difficult
situations. Philosophical patients overcome conflicts and organize their time and habit in
an orderly manner; they eliminate frustrations and learn to adjust rapidly
 Exacting patient: the exacting patient may have all of the good attributes of the
philosophical patients; however, they require extreme care, effort, and patience on the
part of the dentist. These patient are methodical, precise, and accurate and at time make
severe demands. They like each step in the procedure explained in detail.
 Indifferent patient: these patients present a questionable prognosis. They are apathetic,
uninterested and lack of motivation. They pay no attention to instructions, will not co-
operate, and are prone to blame the dentist for poor dental health.
 hysterical patient: the hysterical type is emotionally unstable, excitable, excessively
apphrensive, and hypertensive. These patients must be made aware that their problem
is primarily systemic and that many of their symptoms are not the result of the denture

 The history of the patients dental treatment
should include the beginning and severity of
dental disease and his reaction to the dental
treatment. His opinion of the dentists who had
performed a service for him and his family
experiences with complete dentures should be
investigated. If it is noted that the patient has a
poor regard for dental profession, effort must be
made to change his opinion. The success of the
planned dental treatment requires mutual
respect and co-operation.

 The patients reason for seeking dental
treatment or new dentures at this particular
time should be determined. This is usually
considered to be the patient chief complaint.
The patient chief complaint, his symptom
and the duration of the problem for which he
seeks treatment have important diagnostic
value

 The length of time that the patient has been
edentulous should be noted. Areas of the jaw
that have not healed properly suggest
 1. insufficient healing time
 2. incomplete elimination of pathologic tissue
 3. a health state not conducive to bone
regeneration

 The longer the patient has been edentulous,
the more bone resorption or alveolar ridge
loss will usually be noted. more resorption in
one area than in another indicates a serial
type of tooth loss.
 Only limited success can be anticipated for
the patient who has been edentulous for a
long time and has not had an artificial
replacement.

 Previous denture experience should be
noted. The number of dentures that the
patient has had and the length of time each
has been worn may influence the anticipated
prognosis. A patient who has had successful
denture treatment will probably be happy
again

 The dentures the patient is currently wearing should
be carefully evaluated as to occlusion, border
extension, retention, speech, and aesthetics. The
dentist should attempt to correlate the patient’s
complaints about the dentures with the dentist’s
clinical findings. If the dentist finds a direct
relationship, it is likely that improvements can be
made in the new dentures. On the other hand, a
lack of correlation between the patient’s complaints
and the dentist’s clinical examination should raise
serious doubts concerning the potential successful
outcome and management of the patient.

 The degree of co ordination shown by the
patient should be observed. This can be seen
by how the patient walks, moves, and handles
himself. Generally, the better coordinated
patient will more readily adapt to new denture.
As the diagnosis interview is being conducted,
the dentist should be aware of the patients
speech habits or patterns, as well as what the
patient is saying. Patients who articulate well
with natural teeth or denture usually learn to
speak distinctly with new denture.

 If the dress and the amount of cosmetics the
patient wears are above average, the patient
will usually be more exacting about denture
appearance. Beware the patient who is trying to
regain loss youth or is trying to have his face lift
by a new dentures. We can do much to make a
denture look natural, but it is not a cure for the
natural aging process. The person with a
pleasing countenance who has a zest for life is
usually a prosthodontic risk than is the person
who is tense and depressed about life in
general

 Observe the extra-oral appearance of the face. Both form
and color are important in selecting teeth. Usually there is
a correlation between the form of the face and the form of
the dental arch and the teeth. Likewise, there is a
correlation between the color of the skin, hair, and the
eyes and the color of the teeth.
 Skin color, texture, and the lesions indicate the systemic
condition of the patient. Thin, anemic appearance faces
with poor skin texture often indicate a prolonged period of
adjustment for the denture patient, lesions, such as
angular cheilosis, may indicate that the patient's vertical
dimension of occlusion is over closed.

 Wrinkles due to advancing age cannot and should not be
corrected with new dentures. Some wrinkles caused by a
decreased vertical dimension of occlusion or poor lip
support can be improved with a well made denture.
 The form and length of the patient’s lips vary considerably.
Some patients have thick lips, others have lips that are
very thin. Thick lips give the appearance of adequate
support when no teeth are present. Excessively short or
long lips present a problem in the arrangement of anterior
teeth. The amount of vermillion border that is visible
indicates the amount of loss of support.

 The systemic charting of biologic factors that
are favorable or unfavorable to a successful
service.
 Biologic conditions may be classified as i-
favorable / normal, II –less favorable or
medium, III- unfavorable or poor.

Examine one arch at a time
› Look, then write

 General tissue health
› Mucosa
 attached / non-attached
› Colour
› Character
› Displaceability

Maxilla
› Form of maxillary arch affects retention
› Advise the patient if retention will be
compromised

 Posterior border of denture:
› Hamular notches
 Posterior denture border
 Palpate
 Visually deceiving

› Hamular notches
 Over extension - extreme pain
 Under extension - non-retentive
 Must be captured in impression

 Posterior border of
denture
› Vibrating line
 Identified when patient says "ah"
 Junction of movable & non-movable
soft palate

 Posterior border of denture
› Vibrating line
 If termiminate on:
 movable portion - displacement
 hard palate - no retention

 Vibrating line
 Fovea - close to
vibrating line
 Throat form can affect
width

I
II
III
Maxilla
• Flatter the soft palate, the broader the area
of the vibrating line

 The downward slope of the soft palate at its
junction with the hard palate is important to the
formation of the posterior length of the maxillary
denture.
 Class I: the soft palate gradually down from the
hard palate.
 Class II: the soft palate slope more sharply than the
class I type, thus decreasing the seal area and the
posterior denture length
 Class III: the soft palate drop sharply from the hard
palate. The precise location of the posterior extent
is critical.

› Pterygomandibular raphe
 Have patient open wide as possible.

Glandular tissue
Posterior palatal seal
Posterior palatine salivary glands
• Permits compression of tissues
• Improves adaptation of denture to
compensate for shrinkage of resin
Posterior Palatal Seal

 Tuberosity
› Displaceability
› Palpate for undercuts
- if extreme, denture
might not seat

 Tuberosity
› If enlarged with
fibrous tissue
 surgical reduction to
make room for dentures

Vertical support and retention for the maxillary denture
is partially determined by the shape of the hard
palate. The palate may be classified as flat, U, V-
shaped
 Class I: the broad flat palate offer the best vertical
support and retention.
 Class II: the U shaped palate form generally gives
adequate denture support And retention
 Class III: the V shaped palate offer little vertical
denture support. The depth of the V also makes a
desirable degrees of retention difficult to attain

 Ridge form
› U-shape best
› Non-moveable best
› Advise patient if poor
› Affects:
 retention
 stability

 Labial/Buccal vestibule
› 2-4 mm width

 The patient with a sensitive palate may react
to the denture construction procedures or the
actual wearing of dentures by gagging
 Class I: there is no response to palpation
 Class II: a minimal response to palpation
indicates the patient is sensitive
 Class III: the patient with a hypersensitive
palate will make a violent response to
palpation.

› Flat ridges
 maximize retention by
accurately registering the
vestibule

 Frena - check prominence:
› Buccal frenum
 Usually broader
› Thin labial frenum

 Tori
 Mid palatal suture
› Eliminate binding or
fulcruming
› Discomfort, loss of retention
and possible fracture of the
denture

Mandibular Support Areas
Retromolar Pad Alveolar Process
Buccal Shelf

 Ridge form more
critical
› Less surface area for
retention
› Moveable tongue &
floor
› Displacement if denture
is overextended
 Inform patients

 Retromolar pad
› Terminal border of the
denture base
› Compressible soft tissue
 Comfort
 Peripheral seal
› Must be captured in
impression

 Buccal shelf
› Custom tray, border
molded - should not
feel edge extraorally
› External oblique
ridge
 do not cover

› Easy to overextend
› Check with minimal
manipulation of lips

 Masseter
› affects distobuccal
border
› if more prominent -
concave border of
denture

 Frena
› Labial and buccal frena
 Narrow & wide respectively
› Lingual frenum
 Must allow for movement - or
displaces easily

 Retromylohyoid fossa
› Need to capture
› Especially with severely resorbed ridge

 Observe the lateral throat form while the patient
retrudes his tongue.
 Class I: approximately 0.5 inch space exists
between the mylohyoid ridge and the floor of the
mouth. This is favorable for the lower denture.
 Class II: less than 0.5 inch space exists between
the mylohoid ridge and the floor of the mouth. The
less space here, the favorable is the prognosis for
the mandibular denture
 Class III: the mylohoid fold is at the same level as
the mylohoid ridge. Retention of the lower denture
is almost impossible.

 Mylohyoid Ridge
› Palpate
 If prominent, may need relief
 Mylohyoid muscle
 Raises floor of mouth
 Differences between rest and
activity
 Affects length of flanges

Mucosa in this region is poorly
keratinized and prone to trauma
Mylohyoid ridge
Mylohyoid ridge can cause ulcers if it
is a sharp
Residual Ridge Resorption (RRR)

 Tori
› Rarely need surgery unless large
› May require relief once dentures are
delivered - advise patient

 Genial tubercles
› Bony insertion for the
genioglossus muscle
› May be projecting above
the residual ridge if there
has been severe
resorption

Examination of the area over the
temporomandibular joint- The fingers should be
placed over each joint and have the patient
slowly open and close his mouth. Any pain or
tenderness in this area may be and indication
of an excessive increase or decrease in the
vertical dimension of occlusion. Crepitus,
clicking or abnormal movement should be
noted.

 As the patient slowly opens and closes his mouth,
watch for deviation of the mandible to the side.
Then from a vertical dimension of rest position have
the patient move his mandible to the right and left
lateral position, as well as to the straight protrusive.
 Some patient can perform all mandibular
movement with ease but others can only open and
close the jaws with ease.
 A bilateral balanced occlusion is needed for the
patient with free mandibular movement but is not so
important for those who can move only on hinge
movement .

Class 1: tissues are normal in tone and function.
There are sufficient teeth properly distributed to
retain the normal mandibular position and to
furnish normal tension, tone, and placement of the
muscles. No degenerative changes have yet
occurred in the muscles of expression or
mastication or in the tactile tense of the jaws or
mucosa.
Except in instances of an immediate restoration,
edentulous patients do not have a class 1
musculature, as most have experienced
degenerative changes in varying degrees.

 Class 11: approximately normal function, tone, and tactile
sense have been preserved by wearing of artificial
dentures. Maximum muscular function can never be
utilized once the natural teeth have been lost. Patient who
have been wearing efficient dentures that restore the
correct vertical dimension of occlusion belong to this class.
 Class III: subnormal function, tone, and tactile sense result
from ill health, loss of natural teeth, or the wearing of
grossly inefficient dentures. Frequently over closure
produces wrinkles and a droopy mouth, protrusion of the
mandible, loss of muscle power. With the most efficient
replacement, this class of patient requires varying degrees
of time in which to redevelop tone and power in the
mandible.

 Class I: there is enough muscle control to use denture
efficiently but not to exceed the physiologic tolerance
of the denture supporting tissues by putting excessive
occlusal pressure on the teeth.
 Class II: the patient either chews with a great deal of
force or bruxates. Either of these habits may cause
problems. The heavy force may cause sore mouth
 Class III: patient with slight development of muscle
often cannot control denture adequately. They are
usually light chewers who complain that their denture
will not cut through food

 Class I: the mandible and maxillae are well
developed and the size of one to the other is in the
correct relationship.
 Class II: the mandible is less develop than the
maxillae. This situation is the most difficult to handle
in denture construction. The small size of the
mandible will increase the amount of masticatory
force per unit area covered by the denture. Smaller
jaw offer less support and retention
 Class III: the mandible has had greater
development than the maxillae making it longer ,
wider, or both.

 The amount of remaining alveolar bone determines
the height of the ridge supporting the denture.
 Class I: the alveolar ridge is of adequate height to
give the denture support and resist lateral
movement of the denture base
 Class II: the alveolar has undergone some
resorption, however, there is enough remaining
bone to give some resistance to lateral shifts of the
denture
 Class III: the alveolar ridge is almost or completely
resorbed. There will be little or no resistance to
lateral shift of the denture.

 Vertical forces that are placed on the denture are
resisted in part by the residual ridge. The cross
sectional shape of the ridge determines how much of
this force the ridge can actually offset.
 Class I: the ridge is U- shaped in its cross section.
The broad, flat ridge crest offer excellent vertical
support
 Class II: the ridge is more V- shaped in cross section
than is class I. but the ridge crest is still flat enough to
offer some vertical support
 Class III: this is a so called knife edge ridge. The
remaining ridge has a narrow, sharp ridge crest that
can offer little or nothing to vertical support

 To consider form, one must look at the entire arch.
Generally, arch forms are classified as square, tapering, or
ovoid. Following extractions, the arch may change form to
some extent. It is not uncommon to find the upper arch of
one classification and the lower of another. This irregualrity
may present a problem in tooth arrangement. Arch form is
important in offsetting rotational movement of the denture
base.
 Class I: the square arch is the best form to prevent
rotational movement
 Class II: the tapering form offers some resistance to
movement but to a lesser degree than a square arch.
 Class III: the ovoid form, because of its rounded shape,
gives little or resistance to rotational movement

 When the teeth are gradually lost, the residual
ridges will diverge from each other. If the ridge are
not parallel to the occlusal plane, denture tend to
slide over the basilar tissues when occlusal forces
are applied to them
 Class I: both the ridges are parallel to the occlusal
plane
 Class II: either the mandible or the maxillary ridge is
divergent anteriorly. Only one denture tend to slide
anteriorly
 Class III: both the ridge diverge anteriorly. Both the
denture will slide anteriorly

 Class I: the patient has enough interarch
distance to accommodate the denture
 Class II: there is excessive space. The
denture are usually less stable because the
distance between the teeth and the
supporting bone is so great
 Class III: interarch space is limited .
Placement of the artificial teeth can be a
difficult procedure

 A residual ridge with a bony undercut is most
unfavorable to a stable denture (because relief may
be required during insertion).
 Class I: bony undercuts are absent
 Class II: there are small undercut. (denture can be
placed by changing the path of insertion or by
relieving the completed denture after pressure
indicating paste has been applied to reveal
pressure areas.)
 Class III: prominent bilateral undercut that must be
corrected by surgery are present. Sometimes
surgery can be limited to undercuts on one side
only.

 Small maxillary and mandibular tori normally
present no problem in denture construction.
 Class I: tori are absent or so small that they will not
interfere with the construction or use of denture
 Class II: ridge have tori that offer mild difficulties for
the adaptation of the denture. Surgical intervention
is probably optional
 Class III: tori are excessively large , present
undercut, or extent to the posterior palatal seal
area. Surgical intervention is necessary .if the
mandibular tori prevent correct border extension to
the denture , they definitely should be removed.

 The soft tissues under a complete denture help support of
the denture and acts as a cushion between the denture
and the supporting bone
 Class I: the best oral condition is to have the
mucoperiosteum a uniform thickness of approximately
1mm and firm and not tense
 Class II: the patient has thin mucoperiosteum that will be
highly susceptible to irritation from denture pressure. If it is
still firm but thicker than 1mm , the denture will have a
tendency to shift excessively
 Class III: a poor condition exists when the tissues are not
only thick but also flabby. Surgical removal of the of the
excessive tissues in these situation is usually indicated to
develop and expectable denture base

 The condition of the mucosa should be
classified according to its oral appearance
 Class I: healthy
 Class II: irritated
 Class III: pathologic

 Generally, the lower the frenum attachment, the more
favorable the denture prognosis. All lingual tissues of the
mandible are classified as muscular attachment.
 Class I: the muscle and frenum attachment are close to
the vestibule and are considered to be low
 Class II: the muscle and frenum attachment are higher-
closer to the crest of the residual ridge. To allow for
movement of these attachment, the denture border must
be notched to allow space.
 Class III: the muscle and frenum attachment are too high.
The large notches that will be needed to allow space for
them make a denture seal difficult to maintain, and a lack
of retention usually develops. They may require surgical
correction.

 The tongue plays a major role in the retention of the
mandibular denture. Two components of the tongue
must be considered. Namely, size and position.
 Class I: the tongue is of adequate size to fill but not
overfill the floor of the mouth. Since the alveolar ridges
are exposed, there is space for the denture
 Class II: the tongue slightly overfills the floor of the
mouth
 Class III: the tongue completely fills the floor of the
mouth and cover the alveolar ridges. Impression making
is very difficult with this type of tongue. Denture stability
is also difficult to attain

 The lingual seal of the lower denture is developed by the
tongue. If the tongue does not maintain correct position a
seal cannot be developed
 Class I: the tongue is in corect position. The tip is relaxed
where it rest in the area of the lingual surface of the lower
anterior teeth. The lateral borders of the tongue contact
the lingual surface of the posterior teeth and the denture
base
 Class II: the lateral border of the tongue are in correct
position. But the tip of the tongue turns up or down
 Class III: the tongue is in a retracted position. The tip does
not touch the lower denture or ridge. Much of the floor of
the mouth is exposed. Because of its retracted position,
the tongue appears to be square off.

 Class I: the saliva is normal in amount and
consistency
 Class II: there is and excessive amount of thin,
watery saliva or of thick, ropy saliva. Excessive
saliva may cause gagging and will usually
complicate impression making
 Class III: insufficient saliva reduces the retentive
qualities of the denture and may cause and
excessive amount of soreness.

 Radiographs are valuable aids for examination the
osseous structure that are to support the restoration. They
also will show the nutrient canal and any bony pathology.
For the radiographic examination to be of any value,
however the films must be of sufficient technical standard
for interpretation and must be interpreted correctly.
 Class I: dense bone provides the optimum foundation for
dentures. The trabeculae are compact and the medullary
spaces are few, and the overall picture is one of opacity.
The cortex is solid and well defined. All other factors being
constant, these structures show little or slow resorption

 Class II: cancellated bone will give adequate support if
occlusal loading is within physioloic limit, but generally it
will not withstand excessive loading without early
deterioration. The overall picture is much lighter, and there
is great contrast. The trabeculae and the medullary space
are evenly balanced. The cortex is defined but lighter in
contrast
 Class III: non cortical bone is radiolucent and poor in
organic salts. There is no definite cortex; margins are
feathery, thin, and often apiculated. It offers poor support
for a denture. Unlesss occlusal loading is strictly reduces,
there follows and endless history of discomfort and
resorpyion

 Preoperative records are desirable for all patients.
These records will serve as guides in the
construction of the proposed new denture and will
also be of importance for any subsequent dentures.
Preoperative records can provide information about
the shape, form, color, and position of the natural
teeth, the vertical dimension of occlusion, the
support of the lips, and the relationship of the teeth
to the lip. These records may consist of
photographs, diagnostic casts, tattooing of intraoral
structures, measurements of extraoral structure,
charts of remaining teeth and radiograph.

 A series of photographs made prior to
removal of the remaining teeth should show
the patient in a relaxed state and with a
smile, both from the front and profile. Close
up should be made of individual teeth dental
arches and occlusion

 If the teeth remain diagnostic casts should
always be made serve as guides for the
placement of the artificial teeth and an
indication of the vertical dimension of
occlusion.
Tattooing :
 Records of the vertical dimension of occlusion
can be made by tattoing the attached gingivae
prior to extraction. The distance between the
tattoos is measured

 Permanent landmarks on the face, such as
scars, mole or warts, can be measured. These
measurements can then be used as guides for
establishing the correct vertical dimension of
occlusion. Tattoos also can be placed on the
patient’s face . One above and one below the
mouth. the distance between the tattoos before
the teeth are removed is duplicated when
recording the jaw relations

If the patient old dentures are available the
vertical dimension of occlusion can be
approximated by measuring the dentures.
Further evaluation of the vertical dimension
of occlusion can be made by examining the
esthetics of the patient and his ability to
pronounce the sibilant sounds

 After having the complete case history and diagnosis of the patient,
dentist should create an idea in his mind how to follow or how to
procede for the further steps and the adjunctive cares to undergo
before the commencement of the treatment
 ADJUNCTIVE CARE :
 Elimination of infection
 Elimination of pathology
 Pre-prosthetic surgery
 Tissue conditions
 Nutritional counselling
From the above adjunctive cares nutritional counselling is very important
step in the treatment planning of complete denture. Patient showing
deficiency towards particular minerals and vitamins should be advised
for a balance diet.

 After all the diagnostic information has been
gathered, the dentist should attempt to arrive at
a prognosis for the patient. One must consider
the overall picture, including the patient’s
expectation, understanding, and mental
attitude. At the conclusion of denture treatment
the wise dentist reviews his initial diagnosis and
prognosis to see where he was correct and
incorrect. This will be an aid in future denture
situation

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