DIAGNOSIS AND TREATMENT PLANNING FOR COMPLETE DENTURES .

1. DIAGNOSIS AND TREATMENT
PLANNING FOR COMPLETE
DENTURES
Dr.Himanshu Tiwari
Assistant Professor
Dept.Of Prosthodontics
and Crown & Bridge

2.  A fixed or removable dental prosthesis that replaces
the entire dentition and associated structures of the
maxilla or mandible.
 Successful complete denture therapy begins with a
thorough assessment of the patient’s physical and
psychological condition and determining a treatment
that will deliver a functional complete denture that
will satisfy the expectations of the patient.
COMPLETE DENTURE

3. • Diagnosis is the examination of the
physical state ,evaluation of the mental or
phychological make up,and understanding
the needs of each patient to ensure a
predictable result .
• According to GPT-9:
• The determination of the nature of the
disease.

4.  TREATMENT PLANNING means developing a
course of action that encompasses the
ramifications and sequelae of treatment to
serve the patient’s needs.
 Acc. to GPT-9: It refers to the sequence of
procedures planned for the treatment of a
patient after diagnosis.

6. Diagnosis has following
components
1. History Taking
2. Clinical examination
3. Radiographic examination
4. Pre treatment records

7.  The first appointment is perhaps the most
important time the dentist will spend with a
complete denture patient and should be used
to develop mutual understanding and trust.
 The most important fact that the dentist
needs to know is the chief complaint of the
patient.
GENERAL INTRODUCTION TO THE
PATIENT

8.  This includes
 PERSONAL DATA
 MEDICAL HISTORY
 DENTAL HISTORY
HISTORY TAKING

9.  Personal Data:
❖ Name
❖ Age
❖ Gender
❖ Race
❖ Occupation
❖ Location
❖ Religion and Community

10.  Debilitating disease:
Diabetes,blood dyscrasias and
tuberculosis.
 Diseases of joints: such as
Osteoarthritis
 Cardiovascular diseases
 Diseases of skin such as PEMPHIGUS
etc that have oral manifestations too.
 Neurological disorders like Bell’s palsy
and Parkinsonism.
Medical History

11.  Chief COMPLAINT
 Expectations
 Period of edentulousness
 Pretreatment records
❖ Previous Denture
❖ Current denture
Pre extraction records
❖ Diagnostic cast
Dental HISTORY

12.  Completely unaware of difficulties.
 Assume to continue same eating habits as with their
natural teeth.
 Green Ridge”
 Socket edges not rounded off as desired
 Bony spicules remain from extraction site
 Bony undercuts with a thin mucosal covering.
PATIENT MADE RECENTLY
EDENTULOUS:

13.  Alveolar ridges recently made edentulous subject
to large, rapid changes during the first year.
 The dentist must inform the patient of these
potential changes before beginning to avoid
problems later on.

14.  The problems they present are more difficult to
treat especially if they have been previous denture
wearers.
 These problems must be recognized before
adequate treatment procedures are planned.
 Most important among these are the difficult
denture wearers. Personality characteristics should
be assessed.
PATIENT EDENTULOUS FOR A
LONG TIME:

15.  Begins when the patient enters the dental
clinic.
 Aspects to be observed
Motor skills
Facial features
Attitude and adaptive response.
OBSERVATION OF THE PATIENT:

16. (I) MOTOR SKILLS:
 CVA, Bell’s Palsy, nerve blocks for
trigeminal neuralgia hemiplagia and
dyskinesia.
 Facial tremors/spasms indicate Parkinson’s
disease, nervous habits or possibly drug
induced tardive dyskinesia.
Psychotropic drug therapy may show
 Uncontrollable chewing movements
 Licking and smacking of lips
 Uncoordinated tongue movements

17. Twitching of the nose
Puffing of cheek
These complications often result in prosthetic
failure.
Check fluency and quality of patient’s speech
Best judged during casual conversation.

18. (II) FACIAL FEATURES:
 Dentist must note
 Length of face
 Labial fullness
 Apparent support of lips

19.  Observe for hollowness/puffiness in
❖ Philtrum
❖ Nasolabial fold
❖ Labiomental groove

20.  Size of oral cavity, activity of lips and width of
vermilion border is directly related to degree of
tooth display.
 Profile view indicates position of maxilla to
mandible is first indication of patient’s occlusal
classification.

21. De Van stated that- meet the mind of the patient before meeting
the mouth of the patient.
Factors producing adaptive response to complete
dentures:
 Favorable physical conditions
 Realistic expectationof the patient
 Acceptance of & confidence in dentist.Previous favorable experience &
capacity to cope favorably with change.
 Good learning capacity
 Desire to please the doctor
(III) ATTITUDE & LEVEL OF
EXPECTATION

22.  Factors that produce a maladaptive
response to complete dentures
. Lack of trust in the dentist
Poor dentist-patient communication
Negative previous experience
Unrealistic expectations on the part of patient
Resistance to change
Inadequate tissue tolerance

23.  Proposed by Dr.MM House
 General classification of patient’s mental attitude
 They can be classified as:
Philosophic
Exacting
Indifferent
Hysterical
THE HOUSE CLASSIFICATION

24.  Willing to accept the dentist’s judgement
without question.
 Best mental attitude for denture
acceptance.
 easy going and mentally well adjusted.
 Ideal attitude for successful treatment,
provided the biomechanical factors are
favourable.
PHILOSOPHIC:

25.  Require extreme care, effort and patience on the part of the
dentist.
 Immaculate appearance and dress.
 Methodical, precise and accurate and at times make
severe demands.
 Want written guarantees or remakes at no additional cost.
 Like each step of the procedure to be explained.
 If intelligent and understanding , they are the best or else
extra hours must be spent prior to treatment in patient
education until an understanding is reached.
 Once satisfied , become the dentist’s great
supporters.
EXACTING:

26.  Submit to treatment as a last resort, have negative
attitude, often poor health, unfounded complaints.
 Have attempted to wear dentures but failed , thoroughly
discouraged.
 Emotionally unstable, excitable, apprehensive and
hypertensive.
 Unrealistic expectations.(demand equals to natural
teeth)
 Prognosis is often unfavorable.
 Additional professional help (psychiatric) is required
prior to and during treatment.
HYSTERICAL:

27.  Questionable or unfavorable prognosis.
 Little concern for their teeth or oral health.
 Without dentures or worn out dentures for years.
 Seek treatment because of the insistence of family.
 Pay no attention to instructions, are uncooperative
& give up easily if problems are encountered with
their new teeth.
 Do not value the efforts or skills of the dentist.
 Require more time for instruction on value and use
of their dentures.
INDIFFERENT:

28.  It speaks about the aesthetic expectations of the
patient.
 CLASS I : High cosmetic Index
 CLASS II : Moderate cosmetic Index
 CLASS III : Low cosmetic Index
COSMETIC INDEX

29.  Extra oral examination
 Intra oral examination
CLINICAL
EXAMINATION

30.  The patient’s head and neck region should be
examined in general for the presence of any
pathologic conditions.
 It includes:
❑ Facial Examination
❑ Lip Examination
❑ TMJ Examination
EXTRA ORAL EXAMINATION

31. FACIAL EXAMINATION
Square
Square tapering
Tapering
Ovoid
Facial form according to House & Loop

32. Facial form according to House &
Loop
Class I Normal Class II Retrognathic Class III Prognathic

33. ❑ Muscle tone acc. to House
➢ Class I :Normal muscle tone(immediate denture pt.)
 Class II: Slightly impaired muscle tone(following loss of all
natural teeth)
 Class III: Greatly impaired muscle tone & function
❑ Muscle Development according to
House
 Class I: Heavy
 Class II: Medium
 Class III: Light

34. COMPLEXION
 The colour of eyes , hair and skin helps in
shade selection.

35.  Health of the lips -Cracking, fissuring at corner &
ulceration: indicative of vitamin B-complex deficiency,
candida infection.
 Lip support – adequately supported or
unsupported(collapsed or wrinkled appearance)
 Lip thickness- thick lips require lesser support from
artificial teeth and labial flange.
 Lip length- long , medium and short.
 Lip mobility – normal (class I)
- reduced mobility (class II)
- paralysis (class III)
LIP EXAMINATION:

36.  Lip thickness – thick or thin
 Thick – gives more freedom in teeth setting.
 Thin – any change in labiolingual position can alter
fullness, support or drape of thin lip.
 Lip length long or short.
 Measured from - base of the nose to vermillion border of lip
(ideal = 25 mm). or with index finger tip ,from incisive papilla
to upper lip. VERMILION BORDER
 Long – will hide denture base & most of the tooth (maximum
facial expression is required for display of tooth).
 Short – any expression will expose most of the tooth or even
denture base.

37. 1. Competent lips – lips are in slight contact
when the musculature is relaxed
2. Incompetent lips – morphologically short
lips which do not form a lip seal in a relaxed
state
3. Potentially incompetent lips – normal lips ,
fail to form lip seal
4. Everted lips – hypertrophied lips with weak
muscular tonocity.
LIPS CAN BE CLASSIFIED INTO 4
TYPES

38.  Clicking(disc displacement),crepitations(osteoarthrosis)
 Pain & tenderness on palpation
 Temporomandibular arthralgia
 Impaired mandibular mobility
 Irregularity or deviation on opening & closing of
mandible
 Deflection.
 Locking of mandible.
TEMPOROMANDIBULAR JOINT
EXAMINATION

39.  It includes the following:
• Colour of mucosa
• Saliva
• Arch size
• Arch form
• Ridge contour
• Ridge relation
• Redundant and hyperplastic tissue
• Hard palate and Soft palate
• Palatal throat form
• Bony undercuts and Tori
• Muscle and frenum attachments
• Tongue
• Floor of mouth
• Gag reflex
INTRA ORAL EXAMINATION

40.  Ranges healthy pink to angry red.
 Redness indicative of inflammation:
related to ill fitting denture,
underlying infection, systemic disease
or chronic smoking.
 Pigmented spots or lesions.
 White patches keratotic areas
caused by denture irritation.
COLOUR OF MUCOSA:

41. Flow – regular or irregular.
Quality – thin serous, mucinous, mixed.
Quantity – normal, excessive, scanty.
 Deficient saliva: retention of denture will be affected.
 Excess of saliva: complicates impression making.
 Thick mucous saliva makes dentures more difficult to
wear. It will push out denture by accumulating beneath the
denture.
 Mixture of both Thin serous & Thick mucous saliva is the
best to work with.
SALIVA :

42. ➢ Class I: Large (best for retention & stability)
 Class II: Medium (good retention & stability )
 Class III: Small (difficult to achieve good
retention and stability)
 Determines the amount of basal seat available for
denture foundation
Greater the size, more the support
Greater the contact surface, greater the retention.
Discrepancy in size of the maxilla and mandible
can present a problem of stability in the smaller
arch.
Arch Size

43. ARCH FORM ( House’s Classification)
Class I Square Class II Tapering
Class III Ovoid

44. RIDGE CONTOUR

45.  The positional relation of the mandibular
ridge & maxillary ridge.
 Angle classified ridge relationship as:
❖ CLASS I: Normal
❖ CLASS II: Retrognathic
❖ CLASS III: Prognathic
RIDGE RELATIONSHIP

46.  Both the maxilla and mandible should be
examined for redundant tissue.
 An excessive amount of flabby tissue will
cause the denture base to shift and move
as force is applied .
 In such cases , surgical excision of the
movable tissue will improve the condition.
REDUNDANT TISSUE

47.  Often hyperplastic tissue is present under
an ill-fitting denture which may be an
epulis fissuratum related to a denture
border, papillary hyperplasia under the
denture base.
 Rest to the tissue, proper oral hygiene,
tissue massage will improve the condition.
 If not, surgical correction is needed for the
foundation of new denture.
Hyperplastic tissue

48.  U-shaped palatal vault: most favourable for
retention & lateral stability.
 V-shaped vault: less favourable for retention.
 Flat palatal vault: also unfavourable.
HARD PALATE:

49.  Classified according to configurations based on the
degree of flexure the soft palate makes with the hard
palate and the width of the seal area.
 Class I: Horizontal & demonstrating little muscular
movement. Most favourable condition as it allows for more
tissue coverage for posterior palatal seal. Forms a 10
degree angle.
 Class II: Turns downward forming a 45degree angle to
hard palate. Potential tissue coverage is less than for
classI.
 Class III: Turns downward sharply at 70 degree angle just
posterior to hard palate. Least favourable soft tissue form.
SOFT PALATE:

50.  V- shaped vault: associated with Class III soft
palate
 Flat palatal vault: usually associated with
Class I or Class II soft palate.

51.  Bony undercuts are frequently found on
maxillary and mandibular ridges.
 The rule should be always selective
relief of the denture rather than surgical
excision.
 If the undercuts are severe and previous
denture attempts have failed , surgery
should be considered.
 On mandibular ridge, the only undercut
that can pose a real problem is a
prominent sharp mylohyoid ridge.
BONY UNDERCUTS

52. Preprosthetic surgeries
may be required

53.  Torus palatinus & lingual tori frequently
present.
 Torus palatinus: range from a small
prominence in the midline to one that
covers the entire hard palate.
 Adequate relief must be planned.
 Lingual tori: interfere with denture
construction & unless very small should
be surgically removed
TORI

54.  Class I - Tori absent or minimal in size. Do not
interfere with denture construction.
 Class II – Moderate size. Mild difficulties in denture
construction and use. Surgery not required.
 Class III – Large in size. Compromise fabrication &
function of dentures. Requires surgical recontouring
and removal.
Classification : -

55.  BORDER ATTACHMENTS (HOUSE) :
 Class I – Attachments are away from the crest of ridge (0.5
inches or more between level of attachment and crest of
ridge)
 Class II – Attachments height is 0.25 to 0.50 inches.
 Class III - < 0.25 inches from ridge crest.
 FRENUM ATTACHMENTS (HOUSE):-same as border
attachments
 Class I – frenum located away from crest of ridge.
 Class II – nearer to the crest of ridge.
 Class III – freni encroach on the crest of the ridge and may
interfere with denture seal. Surgical correction may be
required (frenotomy or frenectomy)

56.  If patient has been without teeth for a long
time: tongue becomes enlarged & powerful.
This will create a problem in impression
making & may contribute to denture
instability.
 A small tongue: may jeopardize lingual seal.
 Tongue position is very important to the
prognosis of the mandibular denture.
TONGUE

57.  Class I – normal in size, development, &
function.
 Class II – teeth have been absent for long
time permits change in form & function.
 Class III – excessively large tongue,all
teeth have been absent for a long time,
allowing for abnormal development of the
size of the tongue.
According to House : -

58.  Class I: Tongue lies in the floor of the mouth with the tip
forward & slightly below the incisal edges of mandibular
anterior teeth. Most favourable prognosis.
 Class II: Tongue is flattened and broadened but the tip is in
the normal position.
 Class III: Tongue is tensed, retracted & depressed into the
floor of the mouth with the tip curled upward, downward or
assimilated into the body of the tongue. Least favourable
prognosis.
WRIGHT CLASSIFIED TONGUE
POSITIONS AS FOLLOWS:

59.  The relationship of the floor of the
mouth to the crest of the ridge is
crucial in determining the prognosis of
the lower complete denture.
 If the floor of the mouth is near the
crest of the ridge especially in the
sublingual and mylohyoid regions
,stability and retention of denture is
decreased.
 The patient should touch his upper lip
with the tongue to activate the muscles
of the floor of the mouth.
Floor of mouth

60.  Normal defense mechanism developed by
the body to prevent foreign bodies from
entering the trachea.
 Can be caused by:
Systemic disorders,
Psychological factors,
Extraoral & intraoral physiological factors
Iatrogenic factors.
 Controlled by glossopharyngeal nerve
GAG REFLEX:

61.  Clinical techniques, pharmacological
measures, psychological
intervention.
 Identify the existence of gag reflex
with a thorough conversation with
the patient.
 Careful handling of impression
procedure and constant reassurance
of the patient will suffice.
 In severe cases, a specialist maybe
needed to treat the problem at a
psychological level.
MANAGEMENT OF GAG REFLEX:
:

62. RADIOGRAPHIC
EXAMINATION

63.  The interpretation of the panoramic radiograph
should follow a five step analysis:
1. Screen jaws for defect in structure and bony
enlargement,
2. displacement of jaw parts,
3. unerupted teeth or retained root fragments,
4. foreign bodies,
5. radiolucencies as well as radio opacities.
 TMJ can be screened and findings correlated
with history and clinical examination.
RADIOGRAPHIC EXAMINATION

64.  Describe the appearance of the lesion as well as any bony
changes adjoining the lesion
 Correlate the radiographic findings with the clinical, historical
and laboratory findings.
 Perform a differential diagnosis which includes all the
diseases that could explain the findings.
 Estimate the growth of the lesion by the appearance of the
jaw structures adjoining the lesion

65.  Panoramic radiographs also aid in determining the
amount of ridge resorption.
 Wical & Swoope:They found that the lower edge of the
mental foramen divides the mandible into thirds in
normal dentulous panoramic radiographs.
 Measuring the distance from the inferior border of the
mandible to the inferior margin of the mental foramen
and then multiplying it by 3, the resultant product is a
reliable estimate of the original alveolar ridge crest
height.

66.  The amount of resorption can be classified as follows:
Class I: Mild resorption, is a loss of upto one third of
the orignal vertical height.
Class II: Moderate resorption, is a loss from one third
to two thirds of vertical height.
Class III: Severe resorption, is a loss of two thirds or
more of vertical height.

67.  Diagnostic Casts
 Pre extraction Records
This includes
❖ Diagnostic casts
❖ Old radiographs
❖ Old photographs
PRE TREATMENT RECORDS

68.  Helps dentists avoid a potential problem
 Time consuming
 Aid in determining the inter ridge space,
ridge relationships, ridge shape and form that
cannot be adequately determined by clinical
examination alone.
Diagnostic casts:

69.  Old diagnostic casts: determining both size,
position & arrangement of teeth.
 Old radiographs: determining tooth size &
bony change.
 Photographs: relay information regarding
tooth size,position & display during facial
expressions. Forms an effective tool in
achieving proper esthetics & patient
satisfaction.
Pre extraction records:

70.  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.
 Must have a parallel process of
developing a prognosis.
 Driven by the diagnosis but must
take other factors such as
prognosis, patient health and
attitudes into account.
TREATMENT PLANNING:

71. WHY TREATMENT PLAN?
Treatment Plans
Addresses patient
needs
Lists specific
treatment
Specific logical
sequence
Informed consent
Treatment
Time
Fees
Enables dentist to
Estimate
•Operating time
•Laboratory time
•Calender time
•Fees
Delivered care
•Patient specific
Enables
patient to
Dentist
delivers
Enables
Dentist
to
Patient
receive

72.  Treatment planning determines the patients
problems by way of a thorough case history as
previously described thus making selection of the
treatment option that is most ideally indicated for
the particular case at hand.
 By placing a primer on determining patient
problems, it also places a primer on the various
treatment options that are best suited for those
particular conditions.

73.  Definition- A forecast as to the probable result of
a disease or a course of therapy.
 After considering all the factors of the case, an
experienced dentist should be able to predict the
degree of success that can be expected.
 It includes realization by the patient of what can
& cannot be achieved.
 Ultimately leads to more realistic expectations &
less frustration & disappointment.
Prognosis