Prosthodontic Diagnosis for Complete Denture and Partial Denture.

1. Seminar By
E.SHREEPRADA
III BDS
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2. Diagnosis and Treatment Planning are the most important
parameters in the successful management of a patient.
Inadequate diagnosis and treatment planning are the
major reasons behind the failure of a complete denture.
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Diagnosis
It is defined as
“The Determination of the Nature of the Disease.”
-GPT
Essential Diagnostic data obtained from
Patient Interview, Definitive Oral
Examination, Consultation with Medical
And Dental Specialists, Radiographs,
Mounted and Surveyed Diagnostic casts
should be carefully evaluated during
Treatment Planning.

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DIAGNOSIS
Clinical Diagnosis
Post Clinical or
Derived Diagnosis

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What to do for a proper clinical diagnosis?
• Patient evaluation
• Clinical history taking
• Clinical examination of the patient
• Radiographic examination
• Examination of existing prosthesis

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PATIENT EVALUATION
• Gait
• Age of the patient
• Sex
• Complexion
• Cosmetic index
• Mental attitude

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Gait (How the patient walks?)
People with neuromuscular disorders have different gait
and difficulty to adapt to the dentures.
Age
The age of the patient determines the outcome of the
treatment.
For example, Patient belonging to fourth decade has
good healing abilities compared to patient belonging
to sixth decade.
Sex
Males are mostly busy and bothered only about
comfort but Female patients are more critical about
aesthetics.

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Complexion and Personality
Patient’s complexion and personality, for example,
patient’s eye color, hair color, height, weight, etc. help
us for teeth selection.
Cosmetic Index
It basically speaks about aesthetic expectations of the
patient.
It can be classified as:
Class I:High Cosmetic Index
Class II:Moderate Cosmetic Index
Class III:Low Cosmetic Index

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Mental Attitude of the Patient
De Van Stated “meet the mind of the patient before
meeting the mouth of the patient.”
Hence, Patient’s attitude and opinion can influence
The outcome of the treatment.
Based on Mental attitude, Patient’s can be grouped under
two classifications.
MM House proposed the first classification in 1950, which is
widely followed.

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HOUSE’S CLASSIFICATION
Classified Patient’s psychology into 4 types:
Class I: Philosophical
Easy going, congenial, mentally well adjusted,
cooperative, and confident of the dentist.
Excellent prognosis.
Class II: Exacting
These patient’s are precise, above average in intelligence,
concerned in their appearance, usually dis-satisfied by
previous treatment, do not have confidence in dentist.
Once they become satisfied they become the dentist’s
greatest support.

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Class III: Hysterical
They are hysterical, nervous, very exacting temperament
and will demand efficiency and appearance like natural
teeth.
They usually come out of compulsion from family and
relatives.
They show poor prognosis.
Class IV: Indifferent
Those who are unconcerned or feel no necessity for teeth
for mastication.
They are uncooperative and will hardly try to accustom to
dentures.

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CLASSIFICATION II
Patient’s can also be classified as
Cooperative:
Open minded and amenable to suggestions.
Procedures can be explained very easily and are fully
cooperative.
Apprehensive:
Even though they realize importance of dentures they
have some irrational problem.
The approach to such patient’s is by making them speak
out their thoughts and opinions.

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Apprehensive Patient’s are of different types,
• Anxious
• Frightened
• Obsessive or Exacting
• Chronic complainers
• Self conscious
Uncooperative:
Their general attitude is negative.
They do not feel need for a denture and come due to
compulsion by family and friends.

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CLINICAL HISTORY TAKING
• Name
• Age
• Sex
• Occupation
• Race
• Location
• Religion
• Medical History
• Dental History
Collecting details of the patient for proper treatment
planning. It includes:

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Name
Used for communication and maintaining proper records.
Also gives an idea about patient’s family and community.
Age
Some diseases are pertained to some age groups.
Hence, age can be used to rule out systemic conditions
apart from determining prognosis.
Sex
Some diseases are sex related and hence helpful in ruling
out certain systemic conditions.
Also, Mental Attitudes differ with sex.

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Occupation
The appearance of teeth varies with occupation.
Sales executives require idealistic teeth whereas people
working in high physical exertions have rugged teeth.
Race
Helps in selecting shade of the teeth.
Location
Some disorders are endemic to an area. Eg: Fluorosis.
Religion and Community
Gives an idea about dietary habits and helps to design
Denture accordingly.

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Medical History
• Debilitating Diseases (Diabetes, Tuberculosis, etc.)
• Diseases of the Joints (Osteoarthritis)
• Cardiovascular Diseases
• Diseases of the Skin (Pemphigus)
• Neurological Disorders (Bell’s palsy, Parkinson’s)
• Oral Malignancies
• Climacteric Conditions (Menopause)

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Dental History
• Chief complaint
• Expectations
• Period of Edentulousness
• Pre-Treatment Records
• Previous denture
• Current denture
• Pre-Extraction Records
• Diagnostic casts
• Denture success

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Chief Complaint
The reason the patient has come to the hospital.
Recorded in patient’s own words.
Expectations
The dentist should evaluate the patient’s expectations and
classify them as realistic/attainable and unrealistic.
Period of Edentulousness
The cause for tooth loss must be found out.
This period gives the dentist an idea of amount of bone loss.
Pre-Treatment Records
Includes information of previous denture, current denture,
pre-extraction records and diagnostic casts.

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Previous Denture
The reason for the failure of previous denture must be
found out.
Current Denture
The current denture must be examined thoroughly.
The reason for wanting a replacement should be evaluated.
Gives information about denture experience, denture care,
dental knowledge and parafunctional habits of the patient.

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Factors to be noted in existing prosthesis
• The period for which the patient is wearing the denture.
• The amount of ridge resorption.
• The amount of expected ridge resorption after placement
of new prosthesis.
• Anterior and posterior teeth shade and material used.
• Centric occlusion (“the centered contact position of the
occlusal surfaces of the mandibular teeth against the
occlusal surfaces of the maxillary teeth” ).
• Vertical dimension at occlusion.
• Plane of orientation of occlusion. Improper orientation
leads to Reverse smile line.
Normal Smile Line

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• The tissue surface of the palate should be examined.
• Reproduction of rugae should be noted.
• The patient’s speech pattern should be noted.
• Posterior extension of maxillary denture.
• Posterior palatal seal area should be examined.
• Proper basal seat coverage and adaptation should be noted.
• The midline of the denture should be noted.
Acceptable deviation < 2mm
Unacceptable deviation >2mm
• The amount of space in buccal vestibule.
• Patient’s comfort should be examined.

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• Cross bite should be checked.

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• Denture maintenance should be evaluated.
• Denture wear (due to bruxism) should be evaluated.
• Retention and stability of denture.
• Attachments and other components.
Pre-Extraction Records
Pre extraction photographs, diagnostic casts should be
examined to reproduce anterior aesthetics and guide jaw
relation.
Diagnostic Casts
Helps us to assess inter-ridge space, ridge form and
ridge shape.
Denture success
The patient should be asked about aesthetics and function
of the present denture.

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CLINICAL EXAMINATION OF THE
PATIENT
Extra Oral
Examination
Intra Oral
Examination

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Extra Oral Examination
• Facial Examination
• Muscle Tone
• Muscle Development
• Complexion
• Lip Examination
• TMJ Examination
• Neuromuscular Examination

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Facial Examination
It includes Facial features, Facial form, Facial profile and
Lower facial height.
Facial Features
The following features must be noted
• Length of lips
• Lip fullness
• Apparent support of lips
• Philtrum
• Nasolabial Fold
• Mentolabial sulcus or Labiomental groove
• Labial Commissures and Modiolus
• Width of Vermillion border
• Size of Oral opening
• Texture of Skin (Rough or Smooth and Light color.)

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Facial Form
House and Loop, Frush and Fisher, and Williams classified
Facial Form based on outline of the face as
Square
tapering
facial form
Oval
facial form
Tapering
facial form
Square
facial form

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Facial Profile
It determines the jaw relation and occlusion.
Class I
Normal or
straight
Class II
Retrognathic
profile
Class III
Prognathic
profile

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Lower Facial Height
Normal Lower
facial height
Decreased lower
facial height
Increased lower
facial height
The face appears
wrinkled.
The face appears
stretched.

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Muscle Tone
Muscle tone can affect the stability of the denture.
House classified Muscle Tone as
Class I: Normal tension, tone and placement of muscles of
mastication and facial expression.
Class II: Normal muscle function but slightly decreased
muscle tone.
Class III: Decreased muscle tone and function. It is usually
accompanied with ill fitting dentures, decreased vertical
dimension, decreased biting force, wrinkles in the cheeks
and drooping of commissures.

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Muscle Development
People with excessive muscle development have more
biting force.
House classified muscle development as
Class I: Heavy
Class II: Medium
Class III: Light
Complexion
The color of the eye, hair and the skin guide in selection
of artificial teeth.
Pale skin color is indicative of Anemia.

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Lip Examination
• Lip Support (Adequately supported or unsupported)
• Lip Mobility: Normal (Class 1)
Reduced Mobility (Class 2)
Paralyzed (Class 3)
• Thickness of Lips (Thick or Thin)
• Length of Lips (Long, Normal or Medium and Short)
• Health of Lips
TMJ Examination
The joint should be examined for movements, pain,
Muscles of mastication, joint sounds upon opening
and closing.
Severe pain in TMJ indicates increased or decreased VD.

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Neuromuscular Examination
It includes Speech and Neuromuscular coordination.
Speech
Type 1: Normal
Type 2: Affected
Neuromuscular Coordination
Patients with good neuromuscular coordination can easily
learn to manipulate dentures.
Neuromuscular Coordination of a patient can be classified as
Class I: Excellent
Class II: Fair
Class III: Poor.

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Intra Oral Examination
• Existing Teeth
• Mucosa
• Saliva
• Residual Alveolar Ridge
• Ridge Defects
• Redundant Tissue
• Hyperplastic Tissue
• Hard Palate
• Soft Palate and Palatal Throat Form
• Lateral Throat Form
• Gag Reflex
• Bony Undercuts
• Tori
• Muscle and Frenal Attachments
• Tongue
• Floor of the Mouth

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Existing Teeth
The condition of existing teeth is important for
Single Complete Denture.
The state of remaining teeth influence the success of tooth
supported dentures.
Mucosa
The color, condition and the thickness of mucosa should
be examined.
Color of the Mucosa
The mucosa should have healthy Pink color.
Inflammatory mucosa appears Red (Ill fitting dentures,
Smoking, Infection or Systemic Disease).
White Patches might indicate an area of Frictional Keratosis.

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Healthy Oral Mucosa
Inflamed Oral Mucosa Mucosa In Frictional Keratosis

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Condition of the Mucosa
House classified Condition of the Mucosa as
Class I: Healthy Mucosa
Class II: Irritated Mucosa
Class III: Pathologic Mucosa
Thickness of the Mucosa
House classified Thickness of the Mucosa as
Class I: Normal uniform density of 1mm Thickness.
Investing tissue forms ideal cushion for basal seat of the
Denture.

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Class II: It is of two types
• Thin investing membrane and highly susceptible to
irritation.
• Twice normal thickness.
Class III: Excessively thick investing membranes filled with
redundant tissue which requires treatment.

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Saliva
It can be classified as
Class I: Normal quality and quantity of saliva.
Class II: Excessive saliva. Thick ropy saliva alters the seat
of the denture.
Class III: Xerostomia. Poor retention and excessive irritation.
Residual Alveolar Ridge
Should examine
• Arch size
• Arch form
• Ridge Contour
• Ridge Relation
• Inter-Arch Space

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Arch size
It can be classified as follows
Class I: Large (Ideal Retention and Stability)
Class II: Medium (Good Retention and Stability)
Class III: Small (Difficult to achieve Retention and Stability).
Class I Class II Class III

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Arch form
House classified Arch Form as
Class I: Square
Class II: Tapering
Class III: Ovoid

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Ridge Contour
Ridges can be classified according to contour as
• High Ridge with Flat Crest and Parallel sides
• Flat Ridge
• Knife-Edged Ridge
Classification of Maxillary Ridge Contour
• Class I: Square to gently Rounded
• Class II: Tapering or ‘V’ shaped
• Class III: Flat

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Classification of Mandibular Ridge Contour
Class I: Inverted ‘U’ Shaped
(Parallel walls, medium to tall
ridge with broad ridge crest)
Class II: Inverted ‘U’ Shaped
(Short with Flat Crest)
Class III: Unfavorable
• Inverted ‘W’
• Short Inverted ‘V’
• Tall, Thin Inverted ‘V’
• Undercut (due to Labioversion
or Linguoversion of
the teeth)

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Ridge Relation
Ridge Relation is defined as
“The positional relation of the Mandibular ridge to the
Maxillary ridge.”
• Ridge Relation refers to the antero-posterior relationship
between the ridges.
• Angle classified Ridge Relation as
Class I: Normal
Class II: Retrognathic
Class III: Prognathic

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Ridge Parallelism
Ridge parallelism refers to
“The relative parallelism between the planes of the ridges.”
Ridge Parallelism can be classified as
Class I: Both ridges are parallel to occlusal plane.
Class II: The mandibular ridge diverts the occlusal plane
anteriorly.
Class III: Either the maxillary or both the ridges divert the
occlusal plane anteriorly.

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Inter-Arch Space
• Increased Inter-Arch space will be due to excessive
resorption. These people will have decreased retention and
stability of dentures.
• Decreased Inter-Arch space will make teeth arrangement
difficult. However, stability is increased due to decrease in
leverage forces acting on dentures.
Inter-Arch Space can be classified as
Class I: Ideal Inter-Arch Space.
Class II: Excessive Inter-Arch Space.
Class III: Insufficient Inter-Arch Space.

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Ridge Defects
They include
• Exostosis (Benign Bony Growth)
• Pivots
Redundant Tissue
Movable Flabby tissues tend to cause movement of the
denture when forces are applied.
Leads to loss of Retention.
Hyperplastic Tissues
Most common hyperplastic lesions are Epulis Fissuratum,
Papillary hyperplasia of the mucosa and Hyperplastic folds.
Surgery is considered if following lesions exist.

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Hard Palate
Hard Palates can be classified as
U-Shaped: Ideal for both retention and stability.
V-Shaped: Retention is less, as the peripheral seal is
easily broken.
Flat: Reduced resistance to lateral and rotatory forces.

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Soft Palate
Soft Palates can be classified as
Class I: Horizontal and Little muscular movements.
Class II: Soft palate makes 45° angle to the hard palate.
Class III: Soft palate makes 70° angle to the hard palate.

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Palatal Throat Form
“The relationship between the soft palate and hard palate is
called Palatal Throat Form.”
House classified Palatal Throat Form as
Class I: Large and normal in form, relatively with an
Immovable band of tissue 5 to 12mm distal to the line drawn
across the distal edge of the tuberosity's.

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Class II: Medium sized and normal in form, with relatively
Immovable resilient band of tissues 3 to 5mm distal to the
line drawn across the distal edge of the tuberosity’s.
Class III: Usually accompanies a small maxilla. The curtain
of soft tissue turns down 3 to 5mm anterior to a line drawn
across the palate at the distal edge of the tuberosity’s.

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Lateral Throat Form
Neil classified Lateral Throat Form as
Class I (Deep lateral throat form)
Class II (Moderate lateral throat form)
Class III (Shallow lateral throat form)

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Gag Reflex and Palatal Sensitivity
Some patient’s may have an exaggerated gag reflex.
It can be due to a Systemic disorder, Psychological,
Extra oral, Intra oral or Iatrogenic Factors.
House classified Palatal Sensitivity as
Class I: Normal
Class II: Subnormal (Hyposensitive)
Class III: Supernormal (Hypersensitive)

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Bony Undercuts
Bony undercuts do not help in retention.
Undercuts are seen in both, Maxilla and mandible.
In Maxilla, the undercut is found in anterior region and
only providing relief is enough.
In Mandible, the area under Mylohyoid ridge acts as an
undercut. Surgical reduction or repositioning of
Mylohyoid attachment can be done.

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Tori
Tori are abnormal bony prominences found in middle of
Palatal vault and on the lingual side of the Mandible in the
Premolar region.
Maxillary and Mandibular Tori can be classified as
Class I: Tori are absent or minimal.
Class II: Clinical examination reveals tori of moderate size.
Class III: Large Tori are present. Require surgical contouring
or removal.

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Muscle and Frenal Attachments
In case with residual ridge resorption, Maxillary Labial and
Lingual frenal attachments approximate to the crest of the
Ridge. Such attachments can produce displacement of
Denture during muscular action.
House classified border and frenal attachments.
Classification of Border Attachments
Class I: Attachments are placed away from the crest of the
ridge. There is at least 0.5 inches distance between the
Attachment and the Crest of the Ridge.
Class II: Distance between the Crest of the Ridge and the
Attachment is around 0.25 to 0.5 inches.
Class III: Distance between the Crest of the Ridge and the
Attachment is less than 0.25 inches.

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Classification of Frenal Attachments
Class I: The Frenum is located away from the Crest.
Class II: The Frenum is located nearer to the Crest.
Class III: Freni encroach the crest of the ridge and may
interfere with the denture seal. Surgical correction may be
required.

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Tongue
The tongue is examined for the following
• Size
• Movement and Coordination
House’s classification for Tongue sizes
Class I: Normal in size, position and function. Sufficient
Teeth are present to maintain this form.
Class II: Teeth have been absent long enough to change its
form and function.
Class III: excessively large tongue due to absence of teeth
for a longer period of time.

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Wright’s classification of Tongue Positions
Class I: The Tongue lies on the floor of the mouth with the
tip forward and slightly below the incisal edges of the
Mandibular anterior teeth.
Class II: The Tongue is flattened and broadened but the tip
is in normal position.
Class III: The Tongue is retracted and depressed into the
Floor of the mouth, with the tip curled upward, downward
or assimilated into the body of the tongue.

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Floor of the Mouth
• In some cases, the floor of the mouth is found near the crest
of the ridge, especially in the sublingual and mylohyoid
regions.
• This decreases the stability and the retention of the denture.
• The floor of the mouth can be measured with a
William’s probe.
• The patient should touch his upper lip with the tongue to
activate the muscles of the floor of the mouth.

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Additional Clinical diagnostic procedures for
Partially Edentulous Condition
Clinical Evaluation of Existing Teeth
• Periodontal Health
• Occlusion of the Existing Teeth
• Conservative and Endodontic status of the Existing
teeth.

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Periodontal Health
Clinical Signs of Periodontal Health like
• Inflammation of the Gingiva
• Bleeding on Probing
• Periodontal Breakdown
• Mobility of the Teeth
• Oral Hygiene Index should be evaluated.
The Periodontal Health can also be determined
Radiographically.
The amount of horizontal or vertical bone loss is measured
Radiographically.
After evaluating the Periodontal health, the clinician should
decide whether to retain or extract a periodontal week tooth.

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The Periodontal status evaluated
Clinically using Periodontal Probe.
Bone Loss evaluated
Radiographically.

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Occlusion of Existing Teeth
The Teeth should have a good CUSP TO FOSSA relationship.
Some Teeth may be tilted which couldn’t support the
Prosthesis.
Such teeth can either be extracted or orthodontically
aligned.

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One other factor to be examined is Trauma from Occlusion.
Trauma due to Excessive Occlusal Force is characterized by
the presence of
• Premature Contacts (High Points)
• Mobility of Teeth
• Buttressing Bone Formation
• Wear Facets, etc.

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Conservative and Endodontic Status
of Existing Teeth
The Existing Teeth must be examined to rule out
• Pit and Fissure Caries
• Deep Caries
• Gross Tooth Decay, etc.
• Vitality of the Pulp should
be checked.
• Cracks, Chipped Corners and
fractures should be examined.
Endodontic therapy must be done to such teeth prior to
the start of the treatment.
Retained root stumps must be extracted.

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Radiographic Examination
Considerations for Radiographic Examination
• The jaws should be screened for retained root fragments,
Un erupted teeth, sclerosis, cysts, tumors and TMJ disorders.
• The amount of ridge resorption should be assessed.
Ridge resorption can be classified as
Class I: Mild Resorption (one-third of vertical height)
Class II: Moderate Resorption (two-third of vertical height)
Class III: Severe Resorption(more than two-third loss of
vertical height)
• The quantity and quality of the bone should be assessed.
Branemark et al classified Radiographically
 Bone Quantity as Classes A, B, C, D and E.
 Bone Quality as Classes 1, 2, 3 and 4.

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Derived Diagnosis or Post-Clinical Diagnosis
Derived diagnosis for a Removable Partial Denture include the
evaluation of diagnostic data like DIAGNOSTIC CASTS.
The Diagnostic Casts must be surveyed prior to teeth setting.
The purpose/uses of surveying are
• To Locate and demark the soft tissue undercuts and severe
undercuts located on the surface of existing teeth.
• To determine the need for pre-prosthetic mouth preparation
and also perform mock surgeries.
• To determine the path of insertion of the denture.

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Adjunctive Care
Prosthodontics
Care
Treatment Plan
• Elimination of infection
• Elimination of pathology
• Pre-Prosthetic surgery
• Tissue Conditioning
• Nutritional Counselling
Patient’s destined to be
Edentulous
• Immediate or Conventional
Denture
• Definitive or Interim denture
• Implant or soft tissue
supported denture.
Patient’s already Edentulous
• Soft tissue supported
• Implant supported
• Material of choice
• Selection of teeth
• Anatomic Palate

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Prosthodontic treatment for partially edentulous patient’s can
be divided into SIX separate phases or stages.
• PHASE I
 Collection and evaluation of diagnostic data
 Treatment of emergency conditions.
 Determining the type of prosthesis to be fabricated.
 Patient Motivation.
• PHASE II
 Pre-Prosthetic Mouth preparation
 Making the primary impression
 Patient Motivation

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• PHASE III
 Designing the RPD.
• PHASE IV
 Prosthetic mouth preparation
 Making the Final Impression
 Patient Motivation.
• PHASE V
 Fabrication of the Removable partial Denture.
• PHASE VI
 Insertion
 Post-Insertion management
 Periodic recall and review.

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Advantages of Treatment Planning
• Improves the patient’s cooperation and motivation.
• Helps to communicate between two clinicians.
• Records from the previous dentist give an idea about the
current status of the patient and the outcome of the
treatment.
• Provides the treatment coordination between recall visits.
• Acts as a reminder to complete all the procedures enlisted
for treatment.

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