diagnosis and treatment planning in complete denture

1. 1

2. Diagnosis and
treatment planning
in Complete
Dentures
2
Dr. Vivien Vaz
II MDS
Dept of Prosthodontics

3. Contents
• Introduction
• Definitions
• Personal data
• Chief complaint
• Medical history
• Personal history
• Dental history
• Personality- classification
• Clinical evaluation – extra oral and intra oral
• Evaluation of existing dentures
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4. • Radiographic examinations
• Investigations
• Diagnosis- ACP Classification
• Treatment planning
• Steps in Complete Denture fabrication
• Patients consent
• Conclusion
• References
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5. Introduction
• Successful complete
denture therapy begins
with a thorough
assessment of the
patients physical and
psychological condition
and determining a
treatment that will deliver
a functional complete
denture that will satisfy
the expectations of the
patient. (Winkler)
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6. Definitions
Prosthodontics
• Prosthodontics is the dental specialty pertaining to the
diagnosis, treatment planning, rehabilitation, and
maintenance of the oral function, comfort, appearance, and
health of patients with clinical conditions associated with
missing or deficient teeth and/or maxillofacial tissues by
using biocompatible substitutes- GPT 9
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7. What is Diagnosis?
(According to Heartwell)
• The act or process of deciding the nature of a diseased
condition by examination.
• A careful investigation of the facts to determine the nature of a
thing.
• The determination of the nature, location and the causes of
disease.
Diagnosis- the determination of the nature of a disease - GPT 9
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8. (According to Sheldon Winkler)
Diagnosis- The examination of the physical state, evaluation of
the mental or psychological makeup and understanding the
needs of each patient to ensure a predictable outcome.
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9. Treatment plan
• Developing a course of action that encompasses the
ramifications and sequelae of treatment to serve the
patients needs. (Sheldon Winkler)
• The sequence of procedures planned for the treatment of a
patient after diagnosis – GPT 9
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10. • The first appointment is the
most important.
• Evaluation of patients should
be thorough and well
documented
• Checklist…
• The checklist format makes
the form quick and
convenient to use.
• Kept as patient's dental
record for future reference.
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11. • Checklist provides a greater level of understanding of
the patient's problems, anatomy, and treatment goals.
• Through this a clinician should be able to deliver
improved care to the edentulous patient.
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12. PERSONAL DATA
Name
SSN: A Social Security number or Patient number is required.
Age: Age is an indicator of the patient's ability to wear and to use
dentures.
• Fourth decade of life tissues heal rapidly and are relatively resilient.
• Beyond the fifth decade, however, tissues do not heal as rapidly.
• Women facing the physiologic and psychological problems of
menopause.
Sex
Occupation
Address
Contact number
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13. CHIEF COMPLAINT- abbreviated as CC
• Concise statement--> problem, condition, duration, dentist-
recommended return and other factors requiring a dental
encounter.
• A series of complaints that a patient presents with in-order
of severity that needs urgent attention.
• A subjective report provided by a patient in his/her own
words – why the patient is seeking an oral health care
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14. • Serves as a source of information to the dentist which
he uses in making a set of provisional diagnosis.
• Expectations:
• The foundation for developing a consistent treatment
plan
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15. Medical history
• General Health: A thorough and accurate medical history must be
obtained.
• Provides important insights regarding the patient's dental prognosis
• Systemic factors… to be considered during treatment planning
• History of hospitalization or operation.
• Medication history:
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16. Personal history
• Diet, smoking, chewing, alcohol and drug addiction.
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17. Dental History
• Duration of edentulous, Maxilla/Mandible.
• Reason for tooth loss (caries/periodontal/trauma and
sequence )
• Previous Dentures, Maxilla/Mandible:
-duration,
-number,
-reason for replacement.
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18. • Existing or Current Dentures: duration the dentures are
worn, denture experience, denture care, dental knowledge,
parafunctional habits.
• Denture Success: The patient should be asked about the
aesthetics and function of existing maxillary and mandibular
dentures.
• Pre-Extraction Records: Pre-extraction photographs,
radiographs, casts, and facial measurements may prove
helpful in denture therapy.
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19. Personality
• “Prosthetic attitude” (Winkler) –Dentist should able to identify
negative and positive responses which can influence the treatment
outcome.
(According to House 1937)
• Philosophic
• Exacting
• Hysterical
• Indifferent
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21. Blum 1960- (John J Sharry)
• Reasonable or unreasonable and/or realistic or unrealistic
-Social background
-Unreasonable/unrealistic patients are less well educated when
compared to to reasonable patients.
-Unreasonable/unrealistic patients are frequently labourers, white
collar workers, skilled or semi skilled workers(low income)
-Unrealistic patients expect impossible, demand all the energy of the
dentist and will blame the dentist if their expectations are not met.
-Reasonable/realistic patients often hold professional and managerial
jobs.
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22. John J sharry
• Paranoid patient- feels that everyone is against him and no one will
help him & may be dangerous if his treatment expectations are not
met.
• Manic-de-pressive patient- no consistency in the behaviour, one
minute all is good, his dentures are the best, the dentist is a hero and
the next moment “the teeth were never good”, “my mouth is sore”,
“I’m not getting anywhere”.
• Stress patient- women in menopause, heavy smokers and coffee
drinkers
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24. Clinical evaluation
Extra-oral…
• Facial form(frontal) :According to House and Loop, Frush and fisher
and Williams.
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25. • Facial form ( profile)
-Class I- straight profile-165° to
175°
-Class II- retrognathic-less than
165°
-Class III- Prognathic-greater than
180°
• Glabella: The prominent smooth
area between the eyebrows as
the forehead transitions down to
the bridge of the nose.
• Subnasale: The point at which the
nasal septum merges with the
upper lip.
• Pogonion: The most anterior
point on the contour of the chin
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27. • Muscle Tone: according to House: (flaccid/tense/average)
- Class 1: The patient exhibits normal tension-tone, and placement of
the muscles of mastication and facial expression.
No degenerative changes are apparent. The majority of edentulous
patients have experienced some degree of degeneration. Usually, only
immediate-denture patients have normal musculature.
- Class 2: The patient displays approximately normal function but
slightly impaired muscle tone. Maximum muscle function cannot be
used following the loss of all natural teeth.
- Class 3: The patient exhibits greatly impaired muscle tone and
function. Tags with poor health, inefficient dentures, and loss of
vertical dimension, wrinkles, decreased biting force, and drooping
commissures.
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28. • Cardiovascular accidents, Bell’s
palsy --> hemiplegia
• Facial tremors/spasms -->
Parkinson’s, nervousness or drug
induced
• Psychotropic drugs -->
uncontrolled movements, licking
smacking of lips, uncoordinated
tongue movements.
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29. • Complexion: Fair/medium/dark
-Hair, eye, and skin color provide
useful guides in shade selection.
-Pale, anemic-looking patients-->
underlying systemic diseases and
may require longer adjustment
periods.
-Heavy wrinkles at the
commissures and nasolabial fold
usually suggest decreased Vertical
Dimension of Occlusion (VDO) or
poor support of facial musculature
by the denture.
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30. • Lip
-”Adequately supported" or "unsupported.”
-Lip mobility- Some stroke victims-paralysis of half the lip, leading to
unilateral mouth droop and facial asymmetry.
-Patients must be counselled regarding treatment limitations when
dealing with such physical challenges. Otherwise, patients may have
unrealistic expectations regarding functional and esthetic results.
-Classify lip mobility: normal (class 1), reduced mobility (class 2), or
paralysis, (class 3).
Cracking, fissuring at corners or ulcerations noted: vit defienciency,
candida infection or reduced VD due to existing dentures.
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31. -Lip length also plays an important role in esthetics.
-A long lip reveals little of the anterior teeth, whereas a very short lip allows
the display of the denture base. (long, normal or medium, and short)
-Thin, tight short lips
make impression
difficult- insertion and
removal of impression
trays may be cause
discomfort
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32. Temporomandibular joint (TMJ)
-Bimanual and bi-digital palpation of pre-aricular area:
Lateral aspect of joint is palpated with mouth closed, followed by opening of
slightly.
• With the mouth completely open the posterior aspect of the joint is
palpated.
• Note any crepitus or clicking.
• Deviation of mandible is noted while opening and closing of the mouth.
Neuromuscular Evaluation:
Speech: "normal" or "affected”
Coordination:
• Class 1: Excellent
• Class 2: Fair
• Class 3: Poor
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33. Intra oral examination
• Mouth opening- normal is 45-55mm (three fingers distance)
- Boley gauge or manufacturer’s scale
• Arch Size: Classified as follows:
-Class 1: Large (best for retention and stability)
-Class 2: Medium (good retention and stability but not ideal)
-Class 3: Small (difficult to achieve good retention and stability)
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Arch Form: According to House
-Class 1: Square
-Class 2: Tapering
-Class 3: Ovoid

35. Ridge Form: Maxillary ridge and vault form should be classified as
follows:
Class 1: Square to gently rounded
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37. • Mandibular Ridge Form: Mandibular ridge form is classified as
follows:
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38. Thin inverted “V”
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39. • Atwoods classification of
ridges
• Order I - Pre-extraction.
• Order II - Post-extraction.
• Order III - High, well rounded.
• Order IV - Knife-edge.
• Order V - low, well-rounded.
• Order VI - depressed.
• Green ridge- ridge which have
bony spicules remaining from
extraction sites or bony undercuts
with a thin mucosal covering.
(Winkler) 39

40. Defects:
• Note ridge defects, such as exostoses, that may pose problems for
complete-denture patients or may warrant preprosthetic surgery.
Tori: maxillary and mandibular exostoses classified as:
Class 1: Tori are absent or minimal in size. Existing tori do not interfere
with denture construction.
Class 2: tori of moderate size. Surgery is not required.
Class 3: Large tori are present
 require surgical recontouring or removal.
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41. • Inter-ach Space: Classified as follows:
• Ideal is 20mm to accommodate artificial teeth.
• Less than 20 mm stability of denture base is compromised.
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42. artificial teeth
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43. • Ridge Relationship: According to Angle:
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44. • Maxillary tuberosity
-Favorable
-Underdeveloped
-Interference
• Mylohyoid ridge
-Average
-Sharp
-undercut
Relief is to be given
Or surgical correction
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45. • Lateral Throat Form: According to Neil  important for lingual seal
and lateral stability.
Class 1 Class 2
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Class 1= deep
Class 2= moderate
Class 3= shallow

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Hard palate
• U- shaped palatal vault: most favourable for retention and lateral
stability.
• V- shaped vault: less favourable for retention.
• Flat palatal vault: unfavourable.

48. • Palatal Throat Form: Classified according to House:
-Class 1: Large and normal in form, with a relatively immovable band of
resilient tissue 5 to 12 mm distal to a line drawn across the distal edge
of the tuberosities.
-Class 2: Medium size and normal in form, with a relatively immovable
resilient band of tissue 3 to 5 mm distal to a line drawn across the distal
edge of the tuberosities.
-Class 3: Usually accompanies a small maxilla. The curtain of soft tissue
turns down abruptly 3 to 5 mm anterior to a line drawn across the
palate at the distal edge of the tuberosities.
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50. • Mucosa Thickness: Classified according to House:
• 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.
• Class 2: (a) Soft tissues have thin investing membranes and are highly
susceptible to irritation under pressure (b) Soft tissues have mucous
membranes twice the normal thickness.
• Class 3: Soft tissues have excessively thick investing membranes filled
with redundant tissues. Such conditions may require surgical
correction as retention is difficult to secure.
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51. • Mucosa Condition: Classified according to House:
-Class 1: Healthy
-Class 2: Irritated
-Class 3:Pathologic
• Border Attachments: classified according to House:
-Class 1: Attachments are high in maxilla or low in mandible with
relation to ridge crest (0.5 inches or more between level of attachment
and crest of ridge).
-Class 2: Attachment height in relation to the crest of the ridge is
between 0.25 and 0.50 inches.
-Class 3: Attachment height is less than 0.25 inches from the ridge
crest.
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Color, tone, texture, presence of
any lesions

52. • Frenum Attachments: Classified according to House (classified
in same manner as border attachments):
-Class 1: High in the maxilla or low in the mandible with respect to the
crest of the ridge.
-Class 2: Medium
-Class 3: Freni encroach on the crest of the ridge and may interfere with
the denture seal. Surgical correction may be required. All lingual tissues
of the mandible are classified as muscle attachments
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53. • Saliva
-Class 1: Normal quality and quantity of saliva. Cohesive and adhesive
properties of saliva are ideal.
-Class 2: Excessive saliva; contains much mucus- complicates
impression making, pushes the denture out by accumulating beneath
the denture. (new dentures cause increase in salivary flow-> with time
will subside)
-Class 3: Xerostomia; remaining saliva is mucinous- retention of
denture is affected, causes soreness.
Normal daily production of saliva=0.5 and 1.5 liters.
Unstimulated saliva flow rate = 0.3-0.4 ml / min.
Rate decreases to 0.1 ml / min during sleep and increases to about 4.0-
5.0 ml / min during eating, chewing and other stimulating activities. 53

54. • Tongue: Classified according to House:
-Class 1: Normal in size, development, and function. Sufficient teeth are
present to maintain normal form and function.
-Class 2: Teeth have been absent long enough to permit a change in the
form and function of the tongue.
-Class 3: Excessively large tongue. ->problems in impression making &
denture stability is compromised. May be crowded by denture and
tongue biting can occur.
• All teeth have been absent for an extended period of time, allowing
for abnormal development of the size of the tongue.
• Inefficient dentures sometimes can lead to the development of a
class 3 tongue.
• A maxillary denture against lower
anterior teeth only.
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55. • Tongue Position: Classified according to Wright:
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56. • Gagging reflex
-Normal
-Hypersensitive
• Management –
-Clinical techniques
-Pharmacological
-Psychological
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57. Evaluation of existing
dentures if any
• Esthetics
• Phonetics
• Stability
• Retention
• Extensions
• Hygiene- patient's ability and
motivation to clean the dentures.
• Wear of the denture- an indicator
of parafunctional habits or an
abrasive diet
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58. • Centric Relation and Vertical Dimension of Occlusion: Centric relation
and vertical dimension of occlusion should be assessed and rated
"acceptable" or "unacceptable," If unacceptable, it should be noted
whether the existing VDO is "inadequate" or "excessive.”
• Occlusal Plane Orientation: The orientation of the occlusal plane
should be noted.
• Improper orientation as a result of tooth setting or changes in bony
architecture often creates a "reverse smile line."
• This condition is characterized by teeth that slope downward as one
progresses posteriorly.
• Consequently, the anterior teeth assume a curvature that does not
follow the arc of the lower lip.
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60. • Palate: The palate of the existing maxillary denture should be
examined. The denture base material and thickness should be noted.
• Base Adaptation: The fit of maxillary and mandibular bases should be
assessed using an appropriate disclosing medium, Adaptation should
be rated "acceptable" or "unacceptable.”
• Midline: Maxillary and mandibular midlines should be observed. The
existing maxillary midline should be evaluated using intraoral (e.g.,
incisive papilla) and extraoral landmarks (e.g., nasion, filtrum, middle
of the chin)
• Crossbite: "none “, “ unilateral," or "bilateral.”
• Existing denture bases may be classified as "characterized" or '
'uncharacterized."
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61. Radiographic examination
• Quality of bone
• Retained roots
• Impacted teeth
• Foreign bodies
• Rarefied areas
• Floor of maxillary sinus
• Condylar morphology
• Any other pathology if present
• Other investigations Blood glucose, blood pressure, RBC count,
hepatitis B, HIV
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62. Diagnosis
• Completely edentulous maxilla and mandible
• ACP classification – developed by the American college of
prosthodontics- by McGarry et al
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77. Treatment planning
Pre-Prosthetic- phase 1
1. Diagnostic impressions
2. Mouth preparation
Non surgical
• Tissue conditioning: List proposed therapy as finger massage,
prescribed medications
• Nutrition
Surgical
• Extraction of retained roots, impacted teeth, alveoloplasty,
vestibuloplasty, ridge augmentation.
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78. Prosthetic- phase 2
Steps in complete denture fabrication
• Primary impression- type of tray, impression and material.
• Final impression- special tray, impression material and
impression technique.
• Jaw records- orientation, vertical and horizontal.
• Articulation.
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79. • Tooth Selection: The shade, mold, and material.
• Denture Base Shade: Base shade selection depends on the
complexion.
• List items to improve on in the new dentures, such as
inadequacies of the existing dentures.
• List items not to be changed in the new dentures, such as
good features of the existing dentures.
• Characterisation
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80. • Arrangement of teeth.
• Try in.
• Acrylization.
• Lab remount- to correct errors in occlusion that have occurred during
processing, to return the dentures to the correct vertical dimension of
occlusion and to restore centric contacts and bilateral balanced
occlusion.
• Denture delivery- patient education, base adaptation, denture
extensions, PPS seal.
• Clinical remount.
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81. • Follow up- 24 hour check is done.
• Patients problem if any are enquired and oral examination is done.
• Any correction if required are done with pressure indication paste
and disclosing wax ( ulcers will correspond ) and dentures are
adjusted.
• Occlusal evaluation is done.
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82. Patient’s consent
• Patient approval to the above mentioned treatment plan is utmost
important after thoughtful consideration and understanding.
• Indicates his or her willingness to participate in the treatment.
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83. Conclusion
• Diagnosis and treatment planning help both the clinician and patient
to understand the diagnostic procedures, results, treatment plan, use
of prosthesis and continuing care.
• The treatment plan should be best developed to serve the needs of
the patient thus improving the quality of life.
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84. References
• Robert, Rodney. Patient Evaluation and Treatment planning for complete
denture therapy. DCNA. Vol 40 Number 1- Jan 1996.
• Charles M Heartwell, Rahn. Syllabus of Complete Dentures. 4th edi. Chap 4-
Diagnosis.
• Sheldon Winkler. Essentials of Complete Denture Prosthodontics. 3rd edi.
Chap 4- Diagnosis and Treatment planning.
• John J Sharry. Complete Denture Prosthodontics. 3rd edi. Chap 2 The Person
(psychological aspect).
• Zarb, Hobkirk, Eckert, Jacob. Prosthodontic treatment for Edentulous
Patients. 13th edi. Chap 5- History taking, treatment planning and improving
denture bearing areas for edentulous patients.
• Thomas J McGarry et al. Classification System for Complete Edentulism. ACP.
J Prostho Dent. 1999;8:27-3. 84

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