Treatment plan in complete Edentulous arches /certified fixed orthodontic courses by Indian dental academy
DIAGNOSIS AND TREATMENT PLANNING
COMPLETELY EDENTULOUS ARCHES
INDIAN DENTAL ACADEMY
Leader in continuing dental
Definition Of Diagnosis & Treatment
General Introduction Of the
Clinical history taking
Clinical examination—Intra oral
Examination of existing dentures.
Other investigation for systemic
Diagnosis Comprises of evaluation of patients health
with respect to his/her physical,mental&social health,
and these diagnostic findings decide treatment plan.
Treatment planning is the most important milestone
which depends on the diagnosis.So accurate
diagnosis plays a very important role in ensuring
predictable results of the treatment.prognosis
depends on both diagnosis and treatment planning.
Definition of diagnosis &
• Diagnosis is defind as determination of nature
• Treatment planning is defind as the sequence
of procedures planned for the treatment of a
patient after diagnosis
• Boucher –diagnosis consists of planned
observation to determine & evaluate the
existing conditions, which lead to decision
making based on the condition observed.
• Treatment plans should be developed to best
serve the needs of each individual patient.
diagnosis is the examination of
physical status, evaluation of mental or
psychological make up, &understanding of
needs of each pt to ensure a predictable
Treatment planning means developing
sequence of procedures planned for the
treatment of a patient after diagnosis.
General introduction of the patient &
The first appointment imp for the development of
mutual understanding, trust b/n pt dentist.
Pt should be addressed by name
Dentist should verify the personnel information
collected by the receptionist.
Observation of the patients motor skills,level of coordination steadiness while walking.
Unusual gait –Parkinson`s disease, neurological
disorder, disease of the joint.
EVALUATION OF MENTAL ATTITUDE
The successful prosthodontic treatment depends on both technical skill &p
mgt according to mental attitude.
Neurosis– chr. Anxiety state at phy .State
--increases alters neuromuscular co ordination.
Dr. M .M. House cl of mental attitudes
Philosophical-ideal, co-operative, optimistic .Prognosis good.
Indifferent- least concerned about their oral health
not co-operative, avoid treatment.
Critical-not satisfied with previous dentures &dentist.
Skeptical—poor gen health, unfavorable biomechanical
condition,pessimistic. Pt motivation & education.
Hysterical-poor health, nervous, unrealistic expectation, poor prognosis
education & motivation.
CLINICAL HISTORY TAKING
Diagnosis & treatment planning depends upon
accurate data collection & record maintenance.
Name:patient identification, for addressing.
Sex: patient expectations in the denture
differ with sex.
AGE:diseases related to age,as age advances
decrease in adaptability &neuromuscular coordination,learning ability. Oral&facial tissues loose
Socio-economic status :
Chief complaint:difficulty in speech
>Cause for the tooth loss
>Period of edentulousness
>Problems with existing denture
>expectations in new denture
H/o systemic diseases.
Previous medical records.
Date & reason for the last visit to physician.
Physician tel .ph no.
• - Impaired carbohydrate metabolism because of insulin
deficiency or resistance.
Pt should be for the h/o DM, rule out for DM.
Drug history Insulin,OADA,diet
Pt suffering from DM will show-- 1)Osteoporosis.
2) Residual alv bone resorption
Patient education regarding maintenance of denture
cleanliness oral hygiene. Need for regular check up
Mucostatic impression technique. Avoid surgical intervention.
Angina pectoris: it is a severe ischeamic pain aggravates
on exertion relieved with rest.
Avoid anxiety, exertion
Physician consultation .
Pt with h/o MI avoid treatment for 6 mts.
Physician consultation & reassurance of pt to reduce
Infective bacterial endocarditis:
Pt with artificial heart valves, valvular heart disease prone
Prophylactic Ab therapy prior to surgical procedures.
Anaemia: level of Hb in the blood below normal.(14-
Types of Anaemia:
Iron def. Anaemia:increased loss of iron,
increased physiological requirement, malabsorbtion
of iron as in hypochlorhydria.
Oral Manifestations:atrophic mucous membrane, loss
of normal keratinization.
Megaloblastic anaemia: deficiency of vit B-12 &
Oral Manifestations:angular chelitis
Pernicious anaemia: It is autoimmune
disorder.atrophic gastric mucosa with loss of parietal
cells so def of IF,decreased vitB-12 absorption
Bald tongue atrophy of papilla
Burning sensation in the mouth.
Sickel cell anaemia .:hereditary type of chr.
Hemolytic anemia transmitted as non sex linked
Radiographic features reveal-mild to sever gen
osteoporosis, loss trabaculation of jaw bones with
large irregular marrow spaces, coarse trabaculaton.
DISEASE INVOLVING WBC`S
Leukopenia:decrease in no. WBC`s.
Agranulocytosis: serious disease with decrease in
number of granulocytes.
Oral manifestations: necrotizing ulcers, excessive
Leukemias:characterized by progressive over
production of WBC`s, appear in circulating blood in
O.m—petechiae, ulceration of mucosa, purpuric
DISEASES OF PLATELETS
purpura:decrease in circulating blood
platelets autoimmune disorder.
Thrombocythemia: increase in
circulating blood platelets.
Oral manifestations: petechiae on
the oral mucosa,bleeding tendencies.
Prevent cross contamination
Self precaution &protection of assistant
Disinfections of impression
DISEASES OF BONE & JOINTS
Affects elderly above 45 yrs of age M:F ratio 2:1(age
related degenerative joint disease less frequently
affects TMJ),weight bearing joints
Characterized by deteriorations of articular cartilage
remodeling of underlying bone.
C/f:- pain &crepitaion during mandibular
muscles of mastication tender.
Advanced stage jt disability & atrophy of
Difficulty in wearing and cleaning of denture.
Impression making,jaw relation recording difficult.
Frequent occlusal corrections should be made.
Inflammatory disease affecting joints.
C/f –Affects small joints of hands,feet symmetrically
first followed by wrists, elbows, ankles,knees.
TMJ-pain ,crepitations, limited movements, stiffness,
anterior open bite, vertical facial height increased.
C/f— chronic disease,pt above 40 yr & older age
bone pain ,head ache, deafness compression of
cochlear n,blindness involvement of optic n, dizziness
, facial paralysis, weakness & mental disturbance.
-maxilla progressive enlargement,alv ridge widened,
Ed pt c/o inability to wear dentures.
Disturbance of endochondral bone formation
resulting in dwarfism.
Hereditary condition transmitted as autosomal
C/f dwarf below 1.4mt,brachycephalic skull,bowed
legs,small hands ,stubby fingers, lumbar lordosis.
O/m—Retruded maxilla with relative mandibular
prognathism resulting in jaw discrepancies in size &
CENTRAL NERVOUS SYSTEM
Mild anxiety to anxiety neurosis, depression,phobias,disoriented.
Severe cases psychiatric consultation.
Patient motivation & reassurance.
Require longer appointments
Epilepsy: drug history ,h/o last attack, precipitating factors, frequency,
duration of .
In such pts avoid flickering lights ,instruments which can cause harm.
Facial .n palsy because of cold,trauma, injection of L.A
drugs,nerve impingement ,injury of the n during the parotid
C/f :-unilat facial paralysis.
-Mask like face,drooping of mouth corner.
-inability to close eyes.
-loss of forehead wrinkles .
Difficulty in making impression .
Difficulty in eating & speech.
To avoid cheek biting over contouring denture base on the
affected side. Excessive horizontal overlap in posteriors.
It is a degenerating disease affecting basal ganglia,
decreased dopaminergic output so inhibitory action on sub
thalamic nucleus decreased.
C/f –expressionless face with staring look
-soft rapid speech,fixed posture,impaired balance,altered
gait,muscle rigidity,impaired fine movements,tremors in
Difficulty in making impression , jaw relation recording
Pt should be educated about the difficulty in eating,speech
&retaining mandibular denture.
Disease involving the ns supplying the
face,teeth,jaws &associated structures.
C/f –searing,stabbing ,lancinating type of
pain initiated on touching trigger zone.
In such pts prosthodontic treatment becomes
Pts should be first treated for Trigeminal
neuralgia then continued with prosthodontic
Change in bodily functions occurs during specific
Affects both male& females
In females menopause is the period
Post menopausal syndrome: Gen osteoporosis,
inability to adjust, burning tongue& tendency to gag
DISEASES OF SKIN WITH ORAL
O.m:white or grey velvety thread like
papules in a leniar,annular, retiform
arrangement forming typical lacy,reticular
patches, rings , streakes over the buccal
mucosa, lesser extent on tongue
&palate(Wickham’ s striae)
Erosive (premalignant), vesicular or bullous
forms also causes burning sensation
Erythema multiformae: concentric ring
like vesiculo bullos lesions(bull’s eye)
Hyperemic macules,papules,vesicles become
eroded or ulcerated bleed freely
Tongue, palate, buccal mucosa ,gingiva commonly
Lip may show ulceration/bloody crusting
Pemphigus: auto immune disease
Intercellular antibodies in epithelium of skin,oral
Serious chr disease appearance of vesicles,
Isolated vesiculo bullos lesions ruptures to
Oral lesions with rugged borders covered by
white blood tinged exudate follows by crusting
Severe pain,burning sensation. Inability to eat
Pt informed about existing condition and advised not
to wear the dentures continuously.
Characterized by indurations of skin & fixation of epidermis to
the deeper subcutaneous tissue
O/m:mucosa thin ,pale due to loss of vascularity and elasticity.
Tongue stiff board like, restricted movements.
Lips thin rigid partially fixed
Decrease in mouth opening
Distortion of buccal and labial vestibules
Difficulty in impression making & jaw relation recording
Post insertion probs: soreness, ulceration require constant
adjustments & even remaking
Sjogren`s syndrome :
Auto immune disease characterized by
keratoconjunctivitis sicca, xerostomia,
O/m-xerostomia, burning sensation in the
Contact dermatitis -Lesions occur on skin
&mucous membrane at a localized site after a
repeated contact with causative agent.
Indicate systemic disease,adverse reaction affecting oral
antiparkinson`s,antidepressants, atropine cause xerostomia.
antihypertensives,antidepressants,centrally acting skeletal
Drug induced Parkinson like syndrome by tricyclic
Behavioral changes &confusionantidepressants,corticosteroids,antiparkinson`s,
DIAGNOSIS AND TREATMENT PLANNING
COMPLETELY EDENTULOUS ARCHES
Definition Of Diagnosis & Treatment Planning
General Introduction Of the
Clinical history taking
Clinical examination—Intra oral
Examination of existing dentures.
Other investigation for systemic disease .
TONE FACIAL TISSUES
It depends on the age & health of the patient
Acc to house classified--ClassI—Normal tone & placement of facial muscles of
mastication & expression.
-ClassII_ Displays normal function but slightly
-ClassIII_ Decreased muscle tone function.
Acc to house
Muscle tone for denture retention.
Normal tone &development required for ease of
Skin of face—Dark
Black, brown, blond.
__Blue ,gray, brown, Black.
The color of the skin guides in shade selection of the
Lips examined for cracks , fissures, ulcers
Adequate support is achieved by proper
positioning of upper anterior tooth
Un supported-collapsed appearance,
wrinkles around lip.
Long—hides denture & most of tooth
Short---teeth& denture base exposed.
Vertical face length:
Decreased vertical dimension---Collapsed appearance
with wrinkles ,false prognathic relation.
Increased vertical dimension—taut ,strained
Pain on opening/ closing movements of mandible.
Clicking sound, crepitations
Deviation of mandible on opening
Limitation of mandibular movement
The centric relation depends upon structural & functional
harmony of osseous structures ,the intra articular tissues ,
Examination of the lymphnodes
Intra oral examination
Oral mucous membrane:
Examined for inflammatory lesions , pathological
lesions like precancerous lesions ,oral malignancies
,papillary hyperplasia ,epulis fissuratum,ulcers.
Evaluation of residual alveolar ridge:
The size of the maxilla &mandible determines
the amount denture bearing available.
Discrepancy in jaw size.
Arch size –Large ideal
Disharmony in jaw size
Maxillary may be larger than mandibular or reverse because of
the resorption pattern, disturbance in growth &
Occlusion should be planned similar to disharmony.
According to house cl---Square
RESIDUAL RIDGE FORM
Classified as-High with parallel ridge slopes & well rounded ,broad in width.
High in height & average in width.
High in height & thin in width.
Because of resorption ridge assumes.
Average height broad in width.
Average height & width.
Low in height & broad in width.
In severe resorption the ridge assumes V shape
Unfavorable for retention.
– High V shaped .
– Average V shaped.
– Low V shaped.
In severe resorption ridge becomes knife edge shaped.
High knife edge.
Average knife edge.
Low knife edge
Ridge can be classified as.
High well rounded
Low well rounded
Refers to relative parallelism between planes of the ridge.
Class I-Both ridges are parallel to occlusal plane.
Class II-Mandibular plane diverts from the occlusal plane
Class III-Either the maxillary ridge diverts from
occlusalplane anterioly or both ridges divert.
INTER ARCH SPACE
adequate for the
Excessive inter arch
SAGITTAL PROFILE OF RESIDUAL
It is important to locate from where the
mandibular ridge slopes up towards
retromolar pad & ramus because
occlusal contacts immediately above
the the incline at the back part of the
residual alveolar ridge will cause
denture to slide forward.
The bony undercuts
do not play any role
in retention of the
Bony irregularities –
presence of sharp
bony spicules ,
SOFT TISSUE EXAMINATION
Mucosal thickness :
According to house classified as.
ClassI—Normal uniform thickness approximately 1mm.
Class II—Soft tissue with thin investing membrane & mucous
membrane maybe twice the normal thickness.
ClassIII—Soft tissue with excessively thick investing membrane with
Muscle & Frenal attachments:
Examined in relation to the crest of the ridge because it can interfere with
denture extension &border seal.
House cl border attachments-ClassI-At least 0.5inches
distance between attachment & ridge crest.s
-ClassII- distance between attachment & ridge
crest 0.25 to 0.5inches.
Away from the crest.
Nearer to the crest.
At the crest.
Floor of the mouth:
Neil cl as
EXAMINATION OF THE TONGUE
House classified.—ClassI-Normal ,development ,function.
__ClassII-Change in form & function.
Tongue size can be ---Hypertrophic.
Tongue position:Wrights classified as
ClassI—the tongue lies in the floor of the mouth with tip
forward &slightly below the incisal edgsse of mandibular
ClassII—The tongue flattened & broadened but tip is a
Class III-retracted depressed into floor of mouth with the tip
curled upward into the body of the tongue.
Class I position is ideal with floor of mouth at an adequate
height , so lingual border contacts it & maintains the seal.
In class II &III floor of the mouth is low.
Thin serous normal quantity-favorable for retention.
Thick ropy/mucous saliva—decreases retention & stability.
Normal defense mechanism designed to
prevent foreign bodies from entering the
trachea.Mild chocking to retching .
Causes – anatomical variation ,psychological,
HARD & SOFT TISSUES IN THE MAXILLARY
Soft tissue covering RAR & palate:
Ideally uniform thickness,quite firm, resilient.
Fibrous enlargement of maxillary tuberosity.
Papillry hyperplasia of the palate.
U shaped –Parallel ridge slopes & broad base.
Flat palate with broad base & lower ridge slopes .
The V shaped vault with greater vertical than
favorable ,more tissue
coverage for pps area.
Cl II-Soft palate turns
down at 45 degree
Cl III-Soft palate turns
down at 70 degree angle
just posterior to hard
Bony enlargement at
the midline of the hard
Size- small pea
nut,enlarges till occlusal
Covered by thin less
advised if it extends
near to vibrating line
about 2to 3mm short.
Absence of tuberosity & loss of
Excessive surgical reduction of tuberosity.
Inadequate pps of maxillary denture.
HARD & SOFT AREA IN MANDIBULAR
Soft tissuefibrous cord like soft
tissue ridge in severely
Bony protuberance on
lingual aspect of the
mandible in the
Genial tubercles .
EXAMINATION OF EXISTING
Mucosa examined for pathological changes.
As per the study conducted by Ostlund in 1953 it was reported that in 77%
of the denture wearing patients there will be presence histological changes
even though he mucosa appears clinically normal.
C R & CO, premature contacts ,sliding.
Type of teeth.
Panoramic radiographs play an important role in
diagnosis &treatment planning in completely
Study was conducted by Syropoulos N.D,Patsaks
A.J in 1931.
Study the residual alveolar ridge resorption.
Mandibular RAR resorption can be classified.
Class I—Upto 1/3rd of original vertical height lost
Class II-From 1/3rd to 2/3rd of original vertical
ClassIII-2/3rd or more of original vertical height lost.
Radiographic examination of the bone density by Misch.
Dense cortical bone .
Porous cortical bone.
Coarse trabacular bone.
Fine trabacular bone.
Study the location of anatomic structures.
Tomography:Specialized technique that allows detailed images of
structures in a predetermined plane ,while blurring the
Classic tomography : Several exposures of selected area at
orbitrary intervals or section.Lateral, medial, central parts of joint as
Computed tomography: Scanning of well defined area.
-The computer analyses X-ray absorption at many different points &
converts them into an image on a video screen.
-Gross determination of condyle disk relation
Magnetic resonance imaging:
Aids in the evaluation of anatomy & relationships in absence of
Evaluation of following
Diagnose missed findings
Conform clinical findings
Measuring & determining relation to other structures
Decision about preprosthetic surgery
Pre extraction records:
Photographs showing natural teeth.
Diagnostic casts & radiographs obtained from other dentist.
Using the patient`s existing dentures impression made
& diagnostic casts made.
With tentative CR & face record mount the maxillary
cast on to the adjustable articulator ,orient the
mandibular casts with CR.
Check vertical dimension ,CR &CO.
OTHER INVESTIGATIVE PROCEDERES
To Rule Out DM
Patient’s BP should be recorded.
If any Intra or Extra Oral lesion advise for
Biopsy Histopathological Examination .
The treatment plan should specify regarding the treatment
procedures,operating time,laboratory time,calender time &
fees such that patient informed consent regarding the same
can be obtained.
Treatment plan for completely edentulous patients
Adjunctive care---Pt education &motivation.
----Elimination of infection.
----Elimination of pathoses.
----Treatment of abused tissues.
Prosthodontic care –Conventional complete denture.
--implant supported complete denture.
Information about their dental health &it`s effect on the
Limitation of complete denture.
Problems associated with complete denture initially.
Importance of oral &denture hygiene.
Need for regular check up.
Convincing about the Rx procedure,need for the surgical Rx,
time required, fees.
Motivation of the patient.
Diet counseling:Diet rich in proteins,calcium, vitamins,
minerals,low calorie diet.
If required referred to dietician, physician.
NON SURGICAL METHODS OF TREATING THE
Resting the denture supporting tissues.
Occlusal correction , establishing vertical height
Refitting the dentures.
Drugs to eliminate infection.
Advise for jaw exercise.
1)Correction of hyperplastic ridge tissue ,epulis fissuratum, papillomatosis
,hyperplastic pendulous tuberosity.
Indication—no response to nonsurgical Rx procedures.
--interferes with stability .
Excision of the tissues with vestibuloplasty.Electro surgery.
2)Frenal attachments-maxillary labial frenum broad fibrous band,lingual
tongue tie,prominent buccal freni
Indications—near to crest of ridge.
3)papillary hyperplasia-Small lesion with sharp curettes electro
-Large lesion split thickness supra
4)Vestibuloplasty-Restores the ridge height by lowering the muscle
attachments & attached mucosa.
FABRICATION OF COMPLETE DENTURE
Conventional complete denture.
Previous h/o failures with conventional complete dentures
Patient with compromised motor skills, advanced residual
If dose not like to wear dentures.
It encompasses history taking which includes past dental history
&medical history,patients expectation & studying the mental
attitude of the patients
Diagnosis involve examination of the patient’s right from he
enters the clinic,beginning from the collection of personnel
formations of the patient.and then examination of extra&intra
oral hard&soft tissues structures.
Subjecting the patients to required investigations,to confirm the
diagnostic findings ,and Referring patients to other specialist on
On the basis of Diagnostic findings the Rx plan is framed.
Diagnosis and Rx planning form the first important
milestone for the successful accomplishment of the
Rx &favorable prognosis as the potential problems
are identified & treatment plan is framed accordingly.
BOCHER ‘S Proshtodontics Rx for edentulous patients 11th
Prosthodontics Rx for edentetious patients by Zarb Bolender
Essentials of complete denture prosthodontics by Winkler
Syllabus of complete dentures by Heartwell.4th edition .
Complete Denture prosthodontics by Jhon Joy Mannapali.
Color atlas of common oral diseases by Craig .S .Miller.
The temepomandibular Joint & Related oeofacial disorder by
A text book of oral pathology by shafer 4th edition
Davidson’s principles & practice of Medicine.
DCNA 1977 complete denture.
BDJ volume 188,No.7:April:8:2000.Complete denture an
Diagnostic factors in the choice of impression materials &
methods by George.A.Buckly D.D.S in JPD March:1995:5:2.
Dr.Robert.H.Spring. Diagnostic procedures ---the patients
existing dentures.JPD 1983:49:2:153.
Study conducted by syropoulos ND, Patsuks AJ,in 1981.Finding
from radiology of Jaw of edentulous patients oral surgery Oral
JPD July 1974:32:1:7-12studies of residual alveolar-ridge
resorptionpart1 use of Panoramic radiographs for evaluation &
collection of mandibular resorption by
Leader in continuing dental education