DIAGNOSIS TREATMENT PLANNING cd.pptx

DIAGNOSIS AND
TREATMENT PLANNING
IN COMPLETE DENTURE

CONTENTS
Introduction
Diagnosis
Patient evaluation
History taking
Examination
Treatment planning
Conclusion
Bibliography

INTRODUCTION
• Successful denture therapy begins with a thorough
assessment of the patients physical and
psychological condition and determining a
treatment that will deliver functional complete
denture that will satisfy the patient.
Sheldon winkler; Essentials of complete denture prosthodontics:3rd edition

DIAGNOSIS:
Diagnosis is the examination of the physical state,
evaluation of the mental or psychological make up, and
understanding the needs of each patient to ensure a
predictable result.
TREATMENT PLANNING
Developing a course of action that encompases the
ramifications and sequelae of treatment to serve
the patient needs.

Diagnosis
• Patient evaluation
• History
• Examination

• GAIT
Observations regarding the patient’s walk, steadiness and
the level of coordination can help in gaining an insight
into the patients’ motor skills and any systemic disease
V.Rangrajan et al:Textbook of Prosthodontics;2nd edition
Patient evaluation

This provides information about the mental attitude
and presence of any disorders.
Absence of any expression indicates loss of muscle
tone, trigeminal neuralgia, plastic surgery or disorders
of central nervous system
FACIAL
EXPRESSION

SPEECH
The fluency and quality of the speech should be
noted, as it will help in arranging artificial teeth. If
speech is altered due to poor denture fabrication,
it should be rectified
•Hypernasality—paralysis of palatal musculature.
• Hoarseness—paralysis of both vocal cords, excessive
smoking
•Whistling sound
•Lisping sound

BREATHING PATTERN
Every effort must be made to allow easy and comfortable
breathing during treatment.
Attention must thus be directed to providing a patent airway by
good chair posture, by bringing the head forward so that gravity
carries salivary fl uids and impression materials forward out of
the mouth .
Patients should be directed to breathe slowly and deeply and
with a regular rhythm

MENTALATTITUDE
1.PHILOSPHICAL
2.EXACTING
3.INDIFFERENT
4.HYSTERICAL
Simon gamer et al:MM House classification revisited;J Prosthet Dent 2003;89:297-302.)

Ideal patient: reasonably engaged (+++) and reasonably
willing to submit(+++)
Submitter: (++++) on engagement and (++++) in willingness to
submit or trust.
Reluctant: rates (++) on engagement and (++) on willingness to
submit or trust.
Indifferent: rates (+) on engagement and (+) on willingness to
submit or trust.
Resistant : skeptical of the dentist and there is no trust.

Ideal pt: The dentist may be offended by the pts reasonable
attitude that falls short of dentists need to be idealized.
Submitter: The dentist may be flattered and potentially seduced
into providing treatment aimed at perpetuating the idealization
Reluctant: The dentist may either feel offended by the patient’s
attitude or the dentist may feel challenged by the patient’s
pessimistic expectations.
Indifferent: The dentist may feel offended by the patient’s
disengaged attitude, taking it as a personal failure.
Resistant :The dentist may become angry or disappointed with
patient who persistently distrusts. The dentist may compromise
the treatment in an effort to please the patient.

GENERAL INTRODUCTION TO THE
PATIENT
First appointment most
important time dentist spend
with CD patient.
Develop mutual understanding
and trust
Dentist should engage patient in some
general conversation to further place the
pt. at ease and begin to understand pt. as
an individual.

GENERAL INTRODUCTION TO THE
PATIENT
Name:
Address:
Telephone number:
•To maintain the pts record
.Tavelling distance estimation
•Endemic ds.
•To communicate with the patient
Patients identity, documentation
Patients confidence
Psychological security

Age : Age is an indicator of patients ability to
wear dentures.
Through the 4th decade of life ,tissues
heal rapidly and are more resilient.
Pt adapt to new conditions readiliy and
esthetics is of paramount importance.
Women facing physiological and psychological
problems of menopause.such patients often
present exacting or hysterical behaviour who are
concerned with esthetics.
Robert L et al;patient evaluation and treatment planning for complete denture
therapy:DCNA1996;40(1):1-18

Sex : Ds.COMMON IN
FEMALES
Osteoporosis
Thyroid disorders
Osteoarthritis
PCOD
COMMON IN MALES
CVS
TB
TUMOURS
RESPIRATORY DS
HAEMOPHILIA
Sandeep C et al;exam,diag,treatment plan for acd;j orofacial sci

OCCUPATION
Tooth position is very important for a musician
who plays a wind instrument
Some occupational habits like nail biting of tailors and
cobblers may cause attrition of anterior teeth.
Occupations like public speakers, teachers and
singers are more particular about the phonetics
with their new dentures.

HABITS
Pan chewing ,smoking,chr.alcoholism may evoke
concerns regarding hygiene,maintenance and wear
of denture
Parafunctional habits like bruxism ,clenching
affect the teeth selection and prognosis

NUTRITIONAL
HISTORY
•Record food intake of pt. over 3-5 days period. This
helps to evaluate nutritional status of pt.
•Ability of oral ts to withstand stresses of dentures is
greater in well nourished pts .
•Dietary councelling is necessary for malnourished pts.

Gerodontic nutrition and dietary counseling for prosthodontic
patients. Dent Clin N Am 2003;47:355-71
As the patients become older , amount of protein required
increases.
Protein depletion of body stores in the elderly, is seen
primarily as a decrease of the skeletal muscle mass.
 Proteins is a must for denture wearers.

The chief complaint should be written in patient’s
own words, patient should bequestioned regarding
his chief complaint
According to DeVan, “ the dentist should
meet the mind of the patient before he
meets the mouth of the patient
CHIEFCOMPLAINT

No prosthodontic procedure should be commenced
without evaluating systemic status of an individual.
MEDICAL HISTORY

DEBILITATING DISEASES
Oral manifestation
•Xerostomia
•Infection
• Poor healing
• Increased incidence and severity of
periodontal disease
• Burning mouth syndrome
DIABETES MELLITUS
Sandeep C et al;exam,diag,treatment plan for acd;I.Jour orofacial sci

Iron deficiency causes anaemia, atrophic mucosa, purpura
and burning sensation of mucosa
Pernicious anaemia and Iron deficiency anaemia patients
have fragile mucosa so the dentures should be as smooth as
possible.
ANAEMIAS

DISEASES OF JOINTS
•Osteoarthritis
•Rheumatoid arthritis
•Osteoporosis
•Cadiovascular diseases
•Neurological conditions
•Oral malignancies
•Epilepsy
•Ds of skin
•Medications

When terminal joints of fingers are arthritic it is difficult for
the patient to insert and clean the dentures.
When it affects TMJ, the mouth opening will be restricted
and painful movements of the jaw necessitates the use of
special impression trays.
Shorter appointments, comfortable chair position
OSTEOARTHRITIS

OSTEOPOROSIS
Hirai T et al, indicated that osteoporosis strongly affects
reduction of the residual ridge in edentulous patients.
Oral signs of osteoporosis might be manifested by
excessive alveolar ridge resorption, tooth loss, chronic
destructive periodontal disease, referred maxillary sinus
pain, or fracture
• Focus should be on reduction of the forces on residual ridge.
•Mucostatic , selective pressure impression technique
•Semi anatomic or non anatomic teeth with narrow BL width
should be selected.
• Extended tissue rest intervals by keeping the dentures out of
mouth for 10 hours a day can be advised.
Vinod B et al.osteoporosis,its prosthodontic considerations;Journal of Clinical and
Diagnostic Research. 2015 Dec, Vol-9(12

Lips become rigid and the aperture
narrows, and presents mask like
facial expression.
Restricted mandibular movements
are seen
SCLERODERMA

CARDIOVASCULAR DISEASES
•Hypertension
•Angina pectoris
•Myocardial infarction
•Congestive heart failure
•Infective endocarditis
HYPERTENSION
Afternoon dental appointments maybe
Preferred as recent studies indicate
that BP levels generally increase around
awakening and peaks at morning
Patients with stable cardiac problems under the regular
care of cardiologist are not contraindicated for procedure.
Short appointments may help patients to manage stress
better.
Consultation with physician is required if any invasive
pre-prosthetic surgery is indicated.
Dr ganaraj shetty et al;Int Jour Sci: Basic and Applied Research (IJSBAR)(2015) Volume 20, No
1, pp 260-265

NEUROLOGICAL
DISORDERS
•Epilepsy
•Bells palsy
•Parkinsons disease
EPILEPSY
•Patient may aspirate or break the denture during the seizure.
• It will influence the selection of denture base material and
teeth.
•Patient and close relatives may also need to be educated on
quick removal of the dentures prior to or during seizures.
Diseases like epilepsy, Bell’s palsy, Parkinson’s
disease can influence the denture retention, jaw
relation records and impression making
procedures. Use of anxiety reduction protocol and
stress levels should be minimized.

MEDICATIONS
Xerostomia is a common side effect of antihypertensive and
Antidepressantsdenture retention and cause increased soreness.
Diuretics cause changes in tissue fluids which affect retention and
stability of dentures.

A) REASON FOR TOOTH
LOSS
The amount of bone loss would be more for the patient
with a long history of progressive periodontal disease
than for the patient with a history of caries.
Questioning should also include the general order
of teeth loss. If all the posterior teeth were extracted
prior to the anterior teeth a habit of eating with front
teeth may lead to unstabilized effect on full dentures

B) PERIOD AND SEQUENCE OF
EDENTULOUSNESS
Longer the period, more will be the bone
loss. By understanding the sequence,
bone resorption pattern can be identified.

C) PREVIOUS DENTURE
EXPERIENCE
Traumatic experiences will affect the attitude of the patient
towards dental treatment and they will require more
counselling and education.
Patient’s experience with previous dentures will give an
insight into their attitude, desire and expectations.

PRE EXTRACTION
RECORDS
Includes pre extraction radiographs, photographs,
diagnostic casts. They can be helpful to reproduce
anterior esthetics in complete denture fabrication.

INDICATIONS OF
RELINING,REBASING AND
REMAKING
RELINING:
Resurfacing or correction of denture adaptation to
underlying tissues by the addition of a new resin material to
its fitting surface without changing its occlusal relation.
Addition of material to the tissue side of a denture to
improve its adaptation to the supporting mucosa.
http://www.dentalnews.com/2015/06/16/repairing-complete-denture/

REBASING:
It’s a process of readaptation of a denture to the
underlining tissues by replacing the denture base
material with a new one without changing its
occlusal relation.
http://www.dentalnews.com/2015/06/16/repairing-complete-denture/

BRUXISM AND EDENTULOUS
PATIENTS
Teeth clenching is common and frequent cause of
complaint of soreness of the denture bearing mucosa.
In denture wearers ,parafunctional habits can cause
additional loading on denture bearing ts. In both horizonal
and vertical direction for prolonged possibly excessive
duration of time both diurnal and nocturnal.
The neurophysiological basis underlying bruxism
is an increase in tonic activity of jaw muscles
Zarb and Bolender Prosthodontic Treatment for Edentulous Patients, 12th edn

Should observe for the symmetry of the face,
whether it’s bilaterally symmetrical or not
FACIAL SYMMETRY

FACIAL PROFILE

FACIAL FORM
Robert L et al;patient evaluation and treatment planning for complete
denture therapy:DCNA1996;40(1):1-18
Significance in fabrication of CD
•Helps in selecting artificial teeth as william
formulated a method called law of harmony.
•He believed that relationship exists between the
inverted face form and form of maxillary CI in most
people.

LIP HEALTH
Fissures, cracking or ulcers at the
corner of the mouth indicate vitamin B
deficiency, candidiasis and loss of
vertical dimension or neoplasm.
Sheldon winkler.essentials of complete denture prosthodontics:3rd edition

LIP SUPPORT
•Adequately supported
•Inadequate support
Zarb and blander.prosthodontic treatment of edentulous
patients;12th edition
Insufficient support of the lips results from anterior
teeth that are placed too far posteriorly (palatally)
characterized by:
• Drooping of corners of mouth
•Reduction in visibility of vermilion border,
•Drooping and deepening of nasolabial grooves,
•Wrinkling, reduction in prominence of philtrum.

LIP THICKNESS
Can be THICK /MEDIUM/ THIN
In patients with thin lips any slight change in the labio
lingual position of teeth makes an immediate change in
the lip Contour
Thick lips give little more room for alteration in the
teeth position before obvious changes occur in lip
contour.

LIP LENGTH
•Long
•Medium/normal
•short
•A long lip reveals very little of the anterior teeth,
where as a very short upper lip leads to display of the
denture base.
•Mold selection and denture characterization can be
critical factors in these cases.

MUSCULAR
EXAMINATION
Class 1: Normal muscle function and tone
Classs2: Normal muscle function and mildly decreased tone
Class 3: Decreased muscle tone and function, seen as
drooping commissures, exaggerated nasolabial fold or loss
of vertical dimension.
Tissue tone that’s is too strong or too weak is
unfavourablemore time to complete the clinical
procedure.
If muscles are too tense, cheek and lip manipulation
will be difficult,
If too slack, lips and cheeks may be displaced easily by
impression materials.
Older people tend to have poor motor
coordination and weak muscles.muscle tone
can decrease by as much as 20-25 %which
results in shorter chewing strokes and
prolonged chewing time.(Boucher)

TMJ
Clicking ,crepitus:-disc displacemnt ,rheumatoid
arth,osteoarthrits
Pain and tenderness on palpation: mpds,
Locking of mandible:-inflam of soft ts,disc displacmnt
Irregularity or deviation on opening and closing of
mandible:-disc displacement,muscle spasm
Managemennt of tmj disorders
•Reassurance and self care regimen
•Pharmacotherapy
•Physical modalities
•Biobehavioural modalities

MUCOSA
Normal colourcoral pink
Class 1:Healthy
Class 2: irritated
Class 3: pathologic
Common prosthetic cause of variation in colour
•Overextension
•Ill fitting dentures
•Continuous wearing of denture
•Faulty articulation of teeth
•Rubber suction discs
White patches and brown/blue pigmented spots
should be noted  biopsy may be required
COLOUR
Redness  sign of inflammation ill-fitting dentures,
infections, smoking and systemic diseases such as
diabetes.

MUCOSAL
THICKNESS
Class 1: Normal (firm but not tense)
Class 2: Thin mucosa
Class 3: Thick mucosa
Variations in the thickness of the mucosa leads
difficulty in equalizing pressure under denture

ARCH SIZE
Class 1; large
Class 2; Medium
Class 3; Small
•Large arch size,more surface contact more retention
•Discrepency in arch size poor stability due to poor
teeth relationship

ARCH FORM
•Influences support and tooth selection.
• If opposing arches do not have the same form,
difficulty in tooth arrangement can be anticipated

RIDGE CONTOUR
Ideal ridge is high ridge with parallel sides. offers
max.support and stability.
• Flat ridge lack vertical height  little resistance to
horizontal movement  reduced stability.
• Knife-edged ridge  poorest prognosis  cannot
withstand much occlusal force and can easily become
sore.
•Relief is necessary while making impressions.

RIDGE PARELLISM
When teeth are gradually lost the residual ridges
will diverge from each other.
 If the ridges are not parallel to the occlusal plane,
dentures will slide over the basilar tissues when
occlusal forces are applied to them.reduce
denture stability.

FLABBY TISSUE
Both the arches should be examined for loose
flabby tissue poor stability and support.
Need surgical correction before impressions or
special impression procedures are adopted to
record the same

HYPERPLASTIC TISSUE
Hyperplastic tissues such as epulis
fissuratum and papillary hyperplasia 
ill-fitting denture need to be treated.
Rest the tissues ,maintain proper oral
hygiene and tissue massage, tissue
conditioning , if necessary, by surgical
correction

Tori
Torus palatinus: ranges from small
prominence in midline to one that covers
entire palate.
Lingual tori: interfere with denture
construction unless small one should be
surgically removed

FRENAL ATTACHMENT
Class 1: high in the maxilla as 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.
Inadequate clearance may result in pain and
ulceration of mucosa or displacement of the
denture.
Over clearance may result in a loss of seal and a
loose denture.

HARD PALATE
U-shaped: Provides good retention and lateral
stability
• V-shaped: Provides least retention
• Flat: Provides less retention and poor lateral
stability.

SOFT PALATE RELATIONSHIP TO HARD
PALTE
Class 1 : It is horizontal, makes 10 angle to the hard
palate and demonstrates little muscular movement.
Class 2 : Soft palate makes 45 angle to the hard palate
Class 3 : Soft palate makes 70 angle to the hard palate

TONGUE
Class 1 : normal in size, development 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.
A small narrow tongue contributes to the ease of
impression making , but jeopardizes the lingual seal for
the mandibular denture.
A broad thick tongue always is in the way during
impression making, provides an excellent seal for the
denture.
An extremely large tongue poses additional problems
during impression making and impairs denture stability.

TONGUE POSITION
Normal or Class1: the tongue fills the floor of the
mouth and is confined by the mandibular teeth.
Retracted or Class2 : the tongue is retraced. The floor
of the mouth is pulled downward is exposed back to the
molar area.
Class 3 : the tongue is very tense and pulled back ward
and curled upward.

SALIVA
Class1 : normal quality and quantity of saliva, cohesive
and adhesive properties of saliva are ideal.
Class 2 : excessive saliva, contains much mucous
Class 3 : xerostomia, remaining saliva is mucinous
•Copious Thick ropy saliva interferes with impression
procedures.
• Scanty thin saliva interferes with the seal of the
dentures and provides poor protection against
scuffing and chafing.

LATERAL THROAT FORM
Class1(deep) : Indicates that the
anatomical structures will accommodate a
fairly long and wide flange ..
Class 2(moderate) : It is about half as
long and narrow as the class1 and
twice as long as class3. It can be
classified as moderate.
Class 3(shallow) : This form has minimum
length and thickness.

A complete radiographic study furnishes information
as to the presence of retained roots, foreign bodies,
pathologic areas and generalized osteoporosis in the
bony support.

Class 1: mild resorption with loss of ridge upto one third of
the vertical height.
Class 2: which is moderate resorption with loss of ridge
from 1/3 to 2/3 of original vertical height
Class 3: severe resorption with loss of ridge more than 2/3
of the original vertical height

Blood investigations – Blood glucose levels for
diabetics,
Hb % of blood for anaemic patients is important for
any preprosthetic surgery desired.

TREATMENT PLAN
Treatment planning is the 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

PHASES OF TREATMENT PLAN
1. Systemic phase
2. Acute phase
3. Disease control phase
4. Definitive treatment
phase
5. Maintainance phase
Treatment planning in dentistry bt stefenac N.2nd edition

Prognosis in denture service is an opinion of the prospects for
success of a restoration.
• gross appraisal of the patient,
•patient’s needs and expectations,
•medical, psychological and behavioral considerations,
•anatomic factors,
•physiological factors etc.
PROGNOSIS

A successful restoration does not just happen-. It is
Planned
• Thorough diagnosis enables us to make a realistic
prognosis.
• These data aid in outlining the treatment that is best
suited for the individual patient, i.e. we plan success.
• A step-by-step outline is used to obtain this vital
information.
CONCLUSION

REFERANCES
Boucher’s:Prosthodontictreatment for edentulouspatients,11the
Winkler:Essentialsof completedenture prosthdontics, 2n
dedn.
Rahn& Heartwell: Textbookof completedenture, 5thedn.
Thedental clinicsof NorthAmerica, Jan 1996;40(1)
WicalK.E.& SwoopeC.C.,Studiespf residualridgeresorption.Part I Use of
panoramicradiographsfor evaluation andclassification of mandibular
resorption,JPD1974;32:7-12
Treatment planning in dentistry bt stefenac N.2nd edition
Robert L et al;patient evaluation and treatment planning for complete
denture therapy:DCNA1996;40(1):1-18

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