COMLETE DENUTRE CASE HISTORY.ppt

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HISTORY AND EXAMINATION FOR
COMPLETELY EDENTULOUS
PATIENT
By Dr Puttaraj TK

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• Points with Underlines- important
• Points with Green colour highlight-very
important
IN ALL SLIDES ( NOTE FOR STUDENT)

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• Case history is a planned professional conversation
between doctor & patient in which he/she express
his/her symptoms of the disease which will help the
doctor to arrive to a probable diagnosis.
CASE HISTORY

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• Name
• Age
• Sex
• Address
• Race
• Occupation
• Telephone number
• Reference
• Chief complaint
• Habits
• Personality
PERSONAL DATA

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• Identification of individuals
• Communication
• To build a good reputation
• Patient feels comfortable
• Shows doctor’s concern about him.
• To keep patients record
Name

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• Young patient adapt more easily than older.
• With increasing age progressive atrophy of elements of
the cerebral cortex.
• The oral & facial tissues become progressively less
elastic & non resilient
• Impaired muscular efficiency
Age

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• Tissue sensitivity increases therefore more Prone to
injury.
• Difficulty in communication & following instructions.
• Certain diseases are peculiar to a particular age acute
arthritis, acute osteomylitis etc

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• Generally appearance is higher priority for women than
for men.
• In general, women are more difficult to please with the
appearance of their dentures than men.
 Women during menopause are difficult to treat due to
psychological problems, dry mouth, burning sensation,
and general vague pain
Sex

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• Is important to know how far does the patient stays
from the clinic
• It also tells the socio-economic status of the patient
• To contact patient
Address

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• Race can be a critical factor in the characterization
of dentures.
• It helps in choice of denture base shade, placement
of denture base stains.
Race

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• A patient’s job & social standing determine the value he or
she places on oral health esthetics & other qualities desired
in a denture.
• Professional men & women, whose occupation entails
intimate contact with their fellows
• Public speaker & singers
Occupation

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• Wind instrument players
• A person working in a cafeteria
• The dentist come to know when the patient might
be available for appointments

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• To know the socio-economic status of the patient
• For changing patients appointment day/date/time
Telephone number

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• The information about the way the patient found you
will guide you in discussion regarding office policies,
arranging the appointments, and the type of service
that will be expected.
• If the patient is referred by a dentist,
• If the patient is referred from a physician,
Reference

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• It is written in Patients own language
• It gives the idea to the dentists, what the
patient’s main concern is? Mastication,
phonetics, esthetics, others ,all etc
• The complaint is recorded in the chronological
order of their appearance
Chief complaint

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Period of Edentulousness(Max/Man)-:
Responses to this question provide information
about bone resorption patterns and
progression, as well as the timing of tooth loss.
Reasons for tooth loss
(e.g., periodontal disease, gross caries, trauma,
etc.).

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• The dentist should asses the reason of loss of tooth-
it can be periodontal,caries, congenital or others.
• In periodontal case their will be definite loss of
bone,
• Carious loss gives us the idea of oral hygiene status
as well as patients diet,
DENTAL HISTORY-

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• Congenital tooth loss can be due to hereditary
ectodermal dysplasia
• Next the patient should be asked about sequence of
loss of tooth-anterior/posterior
• Duration of complete edentulousness gives us the
idea of bone loss, patients nutritional and mental
status

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Previous Dentures, Max/Man:- The patient
should be questioned regarding the-
Number and types of previous dentures.
Patients should be asked to comment on the
reasons for replacement.
Patient with a history of several dentures over
a short period of time is a poor prosthodontic
risk
Previous Denture
Experience

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• An exploration of patients habits will help identify
those who might have contributed to their present
condition and those who will help ensure success or
failure for the treatment to be supplied
• Smokers have detrimental effect on the wound
healing and the durability of tissue conditioners
PERSONAL HISTORY
1-ORAL HYGIENE HABITS
2-OTHER HABITS

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1-Family status
2- Educational status
3-Patient Expectation
4-Mental Attitude
House classification
• Philosophic
• Skeptical
• Critical
• Indifferent
SOCIO-
PSYCHOLOGICAL
STATUS

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• These patients are willing to accept the judgment of
their dentists without question.
• These patients are easy going mentally well adjusted,
cooperative & confident in the dentist.
• They accept their oral situation & know that their
dentist will do the best
• They have an ideal attitude for successful treatment.
Philosophic

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• These patients have had bad result with previous treatment
& are doubtful that anyone can help them.
• These patients are often in poor health with severely
resorbed ridges & other unfavorable conditions
• They have tried to be a good patient but their problems
seem to them not make an ideal attitude for treatment.
Skeptical

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• They think the world is against them & doubt the ability
of anyone to help them with problems that are greater
than anyone else has to bear.
• They need kind & sympathetic attitude.
• These patients can become excellent patients if dentists
recognize them & handle them properly but it will take
extra time before, during & after treatment.

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• They were never happy with their previous dentists.
• They will bring them a collection of dentures made by a
number of different dentists & tell their
problems to new dentist what is wrong with each one
Critical

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• Lot of patience is required for the dentist who
treats them.
• These patients can be traumatic in a dental practice
if they are not controlled.
• Many of these patients are in poor health. Medical
consultation is always advisable for critical patients
before treatment is started.

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• These patients are little concern for teeth or oral health.
• They less appreciate the efforts of the dentist.
• These patients will require more time for following their
instruction on the value & use for their denture.
• Their attitude can be very discouraging to dentist who
treats them.
Indifferent

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• General health
• Systemic disease
MEDICAL HISTORY

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• A medical history provides important insight regarding the
patient's dental prognosis.
• General health of patient’s can be estimated by observation
of their posture & gait when they enter in the dental office.
The additional information can be obtained by use of
health questionnaire, by questioning of the patient & by
consultation of the physician.
General health

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• stooped shoulders may indicate changes in he spine
• tremors of head occur in parkinsonism
• tremor of the head is seen in patients on
tranquilizers
• involuntary hurried walking occur in patients with
CNS disorders especially parkinsonism
Posture and walking pattern/
gait

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• Debilitating diseases
• Diseases of joint
• Blood dyscrasias
• Hormonal disturbances
• Nutritional disturbance
• Cardiovascular disease
• Respiratory disease-
• Diseases of the skin-
• Neurological conditions-
• Oral malignancies
• Menopause-
Systemic disease can be-

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• These patients require extra instructions in oral
hygiene, eating habits and tissue rest
• Since the supporting bone may be affected by the
disease, frequent recall appointments should be
arranged to keep the denture base adapted and the
occlusion corrected.
Debilitating diseases

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• Dry feeling in mouth,
• Coated tongue with swollen edges,
• Fissures on the tongue,
• Small abscesses throughout the mouth,
• Faint odour of acetone may be prevalent in advanced cases
and should be treated because dentures can be debased by
the action of acetone.
Diabetes

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• The patient should have medical control for the dental
procedures to start.
• Non- pressure impression should be used for maximum
physiologic compatibility of denture base with
supporting tissues.
• Care should be taken as not to traumatize the tissues
because healing in diabetic patients takes a longer
duration e.g. diabetic ulcers
• If patient has an insulin shock while treating place
some sugar in his mouth. Instructions on eating habits
and oral hygiene should be given.

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• The weight bearing joints are involved in osteoarthritis.
• Heberdens nodes are bony enlargements of the terminal
joints of the fingers. This will make it difficult for the patient
to clean and insert denture
• Osteoarthritis of TMJ makes mandibular movements
difficult. Mouth opening may be limited, jaw relation records
are difficult to obtain, and frequent occlusal correction may
be needed.
Diseases of joint

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Anemia
• Changes in the mucous membrane
• Pallor of the tongue and lips
• Burning, smooth, glossy tongue,
• usually pain in tongue and supporting areas
These patients shows oral manifestation like
• Mucosal atrophy
• Pallor
• Angular cheilitis.
Blood dyscrasias

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• The patient should be placed under good medical
care
• Dentist must achieve good oral hygiene & efficient
dentures,
• Small food table with maximum supporting area
prevent supporting tissues from being over
stimulated.
• Careful patient instruction should be given.

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• Acromegaly- patient may require frequent
adjustments and new dentures
• Hyperthyroidism
• Reduction in salivary flow
• Mucosal inflammation is present.
• Hyperparathyroidism
• It causes increased alveolar resorption.
Hormonal disturbances-

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• Avitaminoses
Tends to lower the defense of mucosa, infectious diseases
may be virulent.
• Hyperkeratosis
May be result of a deficiency of vitamin A
• Angular cheilosis
Is a sign of vitamin B deficiency
• Hypovitaminosis
Cause marked alveolar atrophy.
• Vitamin K deficiency
Manifested by purpura of the oral cavity.
Nutritional disturbance

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• Consultation with the patient’s physician should be
done. Short appointments with premedication may
be required
Cardiovascular disease-

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• Respiratory diseases like bronchitis, asthma,
tuberculosis, lung abscess etc
• In orthopnea the patient is reluctant to sit back
because of difficulty in breathing when in a supine
position
• In asthmatics patients special considerations should
be taken like drug selection & dust free alginate etc
Respiratory disease

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• Dermatological diseases, such as pemphigus, often
have oral manifestations. In these patients, the
constant use of denture is contraindicated, and their
use is primarily for mental comfort.
Diseases of the skin-

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• Vesicles and bullae on the mucous membrane as well as on
skin.
• When the vesicles rupture they leave areas and ulcerations &
the resulting condition causes discomfort and pain.
• Foul odour is usually present in the oral cavity and loss of
body weight is apparent. Medical treatment is necessary
• Supporting tissues are too painful to wear dentures which
should be worn only for mastication & mental comfort.
Pemphigus:

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• Dry and atrophic area, scales over the lesions generally,
sharply demarcated white patches, bases that are red with
some edema.
• Dentures can be worn as lesions are not usually on the
denture bearing area. Occasionally, some lesions are present
on hard palate and need only relief.
• Good oral hygiene is required & periodic check-up to
minimize irritation is required. Polished surfaces of dentures
should not irritate the lesions.
Lupus Erythematosis

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• Term applied to smooth, white, diffuse patches on
the membranes of the lips, tongue and cheeks,
biopsy is the method of diagnosis. If specimen
shows premalignant lesion then the affected area
should be removed.
• If the report says that the patch on the membrane is
heaped up keratin, no surgery is required & can be
covered with a denture.
Leukoplakia:

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• Bell’s palsy and parkinsonism are commonly seen. In
such patients, denture retension and maxilomandibular
record taking are problems.
• If patients say that they are taking Diazepam or some
other tranquilizers the dentist will know there is some
nervous tension involved that may be real problem during
denture construction & adaptation of a new prosthesis.
Neurological conditions-

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• Most oral malignancies are detected by the dentist.
Prosthodontic treatment should be carried out later.
• No denture should be constructed unless it is approved by
radiation therapist
• If the prognosis is favourable but the tissue still have a
bronze colour and lack tonus, denture construction should
be delayed.
Oral malignancies-

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• Recent radiations show bronzing and burning of
external layers of the skin at the site or loss of hair at
area.
• diffuse scaring & slightly pale tissues are seen which
are firm on examination.
• If dentures are to be worn, no abrasion or irritation
should be present on supporting tissues.
• It is best not to use dentures at all over radiated tissues.
Radiation

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• Climacteric is one of the period in the life of
females when an important change in the bodily
function occurs.
• There are changes in glandular function. In some
patients mental disturbances may be seen.
• Some of the other symptoms include burning tongue
and palate, tendency to gag, inability to adjust, etc.
Menopause-

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1. AIDS 13-The metal base proved to be effective in
decreasing the fungal growth typically present in
complete dentures.
Infectious diseases-

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Hepatitis
• It is a systemic viral infection characterized by acute
inflammation of the liver with hepatic cell necrosis
• Dentist can be infected by hepatitis B and possibly
hepatitis C through parentral transmission.
• Prevention- vaccines are available for hepatitis B

Infectious disease:
• Viral agents.
• Bacterial agents.
• Mycotic agents.
Viral agents:
Herpes simplex.
• Cold sore mouth or fever blister.
• Involves lips and skin around mouth.
• Pain, fever, malaise and regional lymphadenopathy.
• Discontinuation of oral prosthesis and active prosthodontic
treatment must be postponed.

• Herpes zoster.
• Affects sensory nerves.
• Patient has reduced ability to use dentures.
• Recurrent apthous ulcers.
• Postponement of prosthodontic treatment for 7-14 days till
healing occurs.
• Hepatitis B virus.
• Prevention of cross infection.

(2)Bacterial agents.
• Sub acute bacterial endocarditis.
• Prophylactic antibiotic coverage to prevent bacteremia
during prosthodontic treatment.
• Tuberculosis .
(3)Mycotic infections:
• Angular chelitis.
• Seen in oral commissure.
• Topical steroid application.
• Restoration of appropriate VDO.
• Thrush.,Candida albicans.,Grayish white elevated
patches.

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Tuberculosis
• Oral Manifestation: Oral lesions are not common in TB
but when present they show long, deep fissures in the
tongue; lesions on the mucosa of check; round,
undermined ulcers that are very painful and firm nodules.

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Cautions & Procedure TB:
• Efficient dentures are necessary as diet is important in
treatment.
• Mouth hygiene is important
• Irritating projections on the dentures must be removed so
that they will not erode the skin and start tubercular
lesions.
• Denture should be checked often for infection.
• Dentist should protect himself by using
mask, gloves and make a thorough scrub of
face.

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Epilepsy: it is a group of disorders of brain function which
cause episodic disturbances of consciousness. -- Use of
radio-opaque materials in prosthesis
The main problems in the dental care of an epileptic patient
are:
• Convulsions and their sequelae.
• Drug reactions.
• Psychiatric disorders.
• Associated handicaps.
• Bleeding tendency caused by sodium valproate.

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 Many diseases reoccur in families eg- haemophilia,
tuberculosis, diabetes, hypertension, peptic ulcer etc
Family history

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• The patient should be asked about all the drugs he
was on
• Special inquiry should be made about steroids,
insulin, antihypertensive, etc
• The patient should be asked whether he or she is
allergic to any drug/diet.
• It should be noted with red type on the cover of
the history sheet.
Previous and present medication
history

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• Nutritional support will improve the tolerance of
oral mucosa to new dentures and prevent rejection
of dentures
• Loss of teeth often leads to selected diet with lower
nutrition
• Dentist can asses major deficiencies and refer the
patient for care.
NUTRITIONAL STATUS-

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EXAMINATION
According to Glossary of Prosthodontic
Terms
“Examination is defined as scrutiny or
investigation for the purpose of making a
diagnosis or assessment”

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• Straight
• Retrognathic profile means convex profile; Class II
disharmony in the centric position.
• Prognathic profile means concave profile ; Class III
disharmony
Facial profile

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FACIAL PROFILE
STRAIGHT
PROFILE
RETROGNATHIC
PROFILE
PROGNATHIC
PROFILE

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Classify according to- House & Loop, Frus & Fisher &
Williams.
• Square
• Tapering
• Square-tapering
• Ovoid
Facial form

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FACIAL FORM
SQUARE TAPERING
SQUARE
TAPERING
OVAL

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• In order to determine what type of patient belong to, the
operator imagines two lines- one on either side of the face,
running about 2.5 cm in front of the tragus of the ear and
through the angle of the jaw. If these lines are almost
parallel, the type is square, if they converge towards the chin
it is tapering, and if it is diverging it is ovoid.

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• an absence of facial expression may indicate a loss
of muscle tonus.
• A mask- like expression may be due to numerous
surgical procedures.
• It can also occur in patients with central nervous
system disorder like paralysis, hypothyroidism.
Facial expression-

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• pallor may be indicative of nausea, hypothyroidism or
nephrosis. It also occurs in patients with systemic
debilitating diseases.
• Ruddy complexion may be seen in polycythemia, chronic
alcoholics or neoplasms
• Bronzed skin may be seen in Addison’s disease and may be
seen in patients who have received radiation therapy
• Lemon-yellow complexion occur in patient with jaundice
due to gall blader, bile duct or hepatic disorder
Complexion

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• The lip should be examined for cracking, fissuring at
the corners & ulceration. These changes could be
caused by a vitamin B complex deficiency.
• Lips are then examined for support, fullness, thickness
length & mobility.
• The lack of proper lip support can lead to a collapsed
appearance & wrinkling.
Lip

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• Classify lip lengths as long, normal or medium &
short.
• Amount of tooth exposure depends upon the length
of lip.
• A short lip exposes most of the tooth & even part of
the denture base.
• A long lip length will hide the denture base & most
of the tooth.
Lip length

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• It is an important factor to note, any change in the
labiolingual position of a tooth can alter the
fullness, support of the lip.
• Thick lips give the dentist a little more opportunity
for variations in the arch form
& individual tooth arrangement before the changes
is obvious in lip contour
Lip thickness

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• Fullness of lip directly related to the support from
the mucosa or denture base & the teeth.
• Lip fullness should not be confused with lip
thickness which involves the intrinsic structure of
the lip.
• An existing denture with an excessively thick labial
flange could make the lips appear too full.
Lip fullness

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• Patient with minimal lip mobility shows very little
of the anterior teeth.
• In case of half lip paralysis , unilateral mouth
droops & facial asymmetry results.
• Lip mobility may vary as-
-Normal
-Decreased mobility
-Paralysis
Lip mobility

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• slapping of the sole of the foot may occur in tabes
dorsalis or may follow injury to the spine
• drooling of the toe may occur in poliomyelitis
• staggering may occur due to excessive alcohol,
excessive medication with muscle relaxant drugs,
hyperventilation or from damage to the spinal cord

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• If patient presents one or more of the following symptoms
are usually considered to be suffering from mandibular or
TMJ dysfunction.
• Symptoms include-
• Pain & tenderness in the region of muscles of mastication &
TMJ.
• Sounds during condylar movements.
• Limitations of mandibular movements & muscles of
mastication
• TMJ should be healthy before new dentures are made.
• Unhealthy TMJ complicates the registration of jaw relation
records
Temporomandibular joint

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• When believe that pathosis exist in the joint , radiographs of
the TMJ should be taken.
• Centric relations depends on both structural & functional
harmony of osseous structures, the intra- articular tissue &
the capsular ligaments.
• If these symptoms are present they must be treated first.
• The treatment usually takes the form of a soft diet,
improvement in fit & occlusion of the prosthesis.
• Prescription of appropriate medication where necessary.
• Simple & accurate explanation of the dysfunction to the
patient, its multifactorial etiology.
• Its consequences, treatment & prognosis should also be
provided to the patient.

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EXAMINATION OF THE TEMPOR MANDIBULAR JOINT:
Good prosthodontic treatment bears a direct relation to the
temporomandibular articulation since occlusion is one of the most
important parts of the treatment of complete dentures. The TMJ affects
the dentures which further affect the health and function of the joints.
CLINICAL EXAMINATION OF THE TEMPOROMANDIBULAR JOINT:
The examination should include the auscultation and palpation
of the TMJ and the musculature associated with mandibular
movements as well as the functional analysis of the mandibular
movements.
PALPATION: lateral palpation, posterior palpation
Lateral Palpation: Exert slight pressure on the condyloid process with
the index fingers, palpate both sides simultaneously. Register any
tenderness to palpation of joint and any irregularities in condyloid
movement during opening and closing maneuvers. The co-ordination
of action between the left and right condylar heads should be
assessed at the same time.

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Posterior palpation: Position the little fingers in the external auditory
meatus and palate the posterior surface of the condyle during
opening and closing movements of the mandible. Palpation should
be carried out in such a way that the condyle displaces the little
finger when closing.
MOVEMENTS OF THE MANDIBLE
Opening movement
Closing
Protrusive excursion
Retrusive
Lateral
All these are examined as part of the functional analysis. The
amount and direction of these actions are recorded during the clinical
examinations. Deviations in speed can only be registered with electronic
devices e.g. Kinesiograph. The first signs of initial temporomandibular joint
problem include deviations of the mandibular opening and closing paths in
the sagittal and frontal planes. The characteristic movement deviations
include incongruency of the opening and closing and uncoordinated zigzag
movements. The ‘C’ and ‘S’ types of deviations are typical signs of
functional disturbances.

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• Palpation of enlarged nodes in the juglar chain and
in the parotid, submaxillry and submental group.
LYMPH NODES-

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• Patient with good neuromuscular coordination can learn to
manipulate denture relatively quickly as compared to
patients with poor coordination or a neurological defect.
• Neurosis is regarded as a chronic anxiety state at the
physiological level.
• Is known to affect the performance of tasks requiring
neuromuscular coordination
• Both learning & skilled performance show optimal
relationships with moderate levels of anxiety, where as
levels of anxiety that are too high or too low appear to be
incapacitating. Neuromuscular coordination must be
excellent , fair or poor.
Neuromuscular evaluation

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• Patient who are capable of articulate speech with
existing dentures or natural teeth usually have no
problem in producing articulating speech with new
dentures.
• Patient with speech impairment or cannot articulate
optimally with their existing dentures require special
attention when the dentist places the anterior teeth &
forms of the palatal portions of denture base.
• If normal muscles activity is altered by significant
changes in tooth placement & denture of adjustment
may be require.

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• Masticatory mucosa
• Lining mucosa
• Specialized mucosa
MUCOSA-

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• Masticatory mucosal displacibility is classified by House
as-
• TYPE I-tissue can be displaced approximately 2mm,
cushion like yet will not permit gross positional
displacement
• TYPE II a- tissue thinner than 2mm, usually unyielding,
often atrophic with smooth surface
• TYPE II b- tissue thicker than 2mm, easily displaced,
poor stress bearing usually occur as flabby redundancy
in region of excessive bone resorption, under ill fitting
and maloccluded prosthesis. It may also occur where
severe bone resorption has occurred laterally
• TYPE III- excessive flabby to the degree that surgical
excision is indicated.

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• The color of mucosa may range from a healthy pink
to an angry red.
• Redness is indicative of inflammation.
• It can be related to ill fitting dentures or underlying
infections.
• Any systemic disease such as Diabetes or chronic
smoking.
Color of the mucosa

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• It is important to determine the cause & remove the
irritant because successful impression making is
not possible until the inflammation is under
control.
• Color changes that should be noted are pigmented
spots or lesions (range from light to dark brown or
blue.)
• White patches which most often (keratotic areas )
caused by denture irritations.
• Biopsy must be required.

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• Class1: normal uniform density of mucosal tissue
investing membrane is firm but not tense & forms an
ideal cushion for the basal seat of denture.
• Class2:
a) Soft tissues have thin investing membranes &
are highly susceptible to irritation under pressure.
b) Soft tissue has mucous membranes twice the
normal thickness.
• Class3: soft tissues have excessively thick investing
membranes filled with redundant tissues. Surgical
correction may require.
MUCOSA THICKNESS

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• Class1: attachments are high in maxilla & low in
mandible with relation to ridge crest (0.5 inches or
more between level of attachment & crest of ridge)
• Class2: attachment height in relation to the crest of
the ridge is between 0.25 &0.50inches
• Class3: attachment height is less than 0.25inches
from the ride crest.
BORDER ATTACHMENTS

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BORDER ATTACHMENTS
CLASS I CLASS II CLASS III

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• Class1: high in maxilla or low in the mandible with
respect to the crest of the ridge.
• Class2: medium
• Class3: freni encroach on the crest of the ridge & may
interfere with the denture seal. Surgical correction may
be required
• Frenal attachment can be
single/multiple/prominent/nonprominent/close to crest
• Make an observation for labial/buccal/lingual and
right/left
FRENUM ATTACHMENTS
(HOUSE)

FRENAL ATTACHMENT
93

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• the various structures of the face are best examined by
bimanual palpation
• Any lesions of the parotid gland must be noted. The
parotid duct is usually identifiable intraorally and
manipulation of duct should elicit a flow of clear watery
fluid
• Submandibular gland is identified by intraoral and
extraoral palpation
• Patency of the duct can be noted by salivary flow.
Salivary gland

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• Adequate retention is a basic requirement for the
acceptance of complete dentures.
• Close fitting dentures and sufficient layers of mucous
saliva are essential for retention because of physical
effects(Kawazoe& Hamada, 1978 kreneret al, 1987).
• Recent studies indicate that the minor salivary glands
of the palatal mucosa are of primary importance for
denture retention, as well as for mucosal resistance to
mechanical, chemical, allergic & biological injuries. .
(Edgerton et al, 1987 Niedermeier & Kramer, 1992).
Quantity & quality of
saliva

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• Reduced salivary rates in edentulous patients are
particularly related to the intake of diuretics &
psychoactive medications; where as age in itself is
minor importance (Persson et al, 1991).
• Patients with a reduced salivary secretion rate
complain of poor denture retention, burning & itching
oral mucosa & that’s food tends to stick to the
polished denture surface.
• Quantity of saliva can very in different individuals it
may be normal, excessive or less.
• Patients with xerostomia or hyposalivation did not
complain about denture looseness because mucous
salivary flow of relatively preserved palatal glands may
be one of the most important factor in denture
stabilization12

97
• It present a wide variety in anatomy and function relation to
the ridge crest. If the floor of the mouth is near the ridge
crest at rest or the magnitude of the movement is great,
retention and stability of the denture is poor. Floor of the
mouth in the sublingual and mylohyoid region may be very
high and close to the ridge crest. At times it may be above
the level of ridge crest and may eliminate the alveololingual
sulcus totally. If these tissues cannot be selectively placed by
denture flange, the prognosis of mandibular complete
denture will be poor.
• It can be high, medium,low.
FLOOR OF THE MOUTH-

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• Smith described two anatomic tongue types-
• long, narrow and tapered
• short, broad and thick
TONGUE

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• Class1: normal in size, development & function.
Sufficient teeth are present to maintain normal
form & function.
• Class2: large tongue. , teeth have been absent long
enough to permit a change in the form & function
of the tongue.
• Class3: excessively large tongue. All teeth have
been absent for an extended period of time,
allowing for abnormal development of size of the
tongue

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0
TONGUE

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1
 Class I- Normal: tongue fills the floor of the mouth
& is confined by the mandibular teeth. The lateral
borders rest on the occlusal surfaces of the posterior
teeth & the apex rest on the incisal edges of the
anterior teeth.
TONGUE POSITION (Wright) 10

10
2
Class2: retracted: the tongue is retracted. The
floor of the mouth pulled downward is exposed
back to the molar area. Lateral borders are
raised above the occlusal plane & the apex is
pulled down into the floor of the mouth.
Class3: retracted: the tongue is very tense &
pulled backward & upward. The apex is pulled
back into the body of the tongue & almost
disappears. The lateral borders rest above the
mandibular occlusion plane. The floor of the
mouth raised & tense.

10
3
TONGUE POSITION

10
4
• It may be present under an ill-fitting denture.
• It may be epulis fissuratum related to denture
borders.
HYPERPLASTIC TISSUE

10
5
• Class1:large (best for retention & stability).
• Class2: medium (good retention & stability but not
ideal)
• Class3: small (difficult to achieve good retention &
stability)
ARCH SIZE

10
6
ARCH SIZE
LARGE MEDIUM SMALL

10
7
• If the arch form is not same in both arches some difficulty in
tooth arrangement.
• Ridge form- U shape, V shape and flat
• U-shaped ridge in either arch is generally favourable for
supporting a denture. This is because it has a broad base for the
resistance to occlusal stresses and parallel sides that enhance
adhesion and resistance to displacement as wel as encourage
border seal.
• As the ridge resorbs it becomes flatter, ‘V’ shape or knife edge
ridges or ridge with multiple bony spicules offer the poor
prognosis.
Arch form

10
8
ARCH FORM
SQUARE TAPERING OVAL

10
9
• Ridge are not parallel to each other will cause
movement of the bases when the teeth occlude
because of an unfavorable direction of forces.
• Ridges should also be observed in their
anterioposterior & lateral relationship as the maxilla
resorbs the crest appears to move upward & inward.
• As the mandible resorb crest of the ridge appears to
move downward forward & laterally because it is wider
at its inferior border than at its occlusal border.
Ridge parallelism

11
0
• Class1: both ridges are parallel to occlusal surface.
• Class2: the mandibular ridge is divergent
(dissimilar) to occlusion plane anteriorly.
• Class3: the maxillary ridge is divergent from the
occlusion plane anteriorly or
• Both ridges are divergent anteriorly.
RIDGE PARALLELISM

Ridge parallelism
11
1
Parallel ridge
Anterior deviation
Of maxilla
Anterior deviation
of mandible

11
2
• residual ridge with bony undercuts is most
unfavourable to stable denture and surgical
reduction may be required. It can be
Absent/Unilateral/Bilateral
Bony undercuts

11
4
• Class1:tori are minimal in size. Extending tori do not
interfere with denture construction.
• Class2: clinical examination reveals tori of moderate size.
Such tori offer mild difficulties in denture construction &
use .Surgery is not required.
• Class3: large tori are present. These tori compensate the
fabrication & function of dentures, surgical recountering
& removal is required.
TORI

TORI
11
5

11
6
Inter arch space may be
• Sufficient,
• Excessive
• Insufficient.
INTER ARCH SPACE

11
7
• SMITH described jaw relationship as the
anterioposterior position of the mandibular residual
alveolar ridge relative to maxillary residual ridge
when the jaws are in centric relation.
• Class1: Normal
• Class2: Retrognathic
• Class3: Prognathic
RIDGE RELATIONSHIP

11
8
• Cross bite A- anterior ridge relation is normal but
posterior ridge relation is proganathic
• Cross bite B-posterior ridge relation is normal but
anterior ridge relation is proganathic
CROSS BITE-

11
9
• ‘U’ shape palatal vault is more favorable for
retention & stability.
• ‘V’ shape vault is least favorable for retention
(slightest movement of the denture base will cause
the seal to be broken with a resultant loss of
retention).
• A flat palatal vault is also unfavorable. Retention
may be satisfactory in a downward direction, any
lateral & rotating force results in poor resistance &
loss of retention.
Hard palate

12
0
• it can be normal/subnormal/ supernormal
• Palatal sensitivity can be evaluated by running a dry
guaze across the palate. A supernormal patient will
immediately gag.
Palatal sensitivity

12
1
• Classification of soft palate based on the degree of
flexure of the soft palate make with hard palate &
width of the palate seal area.
Soft palate (house)

12
2
• This type of palate is horizontal & demonstrates
little muscular movements.
• This is most favorable condition because it allows
for more tissue coverage for the palatal seal.
Class1 soft palate

12
3
• Turn downward at about 45 degree angle to the hard
palate & amount of potential tissue coverage for the
palatal seal is less than for a class 1.
Class 2 soft palate

12
4
• Turn downward sharply at about 70degree angle just posteriorly to
the hard palate.
• This is the most acute relation of the soft palate makes with the
hard palate.
• The available space for coverage by the posterior seal is at a
minimum, least favorable type of soft palate.
• ‘V’ shape palatal vault is usually associated with class3 soft
palate.
• In such cases placement of seal & its depth is more critical for
maximum retention.
• Flat palatal vault usually related to class1 or class2 soft palate.
Class3 soft palate

SOFT PALATE
12
5

12
6
• In 1932 , Neil described the lateral throat form and noted
that the denture could have 3 possible lengths depending
upon tonocity, activity and anatomic attachments of the
adjacent structures.
• Class I- the retromylohyoid flange is longest
• Class II-lateral throat form is about half as long and
narrow as class I
• Class III- has minimum length and thickness
LATERAL THROAT FORM

12
7
• The sulcus is observed during the movement of tongue
and thus it can also be classified according to the
anterior movement of retromylohyoid curtain as the
tongue is extended anteriorly beyond the vermilion
border of lower lip
• Class I- minimal or no pressure is placed on the finger
• Class II- any position of the tissues between extremes
• Class III- heavy pressure is placed on the finger

12
8
• When lower ridge is highly resorbed , the genial
tubercle is higher than the crest of the ridge
• In order to achieve better support and peripheral
seal; mandibular denture often donot extend over
genial tubercles ( can extend over genial tubercles
with spacer in severly resorbe ridge)
GENIAL TUBERCLE-

12
9
• it is only in the neighborhood of the second or third
molars that mylohyoid ridges have any prosthetic
significance, but in this region it is sometimes possible
to carry the denture into the undercut area below &
behind the mylohyoid ridge. In the majority of case
these ridges are felt to be pronounced and sharp,
which is a contraindication for extending the denture
over them, unless the denture is relieved, but where
they feel ill defined and rounded a lingual extension is
usually successful
MYLOHYOID RIDGE

13
0
• Large tuberosity presents a number of problems.
• Encroachment of the inter ridge distance.
• Large & opposing undercuts may be present.
• If maxillary sinus extends into the tuberosity
complicate a surgical solution of the problem.
MAXILLARY TUBEROSITY

13
2
• It should be evaluated to determine physical, esthetic & anatomic
characteristics.
• Shade, mold & material should be recorded for both anterior &
posterior teeth
• General shape of the teeth should be recorded.
• Existing esthetic, phonetics, retention, stability, extension &
contours should be evaluated & rated as
• A) good
• b) Fair
• c) Poor
• Centric relations & vertical dimension of occlusion should be
assessed & rated
• a) Acceptable
• b) Unacceptable
EXISTING DENTURES

13
3
• - a panoramic radiograph is useful in assessing the
amount of ridge resorption. Wical and Swoop7
found that mental foramen divide the mandible into
thirds in normal dentulous panoramic radiographs.
If the distance from the inferior border of the
mandible to the lower border of the mental foramen
was measured and multiplied by 3, it gave the actual
height of alveolar ridge crest
Roent geno grahic
examination

13
4
Class I-(mild resorption) loss of 1/3rd of
the vertical height
Class II-(moderate) loss of 1/3rd to
2/3rd of the original vertical height
Class III-(severe) loss of more than
2/3rd of the original vertical height

13
5
• Radiological examination includes- OPG, IOPAR, Lateral Ceph,
TMJ views
• Ideally a full mouth X-ray examination should be made of every
edentulous patient prior to starting denture construction. X-ray
photograph assist in the diagnosis of the following
• buried roots
• sinuses
• unilateral swelling
• rough alveolar ridge
• impacted canine/ molar

13
6
1-MOTIVATION /PATIENT EDUCATION
2-SURGICAL/ NON SURGICAL PREPARATION OF TISSUE (CONDITIONING)
3-CLINICAL STEPS AND LABORATORY PROCEDURE, MATERIAL & TECHNIQUE
USED
• -PRIMARY IMPRESSIONS
• -SPECIAL TRAY PREPARATION
• -FINAL IMPRESSION
• -JAW RELATION RECORDING
• -ARTICULATION
• -SELECTION OF TEETH
• -DENTURE BASE MATERIAL
• -TEETH ARRANGEMENT & CHARACTERIZATION
-TRY-IN
• -FLASKING & PROCESSING
• -INSERTION & RECALL FOR ADJUSTMENTS
TREATMENT PLANNING

13
7
• Give the prognosis & give reasons for the prognosis
• If being edentulous due to disease, its prognosis would
be largely a matter of studying its symptoms, etiology &
treatment is a matter of eliminating cause or causes.
• To know the methods & means or materials to use in
the replacement of lost part is the next essential. The
third & last is an honest desire to do the best for the
patients that the knowledge & skill one posses will
permit.
• It can be good, fair & poor.
PROGNOSIS

COMLETE DENUTRE CASE HISTORY.ppt

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COMLETE DENUTRE CASE HISTORY.ppt