This document discusses diagnosis and treatment planning for edentulous or nearly edentulous patients. It emphasizes that diagnosis and treatment planning are crucial for successful management of patients. The diagnosis involves a thorough patient evaluation including medical history, clinical examination, and radiographs to determine the nature of the patient's condition. The treatment plan is then developed based on the diagnosis and consists of procedures to best address the individual patient's needs. Key aspects of diagnosis and treatment planning discussed include taking a chief complaint and medical history, classifying patients based on factors like mental attitude and cosmetic expectations, and considering how medical conditions like diabetes may impact care.

1. Diagnosis & treatment planning
for edentulous and nearly
edentulous patients
Improving health of patients denture bearing
tissues and ridge relations
1

2. CONTENTS
• Introduction
• Definition
• Patient evaluation
• Clinical history taking
• Medical history
• Clinical examination of patient
• Radiographic examination
• Examination of existing prosthesis
• Treatment planning
• Adjunctive care
• Prosthodontic care 2

3. INTRODUCTION
• Diagnosis and treatment planning are the most important parameters in
the successful management of patients.
• Inadequate diagnosis and treatment planning are the major reasons
behind the failure of any prosthesis.
• Treatment planning is the most important milestone which depends on
the diagnosis.
• Prognosis depend on both diagnosis and treatment planning.
3

4. Definitions
• Diagnosis is defined as determination of nature of
disease.
• Treatment planning is defined as the sequence of
procedures planned for the treatment of a patient
after diagnosis.
Acc to GPT 9
4

5. 5
• 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
Acc to boucher

6. • Diagnosis is the examination of physical state , evaluation
of mental or psychological makeup , and understanding
needs of each patient to ensure a predictable result.
• Treatment planning means developing sequence of
procedures planned for the treatment of a patient after
diagnosis.
Acc to winkler
6

7. First appointment
• This encounter is used to develop mutual understanding and trust between dentist
and patient.
• Patient is comfortably seated to make him feel at ease.
• Patient should be addressed by name.
7

8. • Essential information from the patient is obtained:-
• Personal data:
 Name
 Age
 Sex
 Address
 Telephone no.
 occupation
8

9. • Significance of personal information:
• NAME
-Useful for establishment of patient identity
-Addressing patient by name gains the patient’s confidence
• AGE
-Age influences denture success.
-Tissues of the older patients are less resilient and the oral mucosa and sub mucosa are
thinner.
-Repair potential of tissues are altered.
9

10. • SEX:
• Females and young men are more concerned with appearance. Old men are more
concerned with function and comfort.
• Women after menopause can be difficult to treat due to psychological problems, dry
mouth, burning sensation in the mouth and general vague pain.
• For female patients the teeth must have softer anatomic features and incisal edges
must follow a curve which suggests softness.
10

11. • OCCUPATION:
- patients job and social standing- determine the value he or she places on oral health &
esthetics.
-Occupations like public speakers, teachers and singers are more particular about the
phonetics with their new dentures.
• RACE:
- Critical factor in characterization of dentures(i.e., choice of denture base shade,
placement of denture base stains, etc.).
- Embedding color fast fibers in the polymer to simulate veins, and hence reproduce
realistic appearance of healthy oral tissues.
11

12. • LOCATION:
- Helps in future communication
- Helps in setting up of appointments
• RELIGION AND COMMUNITY:
• Gives idea about dietary habits
• Helps to design denture accordingly
• PATIENT HABIT:
• Tobacco chewing, smoking, drinking
• Reveals patient concern about oral health
12

13. Chief complaint
• It should be recorded in patients own words.
• Dentist should arrive at the understanding of what the
patient really wants & whether the patient’s goal are
realistic.
• Cheif complain usually belong to following category:
Comfort (pain, senstivity, swelling)
Function (difficulty in mastication or speech)
Social (bad taste or odor)
Appearance (fractured or unattractive teeth) 13

14. General outline of diagnosis and treatment planning
Diagnosis
Patient evaluation
• (Gait, age , sex, complexion , cosmetic index , mental attitude)
Clinical history
 Personal information
 Dental history –
 (chief complain, expectations, period of edentulousness , previous treatment records , denture success.)
 Medical history-
 (deblitating disease , diseases of the joint , cardiovascular diseases , neurological disorders , oral malignancies )
14

15.  Clinical examination:
 Extra oral
 Intraoral
15

16. • Treatment planning
• Adjunctive care
• (elimination of infection, elimination of pathosis , pre prosthetic surgery , tissue
conditioning )
• Prosthodontic care
16

17. Cosmetic Index
• It tells about aesthetic expectations of the patients.
17
class I High CI patients are more concerned
about treatment.
Class II Moderate CI Patients with nominal
expectations.
Class III Low CI patients are not bothered
about treatment and
aesthetics.

18. Evaluation of mental attitude
• De Van - “meet the mind of patient before meeting the mouth of the patient”
• A successful prosthodontic treatment depends upon both technical skills and
patient management according to mental attitude.
• Based on mental attitude
• I classification (House’s classification)
• II classification
18

19. House’s Classification:
( by Dr. Milus M. House in 1950)
Classified patients psychology in to 6 types:
Philosophical Willing to accept dentist’s judgement without any question , cooperative and confident to
dentist.
Excellent prognosis
Exacting Usually dissatisfied by their previous treatment, do not have confidence on dentist
Require extreme care , effort , and patience on the part of the dentist
Demand written gurantee or remake at no additional cost , once satisfied they become
greatest supporter.
Hysterical They have highly negative attitude to dentist & treatment.
They are emotionally ustable, excitable , apprehensive and have unrealistic expectations .
Prognosis is unfavourable.
19

20. Indifferent Little concern for teeth and oral health
Uncooperative & hardly try to become accustomed to dentures
Do not value efforts and skills of dentist
Questionable or unfavourable prognosis
Critical find fault with everything that is done for them
Never happy with there dentist
Exercise firm control over these patients.
Skeptical Often in poor health and unfavourable oral conditions.
Had bad results with previous treatment & doubtful if anyone can help them.
Careful examination and attention will help patient develop confidence in dentist.
20

21. • Patients can also be classified under following categories:
 Cooperative
 Apprehensive -anxious
- frightened
- chronic complainers
- self -conscious
 uncooperativre
21

22. CLASSIFICATION BY GAMER, TUCH AND GARCIA
Based on two factors
1) Patient engagement
2) Willingness to submit
22

23. PATIENT TYPE
• Ideal
• „
Submitter
• „
Reluctant
• „
Indifferent
• „
Resistant
23

24. • IDEAL
• Equivalent to Houses philosophical patient
• Reasonably engaged
• Reasonably willing to submit to treatment Mature
patient with a healthy life balance
• SUBMITTER
• High level of engagement
• High level of willingness to submit
• Incapable of providing genuine informed consent
Cannot be an active partner in treatment
24

25. • ‡
RELUCTANT
• Average in engagement
• Average in willingness
• INDIFFERENT
• Minimally engaged and indifferent to the dentist
‡
• RESISTANT
• Similar to Houses exacting patient
• Average willingness to submit
• They challenge the dentist and have no trust
25

26. History taking
26

27. Clinical history
• It is a systematic procedure for collecting details of the patient to do a proper
treatment planning.
• It includes:
• personal details
• Medical history
• Dental history
27

28. Medical history
• Medical condition of the patient should be ruled out before beginning the
prosthetic treatment.
• Debilitating diseases
• Diseases of the joints
• Cardiovascular diseases
• Diseases of the skin
• Neurological disorders
• Oral malignancies
• Climateric conditions
28

29. • Deblitating disease:
 like diabetes, blood dyscrasias and tuberculosis require special instructions on
denture and tissue care.
 they also require special follow- up appointments to observe response of soft
tissues.
 diabetic patients have excessive bone resorption – frequent relining of dentures.
 Cardiovasvular diseases:
 Require short appointments & consultation from cardiologist before commencing any
treatment.
29

30. • Diseases of joints:
• Osteoarthritis may affects the TMJ – special impression trays are required due to
limited mouth opening and jaw movements.
• Repeated jaw relations and post inserttion adjustments required
• If finger joints are affected - patient may find difficult to insert and clean
dentures.
• Skin diseases:
• May have oral manifestations (ulcers/bullae) – such painful conditions make
denture use impossible without medical treatment.
30

31. • Neurological diseases:
• Such as Bell’s palsy and Parkinson’s can influence denture retention
and jaw relations.
• Oral malignancies:
• Patients undergoing radiation therapy require waiting period before
starting prosthodontic treatment.
• Tissues having bronze colour and loss of tonicity are not suitable for
denture construction.
31

32. • hormonal disturbances:
• Acromegaly – need frequent adjustments and new dentures.
• hyperthyroidism – reduced salivary flow – mucosal inflamation.
• Hyper parathyroidism – increased alveolar resorption.
32

33. • Nutritional disturbances:
• Older patients have decreased appetite – defeciency of vitamins.
• Avitaminosis –lowers defence of mucosa to infectious diseases.
• Vit A def – hyper parakeratosis
• Vit B def - angular chelitis
• Vit D def – marked alveolar atrophy.
• Vit k def – purpura of oral mucosa.
33

34. DIABETES
• Must be under proper medical control
• Oral manifestations
• Xerostomia
• ‡
Infection
• ‡
Poor healing
• ‡
decreased salivary flow
• Burning mouth syndrome
• Increased alveolar bone resorption. ‡
• Osteoporosis. ‡
• May also present with Macroglossia and the tongue may appear red and sore.
34

35. • Blood sugar level should be regularly monitored. ‡
Short and morning appointments. ‡
• Patient must be instructed to have a normal diet before dental appointment. ‡
• Patient educated regarding maintenance of denture cleanliness and oral hygiene. ‡
• A source of sugar, such as orange juice, must be available in the dental office if the
symptoms of an insulin reaction occur.
35

36. • Use of selective pressure impression technique.
• ‡
Rapid rate of bone resorption can occur therefore, relining may be
indicated at regular intervals.
• ‡
It can effect the wound healing capability and therefore must be
taken into consideration if preprosthetic surgery is planned.
36

37. ARTHIRITIS
• Limited movement of mandible
• Impression making may require special trays and procedures
• Occlusal correction must be made often because of arthiritic changes in TMJ
• Difficult to record jaw relations
37

38. PARKINSONS DISEASE
• Control of patient during fabrication of denture can be accomplished
with sedative
• Retention is difficult , adhesive may be necessary
• Difficulty for patient to insert and remove the prosthesis. ‡
• Difficulty in maintaining denture hygiene.
• Due to increased tremors, increased saliva ʹ Prosthodontic procedures
are difficult to perform
38

39. TUBERCULOSIS
• Can be transmitted from patient to dentist and laboratory personnel if adequate
precaution are not taken.
• ‡
Diet is important so fabrication of efficient dentures. ‡
Irritating projections should
be removed
• Following precaution should be taken:
• Wear gloves, mask and eye protection glasses. ‡
Instrumentation should be sterilized
completely and aseptic procedures strongly advocated. ‡
If possible, disposable
things should be used in the treatment.
39

40. Dental history
 Dentist should evaluate patient’s expectation and classify them as
realistic, attainable or unrealistic.
 Period of edentulousness (gives idea about amount and pattern of
bone resorption .)
 Pre treatment records
(previous denture , current denture , pre extraction records ,
diagnostic casts.)
 Previous radiographs
40

41. In Edentulous patients
• Following pre – treatment records are necessary:
 Previous denture
 Current denture
 Pre –extraction records
 Diagnostic casts
41

42. • Reason for failure of previous denture should be enquired. Patients who
frequently change dentures are difficult to satisfy and risky to deal with.
• Current denture should be examined thoroughly and reason for wanting a
replacement should be evaluated
-( it gives us information about denture care and para functional habits of the
patients.)
42

43. Following factors should be noted on the existing
prosthesis:
• Period for which patient is wearing dentures
• amount of ridge resorption determines the expected ridge
resorption after placement of new prosthesis.
• anterior and posterior teeth shade.
• Centric occlusion and also patient profile in centric occlusion.
• Vertical dimension at occlusion should be marked as acceptable or
un acceptable
• Plane of orientation of occlusal plane
• Amount of space in buccal vestibule is acceptable or un acceptable.
43

44. • Denture maintainance should be evaluated and classified as – good ,
fair , poor.
• Wear or breakage may be an indication of bruxism , and classified as –
minimal , moderate or severe.
• Retention and stability of the denture should be examined.
• Presence of cross bite should be checked.
44

45. • PRE –EXTRACTION RECORD
- Radiograph
- Photograph
- Diagnostic cast
• DENTURE SUCCESS:
- Patient asked about the esthetic and functioning of existing denture
- Favourable
- Unfavourable
45

46. Clinical examination
Extra oral examination
Intra- oral examination
46

47. Extra oral examination
• Facial examination
• Muscle tone
• Muscle development
• Complexion
• Lip examination
• TMJ examination
• Neuro- muscular coordinationm
47

48. Facial examination
• Peri oral features :
• Length of lips
• lip fullness
• Facial form
• Facial profile
• Lower facial hight
• Muscle tone
• Muscle development
• Complexion
• Speech
• Neuromuscular examination
48

49. Lip examination
• Lip support:
• Based on the amount of lip support lips can be classified as adequately supported or
unsupported.
• Lip mobility:
• Class I – normal
• Class II – reduced mobility
• Class III – paralysed.
49

50. • Thickness of lips:
• Thin lips – labiolingual position of teeth for their fullness and support.
• Thick lips – need lesser support from artificial teeth.
• Length of lips:
• Short lips tends to reveal more tooth structure & denture base.
• It is an important determinant in anterior teeth selection.
50

51. Insufficient support of lips is characterized by
a reduction in the visible part
of the vermillion border
A drooping and deepening of
the nasolabial grooves
Small vertical lines or wrinkles
above the vermillion border
A reduction in the
prominence of the philtrum
A drooping or turning down of
the corners of the mouth
A deepening of the sulci
51

52. • Facial form: it helps in teeth selection
o Square
o Tapering
o Square tapering
o Ovoid
• Facial profile: determines jaw relation
and occlusion
o Class I – normal straight
o Class II – retrognathic
o Class III – prognathic
52

53. 53

54. • Lower facial height:
- it determines vertical jaw relation.
- in patients who are denture wearers,
lower facial height is examined under
occlusion.
collapsed LFH – loss of VDO
VD – wrinkles
VD – stretched facial tissues.
54

55. • Lower facial height :
55

56. • Muscle tone : affect stability of denture.
• House classified muscle tone into :
• Class I – normal tension , tone and placement of muscle
• Class II – normal muscle function but slightely decreased muscle tone
• Class III – decreased muscle tone and function.
( decreased biting force , wrinkles in the cheeks,
and drooping of comissures)
56

57. • Muscle development:
• People with excessive muscle development have more biting force.
• class I – heavy
• Class II – medium
• Class III – light
• Complexion – eyes , hair and skin guide the selection of artificial
teeth.
57

58. • people with dark complexions generally have lighter teeth that are in harmony with
the color of the face.
• people with fair complexions have teeth with less color range and color saturation
thus, the teeth are darker and in harmony with the colors of the face.
58

59. Examination of TMJ
• it should be examined for range of movements , muscles of
mastication , joint sounds upon opening and closing.
• Examination is carried out through a series:-
o Inspection
o Palpation
o auscultation
59

60. • Palpation
• TMJ can be palpated by extra auricular and intra auricular
methods.
• Palpation can be done by standing at 10 o’clock or 11 o’clock
position
60

61. • Intra auricular method:
• It can be achieved by placing little finger inside the
external auditory meatus
• During movement the posteripor head of the
condylar head can be palpated
• It may be used to elicit capsular ternderness.
61

62. • Extra auricular method
• It is done by placing index finger in the pre
auricular region about 1.5 cm Medial to the tragus
of ear .
• Lateral pole of condyle is accessible during this
examination
62

63. Neuromuscular examination
• It includes examination of speech & neuromuscular
coordination
• Speech:
• Type I: normal
patients are capable of producing normal articulated
speech,
with existing dentures can easily accomodate to new
dentures,
• Type II : Affected
impaired articulation of speech with their existing 63

64. • Neuromuscular coordination:
• Patients gait and coordination of movement are important
points to be considered.
• Any deviation from normal will indicate: parkinson’s disease,
hemiplegia, cerebral diseaase, or even psychotropic drugs.
• Abnormal facial movements, lip smaking, tongue tremors,
uncontrollable chewing movements can influence complete
denture performance and may lead to prosthetioc failure.
64

65.  Intraoral
• Existing teeth
• Mucosa (colour , condition, thickness)
• Saliva
• Residual alveolar ridge (arch size, arch form, ridge contour, ridge
relation, ridge parallelism, inter arch space)
• Ridge defects
• Redundant tissues / hyperplastic tissues
• Hard palate
• Soft palate and palatal throat forms
• Lateral throat forms
• Muscle and frenum attachment
• Bony undercuts/ tori
• Gag reflex
65

66. Mucosa
• Colour:
• Should have healthy pale colour
• Redness indicastes inflamatoer changes – ill fitting dentures
• Inflamed tissues provide wrong recording of while making the
impression.
• Condition of the mucosa:
• Class I : healthy
• Class II : irritated mucosa
• Class III: pathologic mucosa 66

67. • Thickness of mucosa:
• Quality of muco periosteum varies in different part of the arch –
this variation makes it difficult to equalize the pressure under the
denture.
•
• Class I : normal – uniform thickness of 1 mm -ideal cusion for
basal seat of the denture.
• Class II:
Type 1-thin investing membrane- highly susceptible to 67

68. • Saliva:
• Major salivary gland orifice –for patency
• Viscosity:
• Class I : -normal quality and quantity of saliva
• Class II: excessive saliva (contains > mucus)
• Class III : xerostomia
• Thick ropy saliva alters retention of denture as it accumulate b/w tissue and
denture.
• Xerostomia – poor retention
• Hypersalivation- complicates clinical procedures.
68

69. Residual alveolar ridge:
• Arch size:
• > arch size - > denture bearing area – increases retention.
• Class I: large
• Class II : medium
• Class III : small ( difficult to achieve good retention and stability
69

70. • ARCH FORM: House classification arch form
CLASS I : Square
Large and more surface area
Best for retention and stability
CLASS II: Tapering
less retention and stability.
CLASS III: Ovoid
Comparatively less common
70

71. Ridge contour
71

72. • Ridge contour:
• Classification of maxillary ridge contour:
• Class I: square to gently rounded
• Class II: tapering or ‘V’ Shaped.
• Class III: flat.
• Mandibular ridge contour:
• Class I: inverted U shaped
• Class II: inverted U shaped with flat
crest .
72

73. Classification of mandibular ridge height by WICAL and
SWOOPE.
• Mental foramen is considered
as a reference point for the
measurement of amount of
bone loss.
• Distance from lower border of
mandible to mental is
considered as – ‘x’
• Actual ridge height is
considered as – ‘3x’
• height of present ridge is- ‘y”
73

74. • Class I : up to one third of original vertical height lost.
• Class II :from one third to two thirds of the original vertical height lost.
• Class III : two third or more of the mandibular height lost.
74

75. • Ridge relation: Angles classification.
• It is the positional relationship of mandibular ridge to
maxillary ridge.
• Class I : normal
• Class II : retrognathic
• Class III : prognathic.
• can also be classified as :
• Convex - classII jaw relation
• Concave – class III
• Straight- class 1
75

76. • While examining the ridge relation the pattern of resorption of maxillary and
mandibular arches should be remembered
• Maxxila- resorbs upwards and inwards
• Mandible - resorbs downwards and outwards
76

77. • Ridge parallelism :
• Class I: both ridges are parallel to
occlusal plane
• Class II: mandibular ridge diverts from
occlusal plane anteriorly
• Class III : either maxillary ridge diverts or
both ridges diverts from the occlusal
plane anteriorly.
77

78. • Interarch space:
• The increase in the interarch space will be due to excessive residual ridge resorption.
• Decrease in the interarch space makes teeth arrangement a difficulty. However
stability of denture is increased in these patients.
78

79. • The inter-arch space can be classified as :
• Class I – ideal inter-arch space to accomodate
artificial teeth
• Class II – excessive inter-arch space
• Class III – insufficient inter-arch space to
accomodate the artificial teeth.
79

80. • Ridge defects:
• It includes exostoses tha may interfere with fabrication of complete denture.
• Redundant tissue:
• These are flabby tissues covering the crest of ridge
• These movable tissues tends to cause movement of denture when forces are
applied , it leads to loss of retention.
• Hyperplastic tissues:
• Most common hyperplastic lesions are epulis fissuratum, papillary hyperplasia.
• Treatment includes tissue conditioning and denture adjustments.
80

81. Hard palate
• Shape of the vault of palate should be examined.
• U shaped – ideal for retention and stability.
• V shaped – retention is less and the pheripheral
seal is easily broken
• Flat – reduced resistance to lateral and rotary
forces.
81

82. Soft palate and palatal throat form
• Relationship between soft palate and hard palate
is called palatal throat form
• SOFT PALATE:
CLASS I - almost horizontal with little movement
making angle of less than 10º with hard palate
-Most favorable as it allows for
More tissue coverage for
the palatal seal.
82

83. CLASS II - Soft palate makes a 45º Angle with the
hard palate.
-tissue coverage is less than Class I
-Good retention is usually possible.
CLASS III- soft palate makes 70º Angle with the
hard palate
- Least favorable
-Greater movement of soft palate during
function and the narrower seal area.
83

84. Palatal throat forms
• Class I :Large and normal form ,
Immovable band of resilient tissue 5-12 mm
Distal to line across the distal edge
Of tuberosity
• CLASS II :Medium sized & normal in form
relatively immovable band of resilient tissue 3-5 mm
distal to line across distal edge of tuberosities.
• CLASS III :usually accompany small maxila
• soft tissue turn down abruptly 3-5 mm anterior to line
across distal edge of tuberosities.
84

85. Lateral throat form
It is classified according to the extent of anterior movement of
retromylohyoid curtain as the tongue is extended anteriorly beyond the
vernilion border of lip.
85

86. Lateral throat form
• CLASS I: ‡
This form indicates that the anatomical structures will
accommodate a fairly long and wide flange.
• ‡
The retromylohyoid flange is usually the longest.
• ‡
Thickness of the border ʹ usually 2-3mm thick can be used for better
seal.
86

87. • CLASS II:
- Is about half as long and narrow as the class1 and about twice as long as a CLASS III. ‡
- Most edentulous mouth have class1 and class2 lateral throat forms, CLASS III is rare.
87

88. • CLASS III
- This form has minimum length and thickness ‡
- Border usually ends 2-3mm below the mylohyoid ridge or sometimes just at the ridge ‡
- Thickness should be no more than approximately 2mm, or it may even end in a knife edge
if the border terminates at the mylohyoid ridge.
88

89. • PALATAL SENSITIVITY AND GAG REFLEX:
• Normal defence mechanism developed by the body to prevent foreign bodies from
entering trachea.
• This reflex is controlled by glossopharyngeal nerve.
• House classified it as
CLASS I: Normal
CLASSII: Hyposensitive
CLASSIII:Hpersensitive
89

90. • Management of gag reflex:
• Careful handling of impression procedure.
• Management of such patients is through clinical , psychological
and pharmacological means.
• Inject LA
90

91. • Tori:
• Abnormal bony prominences found in the middle of the palatal vault and on the
lingual side of the mandible in the premolar region.
• CLASS I: Tori absent or minimal in size. Do not interfere in denture construction
• CLASS II: Tori of moderate size. Surgery is not required
• CLASS III: Large tori ,interfere the fabrication of denture
91

92. • Management of tori
• To prevent injury to thin mucosa covering the tori, adequate relief should be
provided in that region during complete denture fabrication.
• Large tori needs surgical removal.
92

93. • Muscle and frenal attachment:
• Muscular and frenal attachments should be examined for their position in relation to
crest of ridge.
• These abnormal attachments can displace denture during musculaar movements.
• Resiodual ridge resorption is seen when the maxillary labial and lingual freenal
attachments are close to the crest of ridge.
93

94. • classification of Border attachment:
Class I –attachments are placed 0.5 inches away from
crest of the ridge.
Class II – attachments are placed 0.25 -0.5 inches away
Class III - attachments are placed at a distanc e less
than 0.25 inches
94

95. • CLASSIFICATION OF FRENAL ATTACHMENT:
• CLASS I: Away from crest of ridge
• CLASSII: Nearer to the crest of ridge
• CLASS III: Freni encroach the crest of the ridge and
may interfere with the denture seal.(surgical
correction is required)
95

96. Tongue
• large tongue
• Presence of large tongue decreases the stability of denture.
• And is also a hinderance in impression making.
• Tongue biting is common after insertion of denture.
• Small tongue:
• Does not provide adequate lingual peripheral seal.
96

97. • House’s classification of tongue size:
CLASS I: normal in size, development and function. Sufficient teeth are
present to maintain this normal form and function
97

98. • CLASS II: teeth have been absent long
enough to permit a change in form and
function of tongue
• CLASS III: Excessively large tongue, all
teeth are absent abnormal development
of the size of tongue
98

99. • WRIGHT’S CALSSIFICATION OF TONGUE POSITION:
CLASS I: Tongue lies in floor of mouth with tip slightly forward below the incisal edge
of mandibular anterior teeth.
99

100. CLASS II: Tongue flat and broad
CLASS III: Tongue retracted depressed into floor of mouth, with tip curled downward.
100

101. TREATMENT PLANNING
101

102. Adjunctive care
• Elimination of infection:
• Sources of infection – necrotic ulcers , non vital teeth ,
periodontally compromised teeth should be removed.
• Infective conditions like candiasis , herpes should be cured
before prosthodontic treatment.
102

103. • Elimination of pathology:
• Cysts and tumors should be removed before treatment.
• Some times after surgery - obturator needs to be placed along
with complete denture.
103

104. • Pre prosthetic surgery:
• Frenectomy
• Exicision of flabby tissues & hyperplastic retromolar pad
• Alveoloplasty
• Excision of tori
• Vestibuloplasty
• Ridge augmentation procedures.
104

105. • Tissue conditioning:
• Patient is asked – not to wear previous denture for 72 hrs
before commencing treatment
• Denture relining materials should be applied to avoid tissue
irritation.
• Nutritional counseling:
• Patients are advised – balanced diet
• Prophylactic vitamin therapy is given 105

106. Prosthodontic care
• Type of prosthesis , denture base material , tooth material and
teeth shade should be decided.
• For patients destined to be edentulous:
• Immediate /conventional dentures. – for already edentulous
patients
• Definitive/interim dentures – for patients with few teeth which
are likely
to be extracted
• Denture with obturator – in patients with congenital 106

107. 107

108. 108

109. 109

110. 110

111. 111

112. 112

113. IMPROVING PATIENT’S DENTURE BEARING
AREAS AND RIDGE RELATIONS
(Preprosthetic surgery)
113

114. INTRODUCTION
• Prolonged periods of denture wearing might pose a risk through
adverse changes in the denture foundations
• Several conditions in the mouth require corrections or treatment
before construction of CDs
• These procedures are referred to as pre-prosthetic surgical procedures
114

115. OVERALL OBJECTIVES OF THESE PROCEDURES:
• 1.Elimination of pathology
• 2.Rehabilitation of infected or inflamed tissue
• 3.Reestablishment of maxillomandibular relationships in all spatial
dimensions
• 4.Preservation of alveolar ridge dimensions conducive to prosthetic
restoration
• 5.Relief of bony and soft tissue undercuts
• 6.Establishment of proper vestibular depth
• 7.Relocation of muscle attachments to allow for prosthesis flange extension,
if necessary
115

116. Primary surgery
1.Simple extractions and alveoloplasty
2.Removal of tori and exostoses
3.Maxillary labial frenectomy
4.Lingual frenectomy
5.buccal frenectomies
6.Ridge extensioon procedures
116

117. 1.simple extractions and alveoloplasty
• Include teeth removal
• Alveoloplasty is contouring of edentulous ridges to receive a prosthesis
117

118. CONCLUSION
• 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.

119. 119

120. Aims of pre-prosthetic surgery
• Pre prosthetic surgery is aimed at providing a good healthy
surface for the insertion of dentures.
• To provide optimum ridge in terms of height, width and
contour for adequate bone support.
• To provide adequate soft tissue support and establishment of
optimum vestibular depth.
• Elimination of pre-existing bony deformities i.e tori , genial 120

121. • Correction of maxillary and mandibular ridge
relationships.
• Elimination of pre – existing soft tissue
deformities- epulis, flabby ridges, hyperplastic
tissues.
• Relocation of frenal and muscle attachments.
• Relocation of mental nerve.
121

122. • Pre-prosthetic surgical procedures involve all the procedures
by which an ideal , smooth , healthy U shaped ridge , without
any unfavourable undercuts or bony growths and with
sufficient vestibular depth is achieved.
122

123. Ideal ridge
• An ideal ridge is a U shaped ridge with parallel sides.
• It must provide adequate bony support for the denture.
• It should have sufficient vestibular depth
• It should be covered by an adequate keratinised mucosal lining
of uniform thickness.
• It should not have any undesirable undercuts or bony
protuberances.
• It should be free from high freenal attachments, abnormal
muscle attachments. 123

124. • Various procedures can be discussed under following headings:
• Surgery for ridge correction
• Surgery for ridge extension
• Surgery for ridge augmentation.
• Soft tissue corrections.
124

125. Ridge correction surgeries
• Correction of:
• sharp irregular ridge.
• Over projecting mylohyoid ridge
• Alveoloplasty
• Alveolectomy
• Excision of tori
• Excision of genial tubercles/ enlarge bony tuberosities.
• Reduction of protruding maxilla.
125

126. Ridge extension surgeries:
• Vestibuloplasty
• High mental foramen
• Zygomaticoplasty.
• Tuberoplasty.
126

127. Ridge augmentation
• Ridge augmentation surgical procedure involve replacement of
bone that has been lost due to excessive bone resorption.
• Ridge augmentation is aimed at increase in the ridge height
and width providing a large denture bearing area, protection of
neurovascular bundles and restoration of proper maxillo
mandibular arch relationship.
• Indication: when there is less than 2 cm of bone height.
127

128. Materials used for augmentation of alveolar ridge.
• Autogenous bone graft:
• Allogenic bone grafts:
• Alloplastic materials
• Metal mesh with autogenous cartico cancellous bone.
• Metal mesh with hydroxyapatite.
128

129. Limitations of ridge augmentation procedures :
• Poor physical condition of the patient
• Poor healing capacity
• Nutritional deficiencies.
• Availability of adequate soft tissue coverage.
129

130. • Mandibular augmentation:
• Superior border augmentation
• Inferior border augmentation
• Pedicle or interpositional bone graft (visor osteotomy)
• Hydroxyapatite augmentation.
130

131. • Maxillary augmentation
• Onlay bone grafting
• Interpositional bone grafting
• Hydroxyapatite augmentation
• Tuberoplasty.
131

132. Superior border grafting
• Described by Davis (1970)
• This technique is used for ridge augmentation when thbe ridge
height is less than 10 mm.
• Advantages:
• adds strength/ contour/ height/ preserve mental nerve/
decrease interarch distance.
132

133. • Disadvantages:
• The morbidity associated with removal of ribs.
• Significant postoperative resorption of the graft.
133

134. Inferior border grafting
• Indication and advantage:
• It is indicated when the alveolar ridge is less than 5-8 mm in
height and is at risk of pathological fractures.
• This occurs by using a rib for the augmentation of inferior
border of mandible.
• disadvantage
134

135. Maxillary sinus lift.
135

136. 136

137. Alveoloplasty
• Indications:
• Opposing undercuts
• Lack of intermaxillary space
• Sharp, spinous ridges
• Exostoses
• Extreme irregularities of the alveolar crest
137

138. • Timing :
• Alveoloplasty may be done at the time of extraction
• Advantasge of immediate alveoloplasty : only one surgical
procedure is needed.
• Some factors that necessiate delayed alveoloplasty:
• Infection , systemic factors
138

139. 139

140. 140
The various conditions requiring treatment may be considered in two sections, those involving
the oral mucosa and those involving bone.
(1) Conditions involving the oral mucosa:
(a) Denture stomatitis
(b) (b) Palatal infl ammatory papillary hyperplasia
(c) (c) Angular stomatitis (angular cheilitis)
(d) (d) Shallow sulci (e) Denture-induced hyperplasia (
(e) f) Prominent frena.
(f) (2) Conditions involving the bone: (a) Pathology within the bone
(g) (b) Sharp and irregular bone
(h) (c) Undercut ridges
(i) (d) Prominent maxillary tuberosities
(j) (e) Tori.

141. Bony surgeries
141

142. Alveolectomy
• Surgical removal or trimming of the alveolar process is termed
as alveolectomy.
• Procedure:
• After extraction whenever there is presence of sharp margins
at interdental , interseptal or labiobuccal alveolar crest, they
should be trimmed with bone rounger or round bur and
smoothened with bone file.
142

143. Alveoloplasty:
• Alveoloplasty is defined as surgical recountouring of the
alveolar process.
• This procedure is done with the purpose to take care of bony
projections, sharp crestal bone or undercuts.
• Conservation is the key factor in this procedure.
• Types:
• Simple alveoloplasty
• Interseptal alveoloplasty : deans alveoloplasty ,
obsweger’s modification.
• Post extraction alveoloplasty 143

144. Simple alveoloplasty
• Procedure:
• Bony areas requiring recountouring should be exposed using
an envelop type of flap.
144