this is a lecture prepared by Dr ANMOL ASGHAR for BDS 3RD YEAR STUDENTS

1. DIAGNOSIS & TREATMENT
PLANNING
DR ANMOL ASGHAR
BDS,PGORALIMPLANTOLOGY(ADACERTIFIED)
PGORTHODONTICS& DENTOFACIALORTHOPEDICS(USCSpain)
FACULTY OF DENTISTRY (ADAL MEDICAL UNIVERSITY )
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2. WHAT TO STUDY IN THIS CHAPTER
 • Diagnosis
 • Patient Evaluation
 • Clinical History Taking
 • Clinical Examination of the Patient
 • Radiographic Examination
 • Treatment Plan
 • Adjunctive Care
 • Prosthodontics Care
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FACULTY
OF
DENTISTRY
(ADAL
MEDICAL
UNIVERSITY
)

3. DIAGNOSIS & TREATMENT PLANNING
 Diagnosis and treatment planning are the most
important parameters in the successful
management of a patient. Inadequate diagnosis
and treatment planning are the major reasons
behind the failure of a complete denture. The
following factors should be evaluated to arrive at a
proper diagnosis and treatment planning.
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MEDICAL
UNIVERSITY
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4. DIAGNOSIS/ HISTORY TAKING AND PATIENT
EVALUATION
 DIAGNOSIS:
 ❐ Patient Evaluation
 • Gait
 • Age of the patient
 • Sex
 • Complexion
 • Cosmetic Index
 • Mental Attitude
 ❐ Clinical history taking:
 • Name
 • Age
 • Sex
 • Occupation
 • Race
 • Location
 • Religion
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• Dental History
— Chief Complaint
— Expectations
— Period of Edentulousness
— Pre-treatment Records:
• Previous Denture
• Current Denture
• Pre-extraction Records
• Diagnostic Casts
— Denture Success

5.  • Medical History
 — Debilitating Diseases
 — Diseases of the Joints
 — Cardiovascular Diseases
 — Diseases of the Skin
 — Neurological Disorders
 — Oral Malignancies
 — Climacteric Conditions
 ❐ Clinical Examination of the Patient
 • Extra oral:
 — Facial examination:
 – Facial Form
 – Facial Features
 — Muscle Tone
 — Muscle Development
 — Complexion
 — Lip Examination
 — TMJ Examination
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— Neuromuscular Examination
– Speech
– Co-ordination
• Intraoral:
— Existing teeth (If any)
— Mucosa:
– Color of the mucosa
– Condition of the Mucosa
– Thickness
— Saliva

6.  — Residual Alveolar Ridge:
 – Arch Size
 – Arch Form
 – Ridge Contour
 – Ridge Relation
 – Ridge Parallelism
 – Inter-arch Space
 — Ridge Defects
 — Redundant Tissue
 — Hyperplastic Tissue
 — Hard palate
 — Soft palate and Palatal Throat Form
 — Lateral Throat Form
 — Gag Reflex 6
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— Bony Undercuts
— Tori
— Muscle and Frenum Attachments
– Border Attachments of the Mucosa
– Frenum Attachments
— Tongue
— Floor of the Mouth
❐ Radiographic Examination
• Bone Quality
❐ Examination of the Existing Prosthesis

7. COSMETIC INDEX
 It basically speaks about the aesthetic expectations
of the patient. Based on the cosmetic index,
patients can be classified as:
 Class I: High cosmetic index. They are more
concerned about the treatment and wonder if their
expectations can be fulfilled.
 Class II: Moderate cosmetic patients. They are
patients with nominal expectations.
 Class III: Low cosmetic index. These patients are
not bothered about treatment and the aesthetics. It
is very difficult for the dentist to know if the patient
is satisfied with the treatment or not. 7
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8. MENTAL ATTITUDE OF PATIENTS
 De Van stated, “meet the mind of the
patient before meeting the mouth of
the patient”. Hence, we understand that the
patient’s attitudes and opinions can influence the
outcome of the treatment.
 Based on their mental attitude, patients can be
grouped under two classifications. Dr. MM House
proposed the first one in 1950, which is widely
followed.
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9. HOUSE’S CLASSIFICATION:
 Dr.MM House in 1950 classified patient’s
psychology into four types.
 Class I
 Class II
 Class III
 Class IV
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10. HOUSE’S CLASSIFICATION:
 Philosophical
 Exacting
 Hysterical
 Indifferent
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11. PHILOSOPHICAL
 a. Those who have presented themselves prior to
the extraction of their teeth, have had no
experience in wearing dentures, and do not
anticipate any special difficulties in that regard.
 b. Those who have worn satisfactory dentures, are
in good health, are a well-balanced type, and are in
need of further denture service. Generally they can
be described as easygoing, congenial, mentally
well adjusted, cooperative and confident of the
dentist. These patients have excellent prognosis.
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12. EXACTING
 a. Those who, while suffering from ill health, are
seriously concerned about appearance and
efficiency of artificial dentures. They are reluctant to
accept the advice of the physician and the dentist
and are unwilling to submit to the removal of their
artificial teeth.
 b. Those wearing dentures unsatisfactory in
appearance and usefulness, and who doubt the
ability of the dentist to render a satisfactory
treatment, and those who insist on a written
guarantee or expect the dentist to make repeated
attempts to please them. 12
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13. HYSTERICAL
 a. Those in bad health with long neglected
pathological mouth conditions and who are positive
in their minds that they can never wear dentures.
They are emotionally unstable and tend to complain
without justification.
 b. Those who have attempted to wear dentures but
failed. They are thoroughly discouraged. They are
of a hysterical, nervous, very exacting temperament
and will demand efficiency and appearance from
the dentures equal to that of the most perfect
natural teeth.
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14. INDIFFERENT
 Those who are unconcerned about their
appearance and feel very little or no necessity for
teeth for mastication. They are, therefore
uncooperative and will hardly try to become
accustomed to dentures. They will not maintain the
dentures properly and do not appreciate the efforts
and skills of the dentist
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15. CLASSIFICATION II
 Cooperative
 Apprehensive
---Anxious
---Frightened
---Obsessive or exacting (giving advice to doctors)
---Chronic complainers
---Self-conscious
 Uncooperative (These patients present themselves
usually upon being urged by relatives or friends.
They do not feel a need for dentures)
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16. GAIT ABNORMAILITIES
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17. ORAL CANCER
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18. DRY MOUTH / XEROSTOMIA
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19. REDUNDANT TISSUE
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20. HYPERPLASTIC TISSUE
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21. TORI
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22. TORI…
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23. BONY UNDERCUTS
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24. TREATMENT PLANNING
 Adjunctive care:
 • Elimination of Infection
 • Elimination of Pathosis
 • Pre-prosthetic Surgery
 • Tissue Conditioning
 • Nutritional Counselling
❐ Prosthodontics care
 • Patients destined to be edentulous:
— Immediate or Conventional Denture
— Definitive or Interim Denture
— Implant or Soft Tissue Supported Denture
 • Patients already edentulous:
— Soft Tissue Supported
— Implant Supported (Fixed or Removable)
— Material of Choice
— Selection of Teeth
— Anatomic Palate
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OF
DENTISTRY
(ADAL
MEDICAL
UNIVERSITY
)

25. DENTAL HISTORY
 Although other sections in history are important,
dental history is the most important all of them.
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26. CHIEF COMPLAINT
 It should be recorded in the patient’s own words. It
gives ideas about the patient’s psychology
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27. EXPECTATIONS
 The patient should be asked about his/her
expectations. The dentist should evaluate the
patient’s expectations and classify them as realistic
or attainable and unrealistic
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28. PERIOD OF EDENTULOUSNESS
 This data gives information about the amount and
pattern of bone resorption. The cause for the tooth
loss should be enquired (caries, periodontitis, etc.)
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29. PRE-TREATMENT RECORDS
 The pre-treatment record is a very valuable
information. Pre-treatment records include
information about the previous denture, current
denture, pre-extraction records and diagnostic
casts.
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30. PREVIOUS DENTURE
 It denotes the dentures, which were worn before
the current denture. The reason for the failure of the
prosthesis should be enquired with the patient. The
patients who keep changing dentures in a short
period of time are difficult to satisfy and are risky to
deal with
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FACULTY
OF
DENTISTRY
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MEDICAL
UNIVERSITY
)

31. CURRENT DENTURE
 The existing denture, which is worn by the patient
at present, should be examined thoroughly. The
reason for wanting a replacement should be
evaluated. This denture gives us information about
the denture experience, denture care, dental
knowledge and parafunctional habits of the patient.
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32. THE FOLLOWING FACTORS SHOULD BE NOTED
ON THE EXISTING PROSTHESIS:
 The period for which the patient has been wearing
the denture should be determined. The amount of
ridge resorption should be assessed to determine
the amount of expected ridge resorption after
placement of the new prosthesis.
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)

33. CENTRIC OCCLUSION
 Anterior and posterior teeth shade, mould and
material.
 • Centric occlusion and also the patient profile in
centric relation. (Centric occlusion is “the centered
contact position of the occlusal surfaces of the
mandibular teeth against the occlusal surfaces of
the maxillary teeth”-GPT). It should be marked as
acceptable or unacceptable.
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34.  Vertical dimension at occlusion. It should be
marked as acceptable or unacceptable.
 Plane of orientation of the occlusal plane.
Improperly-oriented plane will have teeth arranged
in a reverse smile line
 • The tissue surface and the polished or cameo
surface of the palate should be examined.
 • The patient’s speech pattern should be noted for
any valving nasal twang.
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35. 35
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36.  The posterior extension of the maxillary denture
should be noted.
 The midline of the denture should be checked.
 The amount of space in the buccal vestibule should
be examined. It should be marked as acceptable or
unacceptable.
 Presence of cross-bite should be checked.
 Patient’s comfort should be enquired.
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FACULTY
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UNIVERSITY
)

37.  The denture maintenance should be evaluated. It
can be classified as:
 1. Good
 2. Fair
 3. Poor
37
FACULTY
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UNIVERSITY
)

38.  Wear or breakage. This may be an indication of
bruxism. Denture wear can be classified as:
1. Minimal
2. Moderate
3. Severe
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FACULTY
OF
DENTISTRY
(ADAL
MEDICAL
UNIVERSITY
)

39. FACIAL EXAMINATION
 It includes the evaluation of facial features, facial form, facial
profile and lower facial height. Facial Features The following
features on the face should be noted during diagnosis of the
patient:
 Perioral features:
• Length of the lips.
• Lip fullness
• Apparent support of the lips.
• Philtrum.
• Nasolabial fold.
• Mentolabial sulcus or labiomental groove.
• Labial commissures and modiolus.
• Width of the vermillion border It influences the degree of tooth
display.
• Size of the oral opening. It also influences the degree of tooth
display.
• Texture of the skin: (rough or smooth and light colour)
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40. PHILTRUM
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41. NASOLABIAL FOLD
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42. MENTOLABIAL SULCUS OR LABIOMENTAL
GROOVE
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43. LABIAL COMMISSURES AND MODIOLUS.
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44. ORAL OPENING
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45. FACIAL FORM
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46. FACIAL PROFILE
 Facial profile Examination of the facial profile is
very important because it determines the jaw
relation and occlusion. Angle classified facial profile
as:
 Class I: Normal or straight profile
 Class II: Retrognathic profile
 Class III: Prognathic profile
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47. 47
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48. LOWER FACIAL HIGHT
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49. INTRAORAL EXAMINATION
 Check for
 Existing Teeth
 Mucosa
---Colour of the mucosa
--- Condition of the mucosa
1. Class I: Healthy mucosa.
2. Class II: Irritated mucosa.
3. Class III: Pathologic mucosa.
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50. CLASS I: HEALTHY MUCOSA.
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51. IRRITATED MUCOSA
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52. PATHOLOGIC MUCOSA.
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Fronto-lateral, hypertrophied, Hyper Keratinized Flabby Ridge

53. FRENUM ATTACHMENT
53
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54. EXISTING TEETH
 The condition of the existing teeth is of importance
for single complete dentures the state of the
remaining teeth influence the success of tooth
supported over dentures. The diagnosis and
treatment planning for a over denture will be
discussed in detail in upcoming lectures.
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55. RESIDUAL ALVEOLAR RIDGE
 While examining the residual alveolar ridge the arch
size, shape, inter-arch space, ridge contour, ridge
relation and ridge parallelism should be noted.
 Denture bearing area increases with arch size and
in turn increases the retention. • Discrepancy
between the mandibular and maxillary arch sizes
can lead to difficulties in artificial teeth-arrangement
and decrease the stability of the denture resting in
the smaller one of the two arches.
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56. ARCH SIZE CAN BE CLASSIFIED AS FOLLOWS:
 Large
Ideal retention and stability
 Medium
Good retention and stability
 Small
Difficult to achieve good retention and stability
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57. SHAPE OF ARCH
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58. RIDGE CONTOUR
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Ridges should be both inspected and
palpated. The ridge should be palpated for
bony spicules which produce pain on
palpation. Ridges can be classified as
based on their contour as: •
High ridge with flat crest and parallel sides
(most ideal) (Fig. 2.23). •
Flat ridge (Fig. 2.24). •
Knife-edged ridge (Fig. 2.25

59. CLASSIFICATION OF MAXILLARY RIDGE CONTOUR:
 There is another classification for ridge contour.
According to that classification, the maxillary and
mandibular ridges are classified separately.
Classification of maxillary ridge contour:
 Class I: Square to gently rounded.
 Class II: Tapering or ‘V’ shaped.
 Class III: Flat.
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60. CLASSIFICATION OF MANDIBULAR RIDGE
CONTOUR:
 Class I: Inverted ‘U’ shaped (parallel walls, medium
to tall ridge with broad ridge crest (fig. 2.26)
 Class II: Inverted ‘U’ shaped (short with flat crest)
(Fig. 2.27). Class
 III: Unfavourable • Inverted ‘W’ (Fig. 2.28)
 Short inverted ‘V’ (Fig. 2.29).
 Tall, thin inverted ‘V’ (Fig. 2.30).
 Undercut (results due to labioversion or
linguoversion of the teeth (Fig. 2.31).
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61. 61
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62. RIDGE RELATION
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63. RIDGE PARALLELISM
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Ridge parallelism can be classified as:
Class I: Both ridges are parallel to the occlusal
plane (Fig. 2.35).
Class II: The mandibular ridge diverts from the
occlusal plane anteriorly (Fig. 2.36)
Class III: Either the maxillary ridge diverts from the occlusal plane
anteriorly or both ridges divert from the occlusal plane anteriorly (Fig.
2.37).

64. INTER-ARCH SPACE
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Class I: Ideal inter-arch space to accommodate
the artificial teeth (Fig. 2.38).
Class II: Excessive inter-arch space (Fig. 2.39).
Class III: Insufficient inter-arch space to accommodate the artificial
teeth (Fig. 2.40)

65. SAHPE OF PALATE
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• U-shaped: Ideal for both retention and stability (Fig. 2.41).
• V-shaped: Retention is less, as the peripheral seal is easily
broken (Fig. 2.42).
• Flat: Reduced resistance to lateral and rotatory forces (Fig.
2.43).

66. HOUSE’S CLASSIFICATION OF TONGUE SIZE
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Class I: Normal in size, development an function. Sufficient teeth are present
to maintai this normal form and function (Fig. 2.63).
Class II: Teeth have been absent long enough to permit a change in the form
and function o the tongue (Fig. 2.64).
Class III: Excessively large tongue. All teeth have been absent for a extended
period of time allowing for abnormal development of the size of the tongue.
Insufficient denture can sometime lead to the development o class— 3 tongue
(Fig 2.65)

67. CONSIDERATIONS DURING RADIOGRAPHIC
EXAMINATION
 The jaws should be screened for retained root
fragments, unerupted teeth, rarefaction,
sclerosis, cysts, tumours and TMJ disorders.
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68. RADIOGRAPHIC ASSESSMENT OF BONE
RESORPTION
 Class I: (mild resorption) loss of upto one-third of
the vertical height.
 Class II: (moderate resorption) loss of upto two-
thirds of the vertical height.
 Class III: (severe resorption) loss of more than two-
thirds of the vertical height
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69. RADIOGRAPHIC ASSESSMENT OF BONE
QUANTITY AND QUALITY
 Branemark et al classified bone quantity radio
graphically as Classes A,B,C,D and E (Fig. 2.70).
 He classified bone quality radio graphically as
Classes 1,2,3 and 4 (Fig. 2.71)
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70. ADJUNCTIVE CARE
 Elimination of Infection
 Elimination of Pathology
 Preprosthetic Surgery
 Tissue Conditioning
 Nutritional Counseling.
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71. 71
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