DIAGNOSIS AND TREATMENT PLANNING OF

COMPLETELY EDENTULOUS PATIENT

CONTENTS

Introduction

Demographic data of the patient

Chief complaint

Past medical history

Past dental history/ denture history

Extra oral examination

Intra oral examination

Investigations

Conclusion

Bibliography
Introduction

The complete denture more then any other dental treatment depends for its success not

only on the oral cavity of the patient but also on his /her general health and attitudes. A

complete denture health service involves treating the patient and not just the oral cavity.

Hence forth, the physical and psychological status of the patient along with oral health

should be thoroughly assessed.

Examination (def): - Examination is the suctioning or investigation for the purpose of

making a diagnosis or assessment.

Diagnosis (def): -

It is the act or process of deciding the nature of a disease by examination.

---By Heartwell

It is the determination of the nature the disease

---By glossary of prosthodontics

GENERAL (DEMOGRAPHIC) INFORMATION ABOUT THE PATIENT

Name: addressing the patient by name makes the patient feel the treatment more

personalized, enhancing the patient cooperation. It also helps to maintain proper record.

Age: Age has a baring on complete denture patient more then any other field of

dentistry. The approach to ascertain the age of the patient must be proceeded by certain
polite questions like asking the patient when he was born rather then directly asking the

age. The following changes can be expected out of ageing.

1.C.N.S: progressive atrophy of the elements of cerebral cortex leads to decreased

readiness to form habits and decrease in muscular efficiency.

2. Skin & mucosa: loss of elasticity causes easy injury due to manipulation during

impression making and jaw relations. Tendency to hyperkeratosis causes dryness and

atrophy of mucosa

3. Salivary glands: decrease in secretion causes absolute or relative xerostomia leading

to abnormal taste sensation and stomodynia, reduced retention & increased functional

trauma to mucosa

4. Dietary insufficiency: leads to angular chelosis, atrophic glossities, delayed wound

healing e. t. c.

5. Body image changes: senile dementia and character deficiencies associated with old

age are roadblocks to complete denture treatment.

Sex: Women during menopause exhibit difficult situations like dry mouth, burning

sensation, vague pain, psychological disorders intolerance, anemia and osteoporosis.

Sex of the patient plays a significant role in selection of teeth.

 Occupation:

1. Public speakers, singers, and lecturers require not only perfect retention but also particular

attention to the palatal shape and thickness because of its importance in phonation

2. Executives who are subjected to many situations of anxiety many exhibit bruxisum, which

require proper selection of teeth and distribution of occlusal load.

3. Wind instrument players often a spatial modification of shape and position of anterior teeth

and extra retention aids like spring retained dentures.

4. Mine workers who are exposed to dust may show abnormal wear of the teeth surface &so

require wear resistant materials like porcelain teeth.

CHIEF COMPLAINT:

It is obtained by asking the patient to describe the problem for which help is sought or reason

for seeking the treatment. It should be recorded in patient’s own words as much as possible.

Patient with no denture experience can complain about

 In ability to chew

 Impaired speech

 Poor appearance

Patient with denture experience can complain about

1) Comfort 2) inability to chew 3) inability to speech 4) loose ness 5) gagging 6) biting the

check or tongue 7) food under the denture 8) clicking of teeth 9) inability to keep the denture

clean
Once this is known the dentist will know, which part of the procedure will be most critical and

to overcome thus how to adjust the time schedule.

DENTAL HISTORY:

a) Reason for the loss of teeth:

Periodontal: this implies the reduced potential ridge structure available for denture suppor

Caries: Optimal bone support may be expected if caries did not cause complications like

alveolar abscess.

Congenital: Bone support may be impaired badly in ectodermal dysplasia and osteogenesis

imperfecta

Trauma: It may cause complications in prosthetics because of a)Bone loses b) scar tissue c)

irregular ridges or shortened ridges d) Traumatic neuroma. E.t.c.

Surgical intervention: It may cause significant loss of bone and adjacent structure

b) Duration of edentulism & sequence of lose of teeth:

 Patients whose mandibular anterior teeth were retained for a significant period of

time after the loss of posterior teeth, may often present with ridge configuration at two

levels of vertical height after ultimate removal of the remaining teeth.

 If mandibular anterior teeth have supported a removable partial denture worn

against a maxillary single complete denture, one can see greater of maxillary ridge relative

to the posterior quadrant. This is called ‘combination syndrome’ this is due to unfavorable

distribution of functional stresses and change in support to the prosthesis.

 If the teeth on one side of the mouth are extracted, the patient has to chew to the

side to which teeth are present. This may lead to jaw deviation towards the extracted side.

Jaw physiotherapy should be given before the jaw relations are taken in order to get an

accurate recording.

 If all the posteriors were extracted some years before the anterior and no partial

denture was given in the mean time, then a habit of eating with the anterior would have

been formed. If persisted it will have pronounced unstabilizing effect on the complete

denture. Similar condition will exist for total edentulisum for an extended period of time.

 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. Patients displaying consistent patterns of remarks should be

educated regarding the realities of denture service. A patient with a history of several

dentures over a short period of time is a poor prosthodontic risk.

 Existing or Current Dentures: The patient should be questioned about the length of

time he or she has worn the current dentures. Responses should be compared with clinical

observations. Careful observation may provide valuable information about denture

experience, denture care, dental knowledge, parafunctional habits, etc.

 Denture Success: The patient should be asked about the esthetics and function of

existing maxillary and mandibular dentures. Responses may indicate the patient's ability to

wear or adjust to complete dentures. Denture success for each arch should be rated

"favorable" or "unfavorable."
Medical history & systemic examination

There are three techniques for obtaining health history.

1. Direct interrogation by the dentist

2. A comprehensive questionnaire

3. A combination of both of the above

Direct interrogation by the dentist: This technique offers the dentist the greatest latitude .The

questions can be brief and general in nature or they can be probing and overlapping on the

points the dentist seems important

Advantages:

 The questionnaire can be very revealing.

 It offers the dentist an opportunity to develop a rapport with the patient and

evaluate the patient’s attitude towards previous medical & dental history.

Disadvantages:

 Very time consuming in comparison to the comprehensive questionnaire

 It also relies heavily on the skill and experience of the dentist in order to be effective

and easy to forget necessary questions

Questionnaire approach :

Advantages: It is easy, quick and can be filled by the patient in the waiting room

Disadvantages: There are some inherent dangers in this type of health history

 Many patient don’t read this form carefully and view them as a nuisance and try to fill it

as quickly as possible
  Important information can be skipped out

 Some patients may not be able to read the small print, which is common to these

forms.

 They may not understand some of the questions and may simply give the

forms to their companions to complete them

Combination:

Questions that are more general and more easily understood can be asked in the questionnaire

and then verbally reviewed by the dentist in detail about any positive response or any thing in

doubt

The past medical history includes information about any significant or serious illness a patient

may have had as a child or adult, and usually characterized into following subdivisions

Neurologic disorders:

Bells palsy and Parkinson disease are indicative of neurologic involvement. Patients with these

diseases can be treated, but it is essential that they understand their problems. Such patients

have inability to control lip or facial structures, which affects speech and mastication. Denture

retention, maxillo-mandibular relation records, and supporting the musculature are some of the

added denture problems.

Cardiovascular diseases:

Consultation with the patient’s cardiologist is indicated for a patient with a cardiovascular

disease. Denture procedures of any nature may be contraindicated. Stress during treatment

may precipitate anginal attack or myocardial infarction. If a patient gets an attack of angina in
dental chair, nitroglycerine tablets must be placed sublingually. Short appointments with

premedication may be required in such conditions. Anti-anxiety and anti-stress tablets can also

be given to the patient before the dental procedure.

Endocrine system:

Diabetes mellitus: Due to lowered systemic resistance the patients with diabetic mellitus are

subjected to a broad range of bacterial infection. These patients have reduced tissue tolerance

and heating potential and are prone to injury. Bone response to prosthetic stress is poor and

requires a pressure free impression technique. 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.

Hyper parathyroidism: Increased secretion by parathyroid glands mobilizes excess calcium from

the bones resulting in increases serum levels of calcium and alkaline phosphatase. In such cases

radiographic examination is important because edentulous jaws also reflect the characteristic

decalcification that produce a loss of bony contrast and morphologic detail

roentgenographically.

Blood:

Anemia: Oral manifestations of anemia include glossitis, apthous ulcerations often

accompanied by smooth but fissured surface caused by papillary atrophy. It decreases the tissue

tolerance. The painful burning sensation prevents the use of denture prosthesis.

So the underlying cause for anemia must be determined and prosthetic treatment will have to

wait till the recovery phase.

]Other blood diseases like leucopoenia and leukemia presents with oral manifestations like

xerostomia, bone lesions, necrosis, and ulcerations. The hosts are more susceptible to injury

and reduce healing potential. Thus any preprosthetic surgical procedures are contra indicated in

such patients. (Principles of internal medicine vol1-15`Th edn)

skeletal:

Osteoporosis: Osteoporosis results from the loss of bone, especially the spongy spicule of bone,

which support the weight bearing parts of the skeleton. Osteoporosis is common in the ageing

person. Especially in the post menopausal women in whom the estrogenic blood level has

dropped precipitously. In elderly men and women, osteoporosis is caused by a variety of factors.

They are:

1) Lack of calcium intake

2) Lack of calcium absorption

3) Lactase deficiency

4) Low estrogen.

Osteoporotic bone does not with stand functional stress and may be subjected to rapid

resorption and fracture. Frequent recall appointments for such patients is mandatory for better

adaptation of denture base and occlusal correction.

Paget’s disease: It is a condition of order individuals in which there is an imbalance between the

normal process of bone deposition and resorption. As a result there is overall growth and

distortion of the bone.

Muco cutanious lesions:

In addition to mucocutanious discomfort , the use of corticosteroids in immunologically

mediated disorders causes adverse effects like excessive resorption of bone e.t.c . phemphigus

in addition to has a negative bone factor in it self .

Scleroderma causes limitations in mouth opening . Soft palate and tongue can be affected and

can cause dysphagia. Faster resorption is also seen.

Infectious diseases:

Herpes simplex: It might be single or multiple lesions occurring continuously at the lips and

skins around the mouth. The symptoms are mainly pain, fever, malaise, and regional

lymphadenopathy.

The patients with such conditions are advised to remove the prosthesis during the

infected phase and any other prosthodontic treatment must be delayed until the acute phase.

Herpes zoster: Herpes Zoster (shingles) and varicella (chicken pox) are caused by the same virus.

These are characterized by groups of vesicles or crusted lesions along the nerve involved

especially 5`th & 7`th cranial nerve. Severe lancinating pain is common but not invariable. The

affected patients have difficulty to use the denture because of severe pain. Any prosthodontic

treatment has to be delayed until the situation subsides.

Sub-acute bacterial endocarditis:

Any patient with cardiovascular complications must be treated cautiously. Stress for such type

of patients must be avoided. Patients with prosthetic valve, fibrillation, rheumatic fever, septal

defect etc should be premedicated especially during preprosthetic procedure. Manipulation in

the oral cavity can result in the introduction of bacterial stain into the blood stream that can

cause bacteremia and infection of the heart valves.

Tuberculosis:

Oral manifestations of TB are not common but can get involved secondarily to primary lesions in

other parts of the body. If bone is involved there will be sinus formation and sequestration,

which leads to pathologic factor. Calcifications of lymph nodes are also common. The dentist

must be careful to prevent contact of the infection.

Oral thrush:

Candida albicans is the causative organism. It produces greyish white elevated patch consisting

of fungus myecilia. They grow under old dentures and can cause destructive abscess and sinus

tracts.

Neoplasm:

The importance of neoplasm is surpassed by the frequent occurrence of premalignant condition

such as leukoplakia. Tissues chronically abused by poorly maintained natural or artificial

dentition, alcohol, and tobacco predispose the oral tissue to malignancy. Any oral ulcers are

allowed to heal and if suspected of neoplasm, send for biopsy.

Medications

Most frequently prescribed medications for elderly

1) Diuretics
Furosemide, Triamterene – Dry mouth, increased thirst, and lichenoid

drug reactions.
2) Cardiac vasodilators
Enalapil, lisinopril – Taste changes, oral ulceration, dry mouth,

angioedema, lichenoid drug sell, gingival

bleeding
3) Calcium channel blockers – Gingival hyperplasia, dry mouth, facial

-Nifedepine edema, erythema multiforme

4) Antianginals – Dry mouth, glossitis taste changes

- Nitroglycerine
5) Beta blockers – Dry mouth, lichenoid drug

- Propranalol, metaprolol
6) Cardiac glycosides – Dry mouth, lichenoid drug

- Digoxin
7) Anticoagulant/antiplatelet – Gingival bleeding, soft tissue complex,

-warfarin stomatitis, salivary gland pain

8) NSAIDS
Ibuprofen – Dry mouth ulceration, stomatitis
9) Gastro intestinals
Ranitidine, cimetidine – Erythema multiforme
10) CNS agents,
Diazepam, alprazolam – Dry mouth ulceration
11) Nitrogen conjugated – Exacerbates gingivitis, bleeding

History of Allergies:

History of any allergic disorders such as urticaria hay fever, eczema, as well as any untoward

reactions to medications [including local anesthetic agents and acrylic plastic] the reactions

should be differentiated from psychological reactions.

Nutritional status:

A normal person is well nourished as regard proteins, fats, vitamins, and minerals. Certain

clinical signs help to diagnose deficiencies one or more of these nutrients.

Proteins: Hypoproteinemia causes rough skin and later edema of feet and brittle hair.

Fats: fat malnutrition leads to cachexia with hallowing of cheeks, loss of shape of hips [due

to loss of fat] flat abdomen and absent fat over the subcutaneous tissue of the elbows.

Carbohydrates: Carbohydrate malnutrition is difficult to diagnose clinically because there is

gluconeogenesis from fats and proteins.

Minerals: deficiency of two minerals can be diagnosed clinically. Iron deficiency causes

koilonychias and pallor where as calcium deficiency causes tetany.

An ideal nutrition for elderly person in good health does not differ significantly from a

normal young individual. In patients with predominant non-vegetarian diet, chewing is in a

puncturing action. The diet being fleshy, it is torn and ripped by sharp incisors and then the

bolus is chewed by steep cusped posteriors.

A patient with strictly vegetarian diet, mastication is primarily maceration, grinding and

commutating to small pieces. For this type of mastication, flat crushing type posteriors

teeth incorporated with sharp irregular ridges on the surface are needed. The jaw action

primarily required is extensive lateral grinding.

No one type of teeth is best suited for all the variables encountered in the complete

denture
PATIENTS MENTAL ATTITUDE:

Classify the patient according to House:

- Philosophic: Those patients are easygoing, congenial, mentally well-adjusted,

cooperative, and confident in the dentist. Prognosis is excellent.

- Exacting: These patients are precise, above average in intelligence, immaculate in dress

and appearance, often dissatisfied with past treatment, doubt the ability of the

practitioner to satisfy him or her, and often want written guarantees or remakes at no

additional charge. Once satisfied, an exacting patient may become the practitioner's

greatest supporter.

- Hysterical: These patients submit to treatment as a last resort, have a negative attitude,

are often in poor health, are poorly adjusted, often appear "exacting" but with

unfounded complaints, have failed at past attempts to wear dentures, and have

unrealistic expectations (hysterical patients often demand esthetics and function equal to

or greater than natural teeth). Prognosis is poor.

- Indifferent: These patients are not concerned with appearance, often go without

dentures for years (or wear poor or worn-out dentures far beyond serviceability), do not

persevere, and do not adapt well. Such patients have no desire to wear dentures and do

not value the efforts or skills of the dentist.

HABITS:

“Old habits die-hard” It is never too easy to alter the habits of a patient

especially if the patients are old. The patient may have un healthy habits like pan chewing,
 smoking nail biting, teeth clenching e.t.c .in all the above cases the patient is educated

about the adverse effects of such habits. The patient is instructed for additional

maintenance and frequent fallow up visits. In case of bruxo-mania, porcelain teeth should

be avoided.

GENERAL PHYSICAL EXAMINATION

Built: Built is the skeletal structure in relation to age and sex of the individual as to a normal

person.

Aesthenic- (thin physique) They possess narrow dental arches

Pletoric - (obese) = they possess large square dental arches

Athletic - (normal built) = they have normal sized arches

EXTRA ORAL EXAMINATION

The patient position for extra oral examination is up right and head positioned so that

the eyes are directed straight ahead. A nearly supine position with feet elevated should be

avoided for examination because it distorts the perspective when examining the facial and

neck tissue, facial expression, mandibular posture, occlusal plane orientation, horizontal

and vertical symmetry.

Facial symmetry:
 It has to be checked both from frontal and profile view.

Frontal view: from the front the face should be examined for bilateral symmetry, size

and proportion. A small degree of asymmetry exists essentially in all the individuals

Profile symmetry: Establish whether the jaws are positioned proportionately in the

Anteroposterior plane by placing the patient still and asking him to look at a distant point

.The inter canthel distance is about equal to the ala nasal basal width. The mouth is as wide

as the distance from the right to left medial limbus.

Facial form:

Classify according to House and Loop, Frush and Fisher and Williams:

Square Tapering Square- Tapering Ovoid

Facial profile:

The patient should be up right and comfortable one with the head supported by the spine,

wet the lips, place the lips into light contact and relax. It is determined by an imaginary line

joining the forehead, nasion, and menton. Classify according to Angle:

 Class 1 Class 2 Class 3

Normal Retrognathic Prognathic

Facial skin color:

It is important in the selection of the shade of the anterior teeth.

Muscle development :

Classify according to House:

Class 1: Heavy

Class 2: Medium

Class 3: Light

Facial muscle tone:

it can be classified in to 3 classes according to House

 In Class 1, the tissues are normal in tone and’ function. There are sufficient teeth in

the mouth, and they are properly distributed to retain the normal position of the

mandible to the maxillae and to furnish normal tension, tone, and placement to the

muscles of power, expression, and deglutition. Degenerative changes have not yet

occurred. Except in instances of immediate restorations, edentulous patients do not

have a Class 1 musculature. The majority of denture patients have experienced

degenerative changes in varying degrees.

 In Class 2, the tissues are slightly impaired in tone, and approximately normal

functions have been preserved by the wearing of efficient dentures. “Approximately

normal function” is a good description because there never can be ideal muscle

tone with dentures. With the most efficient service, the pressure exerted in

mastication with dentures will be considerably less than that of a normal dentition.

The maximum muscular function can never be utilized once the natural teeth have

been lost.

 In Class 3, the tissues are greatly impaired in tone and function. It presents a

subnormal condition as a result of ill health or health decline, loss of natural teeth,

or the wearing of inefficient dentures. Frequently with this condition, there is an

overclosure or shortening of facial dimensions. With overclosure, wrinkles in the

face and a droopy mouth develop. Due to overclosure, the body of the mandible

will move forward completely out of its normal range. With every degree of vertical

closure, there is a proportionate degree of protrusion of the body of the mandible.

Overclosure decreases the possibility of maximum power and function in

 mastication, due to lack of normal correct centric and vertical relations of the

mandible to the maxillae, and further impairs the tissue tone of the face and

muscles. With the most efficient service possible, a Class 3 condition requires

varying degrees of time in which to redevelop tone and power in the muscles and

tissue. The time required will depend upon the patient’s age, general health

condition, nervous emotions, and the length of time over which degenerative

changes occurred. It is essential that the patient be informed of the time required

for correction and redevelopment.

Neuromuscular coordination:

Patients with good neuromuscular coordination can be expected to learn to manipulate

dentures relatively quickly and likewise adapt readily to new dentures. Patients with poor

coordination or a neurologic deficit (such as from a stroke) may never adapt to a denture

completely. Classify neuromuscular coordination as follows:

Class 1: Excellent

Class 2: Fair

Class 3: Poor

Lips:
These should be examined first with the mandible in postural position. Normally the lips are

in light contact; if they are separated this may be due to mouth breathing due to nasal

obstruction or it may be the normal posture of the lips.

Incompetent lips are those unable to produce a labial seal with the mandible in

postural position with out a conscious contraction of the circum oral musculature. There

may be incompetence because of shortness of the upper lip or obtuseness of the mandible,

or both. Incompetence of the lip may continue into the edentulous state and therefore

must be noted, as the lip relation is one of the aids at the stage of occlusal relation.

A rolled in vermilion border is evidence of inadequate lip support and historically

characterized denture wearing. If the problem appears to be anterior teeth set too far

lingual, the lack of support can be tested by adding wax to the labial surface. If the addition

of wax improves the support of the lip, plan can be made to bring the new denture teeth

forward and thus provide necessary support to the lip and remove the wrinkles.

The lips must be palpated and their relative thickness, tonicity and mobility noted,

bearing in mind the relation between these factors and the stability of the denture. A finger

inserted behind the lips enables their resistance to forward movement to be assessed .The

length of the lip can be assessed by placing the fore finger on the incisive papilla and

measuring the lip length on the finger when the lips are in rest position.

 Tight and short lips make impression making difficult. It also causes Problems as patient

reveals the entire maxillary ridge while smiling or speaking.

 Thin lips may effect facial expression significantly with slightest deviation of teeth

anteroposteriorly .
  Tense taught lips may be found in highly nervous individuals, or in naturally constricted

orifice and in presence of scar tissue around the lip

Arnett and Bergman:

Length of lip:

Long

Normal

Short

Thickness of lip

Thin-

Thick-

This may be measured horizontally from a point on the anterior aspect of the maxillary alveolar

process, to the anterior surface of the upper lip.

Lip Contour:

It is classified

1.adequately supported

2. unsupported.

Lip mobility:

Class 1 : normal

Class 2:reduced mobility

Class 3 paralysis

Philtrum:
It is a diamond shaped depression, which is normally seen in the center of the upper lip and

below the base of the nose. If it is flattened it indicates poor support of the upper lip or

excessive support.

Nasolabial groove: It extends lateral and downward from the side of the nose. It becomes more

pronounced with age and also with loss of occlusal face height and horizontal support from the

teeth. The patient’s initial complaint may concern this accentuation of nasolabial groove. It is

not easy to eliminate these folds by prosthesis and the dentist should be guarded in his

comments on any possible improvement in appearance. New dentures will not correct wrinkles

caused by the age and health of the patient. They also will not correct the wrinkles in other

parts of the face. However if the wrinkling is only present around the modiolus of the mouth

and the vermilion border of the lip is week, turned in, and not very visible, then improvement

can be expected in the new denture.

Labiomental angle:

It runs between the lower lip and the chin and gives the indication of the jaw relationship. The

sulcus has an obtuse angle in class I and class II div 1. It is acute in class II div 2. Hardly any

sulcus is seen in class III. When over closure in present the sulcus is deepened and the angle is

made less, while an opposite effect is achieved with too great an occlusal height.

T.M.J. & Mandiblar movements:

Good prosthodontic treatment bears a direct relation to the temporomandibular articulation

since occlusion is one of the most important part of the treatment of complete dentures. The

TMJ affects the dentures which further affect the health and function of the joints.

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:

Exert slight pressure on the condyloid process with the index fingers, palpate both

Sides simultaneously. Register any tenderness to palpation of the joint and any irregularities in

condyloid movement during opening and closing maneuvers. The coordination of action

between the left and right condylar heads should be assessd at the same time.

Posterior palpation:

Position the little fingers in the external auditory meatus and palpate 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 and closing movements, protrusive, retrusive and lateral excursions are examined as

part of the functional analysis. The amount and direction of these actions are recorded during

the clinical examination. Deviations in speed can only be registered with the electronic devices

Kineograph. The first sign of initial temporomandibular joint problem include deviation of the
mandibular opening and closing paths in the sagittal and frontal planes. The characteristic

movement deviations include incongruence of the opening and closing and uncoordinated

zigzag movements.

A bilateral balanced occlusion is more important for those patients who can easily perform all

eccentric movements but the same may not be as important for those who can perform only

the hinge movement.

INTRA ORAL EXAMINATION:

Visual and digital examination has to be carried out.

Inter ridge distance:

Entry to the oral cavity is made by asking the patient to count aloud from 60 to 70, to repeat

various sibilant sounds or to pronounce words that encourage the highest speaking level of the

mandible. In this manner the interoocclusal distance during function is evaluated.

Classified into three classes

 Class I: Enough inter arch distance to accommodate the dentures (1.5cm to 2 cm)

 Class II : Excessive space. Dentures are usually less stable

 ClassIII: limited space. Difficulty in placing teeth.

An excessive amount of space due to resorption will result in poor stability and retention

because of the increased leverage.

A small amount of interridge distance will lead to difficulty in setting teeth and maintaining a

proper freeway space. However, this condition greatly enhances the stability of the dentures
because the occlusal surfaces of the teeth are close to the ridge minimizing leverage, tilt and

tongue forces.

Ridge relations :

Smith described ridge relationship as anteroposterior position of the mandibular residual ridge

relative to the maxillary residual ridge when the jaws are in centric relation and separated by

the distance they will be separated by the prosthesis. These relationships in the edentulous

patients may be categorized as follows.

Normal (Angle1): anterior segment of the mandibular ridge is directly below or slightly

posterior to the maxillary anterior ridge segment.

Orthognathic (angle class II): anterior segment of the mandibular ridge is retruded beyond the

normal position as it relates to the maxillary anterior ridge segment.

Prognathic (Angle class III): anterior segment of the mandibular ridge is protruded beyond the

normal position as it relates to the maxillary anterior ridge segment.

Cross bite A: Anterior ridge relation is normal, but posterior ridge relation is prognathic.

Cross bite B: Posterior ridge relation is normal, but anterior ridge relation is prognathic.

According to House:

Variance of arch form and arch size in the same mouth, changes due to resorption or surgery,

and varying degrees of closure alter the ridge relations. A long development of the maxillary

arch with a short development of the lower arch will cause a retrusive relationship of the

mandible to the maxillae. Other variances in the ridge relations may cause a unilateral or
bilateral “cross-bite” relation in the posterior segments of the arch and, less frequently, a “cross-

bite” in the anteriors.

Due to the development of the arch form and ridge relations, there are four possible relations

of the anterior and posterior teeth. The relations of the anterior and posterior teeth govern the

application of esthetics and occlusion, as well as the leverages and stresses applied in a

dentition or a complete denture.

The four possible relations of anterior teeth are : (1) a normal vertical overlap of the upper

anterior teeth to the lower teeth, (2) an end-to-end relation, (3) a protrusive relation of the

lower to the upper teeth with varying degrees of horizontal overlap, and (4) retrusive relation of

the lower teeth to the upper with varying degrees of horizontal overlap.

The four possible relations of the posterior teeth are: (1) a normal vertical overlap of the upper

teeth to the lower, (2) an end-to-end relation, (3) a unilateral “cross-bite” (one side normal and

the other crossed), and (4) a bilateral “cross-bite.”

End-to-end relations of the posterior teeth in artificial dentures are to be avoided because

cheek-biting would result.

According to Engelmeier:: Classify according to Angle:

Class 1: Normal Class 2: Retrognathic Class 3: Prognathic

Ridge parallelism:

The maxillary and mandibular ridges should be observed at the appropriate vertical dimension.

Ridges that are not parallel to each other will cause movement of the bases when the teeth

occlude because of unfavourable direction of forces.

Classify ridge parallelism as follows:

Class 1: Both ridges are parallel to the occlusal plane.

Class 2: The mandibular ridge is divergent from the occlusal plane anteriorly.

Class 3: The maxillary ridge is divergent from the occlusal pladne anteriorly or both ridges are

divergent anteriorly,

Mucosa:
Lining and enveloping the bony structure of the jaw are soft tissues with particular morphologic

and physiologic characteristics. Traditionally the oral mucosa has been classified into

masticatory, lining and specialized mucosa.

Mucosa is checked for any inflammation. The following are some conditions where

inflammation can be seen.

Prosthetic reasons: 1) over extension 2) ill fitting denture 3) continuous wearing of the denture

4) faulty occlusion 5) rubber suction disk 6) traumatic 7) small spicules of alveolar bone e.t.c

Common oral conditions: 1) Apthus ulcers 2) vesiculo bullus lesions 3) pre cancerous and

cancerous lesions e.t.c.

Masticatory mucosa: The masticatory mucosa covers the alveolar ridge and the attached

gingival and the hard palate. Since it is exposed normally to masticatory forces, it has a

characteristic thickness, degree of keratinization, density, lamina propria firmness and

immovable attachment to underlying structures.

Palpation of the masticatory mucosa with an instrument or finger should indicate to the dentist

the degree of stability of the prosthesis that might be expected as well as the capacity of the

soft tissues for adaptation to the prosthesis.

Mucosa Thickness: Classify thickness according to House:

Class 1: Tissue can be displaced approximately 2mm , cushion like yet will not permit gross

positional displacement.

Class 2:
 (a) Tissues thinner than 2mm, usually unyielding, often atrophic with smooth surface

and poor for developing good adhesion and marginal seal.

(b)Tissues thicker than 2mm, easily displaced, poor stress bearing. Usually occurs as

flabby redundancy in regions of excessive bone resorption under ill fitting or

maloccluded prosthesis. Also may present as anteroposterior folds over resorbed

posterior ridges or fibrous ridges where bony resorption has occurred laterally.

Class 3: Excessive flabby to the degree that surgical excision is indicated.

The quality of the mucoperiosteum may vary within each arch. Tissues may be extremely thin in

one area where teeth have been missing for a long time and normal where teeth were removed

recently. Other areas may be excessively thick with localized regions of redundant tissue. When

tissue thickness varies, special problems are created. Such variations make it difficult to equalize

pressure under the denture and to avoid soreness.

Mucosa Condition: Classified according to House:

Class 1: Healthy

Class 2: Irritated

Class 3:'Pathologic

Border tissue Attachments:

Attachments should be classified according to House:

Class 1: Attachments are high in maxilla or low in mandible with relation to ridge crest (0.5

inches or more between level of attachment and crest of ridge).

Class 2: Attachment height in relation to the crest of the ridge is between 0.25 and 0.50 inches.

Class 3: Attachment height is less than 0.25 inches from the ridge crest.

Frenal attachments:

It can be classified in to three classes

 Class I: the attachments are low and close to the vestibule. most favorable kind of

attachments

 Class II: Muscle and frenal attachments are high and close to the ridge. Relief should be

given in the denture

 Class III: Very high attachments. Surgical corrections may be required

Arch Size: Classify arch size as follows:

Class 1: Large (best for retention and stability)

Class 2: Medium (good retention and stability but not ideal)

Class 3: Small (difficult to achieve good retention and stability)

- Arch Form: Classify according to House:

Class 1: Square Class 2: Tapering Class 3: Ovoid

Many arches are combinations of the aforementioned categories (e.g., square-tapering).

The form of the arch will influence the available support of the denture and perhaps the teeth

selection. If the arch forms are not same in both the arches one can anticipate some difficulty in

tooth arrangement.

Ridge Form: Maxillary ridge and vault form should be classified as follows:

Class 1: Square to gently rounded

Class 2: Tapering or "V" shaped Class'3: Flat

Mandibular Ridge Form: Mandibular ridge form is classified as follows:

Class 1: Inverted "U" shaped Class 2: Inverted "U" shaped (parallel walls

from medium to (short with flat crest)

tall with broad crest)

Class 3: Unfavorable:

Inverted "W" Short inverted "V" Tall Thin inverted "V"

Residual ridge height:

Classified into three classes

Class I: adequate height

Class II: Undergone some resorption but enough height to resist lateral shift of the denture

Class III: Almost completely resorbed . No resistance to lateral shift of the denture.

Bony undercuts:

On the maxilla, the undercuts are usually present on the anterior ridge and lateral to the

tuberosities. These usually pose no real problem to the denture insertion and the rule should

always be selective relief of the denture rather than surgical correction .The alveolar ridge
resorbs rapidly enough with out surgery. The undercuts do not aid in retention and may cause

some loss of border seal. On occasion a severe anterior undercut may exist along with bilateral

tuberosity undercuts. Once again it is judicious to relive the denture lateral to the tuberosity.

On the mandibular ridge, the only undercut that can pose a real problem is a

prominent and sharp mylohyoid. Here surgical correction and reattachment of the mylohyoid

muscle can be beneficial.

Tongue:

Use a gauze pad to aid in pulling the tongue forward and examine for any pathology especially

the lateral borders. The tongue develops lingual seal for mandiblar denture. If the tongue does

not maintain correct position a seal can’t be developed.

Normal tongue: The tongue completely fills the floor of the mouth, has a dorsal surface that is

round smooth and free of muscle contractures, and has lateral borders that rest on the incisal

edge of the lower anterior teeth or anterior edentulous ridge.

Tongue: Classify tongue according to House:

Class 1: Normal in size, development, and function. Sufficient teeth are present to maintain

normal form and function.

Class 2: Teeth have been absent long enough to permit a change in the form and function of the

tongue.
Class 3: Excessively large tongue. All teeth have been absent for an extended period of time,

allowing for abnormal development of the size of the tongue. Inefficient dentures sometimes

can lead to the development of a class 3 tongue.

Tongue Position:

Classify according to Wright:

Class I: The tongue fills the floor of the mouth and is confined by the mandibular teeth. The

lateral borders rest on the occlusal surfaces of the posterior teeth and the apex rests on the

incisal edges of the anterior teeth. There is, no aberration in tongue size or activity.

Class II: Retracted: The tongue is retracted. The floor of the mouth pulled downward is exposed

back to the molar area. The lateral borders are raised above the occlusal plane and the apex is

pulled down into the floor of the mouth.

Class III: Retracted: The tongue is very tense and pulled backward and upward. The apex is

pulled back into the body of the tongue and almost disappears. The lateral borders rest above

the mandibular occlusal plane. The floor of the mouth is raised and tense.

The class I position has the most favourable prognosis. The class II and especially class II are

unfavourable tongue positions.

Floor of the mouth :

The contents of the floor of the mouth are best palpated digitally; specifically one finger is

applied inside the mouth and two fingers of the other hand are applied extra orally . The
outside fingers prevent the displacement of the structures during plapation by the inside

fingers. The patency of the whartons duct and the production of saliva by submandibular gland

should be demonstrated by watching the expression of saliva from the duct orifices as the gland

and duct are gently squeezed.

The floor of the mouth in the sublingual gland and mylohyoid areas can be very high and

close to the ridge crest and at times may spill over the ridge and eliminate the alveololingual

sulcus altogether. If the denture flange cannot selectively place these tissues, the prognosis of

the mandibular denture is poor.

Alveo lingual sulcus:

Extends posteriorly from lingual frenum to the retromylohyoid curtain on either side. This sulcus

is available for the lingual flange of the denture. It can be divided into three parts.

1. Anterior third: Extends from the lingual frenum to the place where the mylohyoid

ridge curves down the level of sulcus (pre mylohyoid fossa )

2. Middle third: Extends from the pre mylohiod fossa to the distal end of mylohyoid

ridge

3. Posterior third: It is the retro mylohyod space. Extends from the end of mylohyoid

ridge to the mylohyoid curtain.

Lateral throat form:

Also called the retro mylohyoid curtain. This is classified into three classes according to the

extent of anterior movement of retro mylohyiod curtain with the tongue extended anteriorly
beyond the vermin border of the upper lip and the index finger passively contacting the curved

wall of the retro molar fossa.

Lateral Throat Form: Classify according to Neil:

The lateral throat form is classified according to the extent of anterior movement of the

retromylohyoid curtain as the tongue is extended anteriorly beyond the vermilion border of the

lower lip. With the index finger passively contacting the curved wall of mucosa in the retromolar

fossa with the tongue at rest, the patient is instructed to protrude the tongue.

If the lateral throat form changes configuration so as to place heavy pressure on the finger it is

known as class 3

If there is minimal or no pressure exerted it is class 1

Any position of the tissues between the extremes is class 2

Overextension in this area results in loss of border seal. Displacement of the dentures or

soreness that readily radiates to the floor of the mouth, throat and neck.

Class 1: Class 2:
 Class 3:

Palatal Throat Form: Classify according -House:

Class 1: Large and normal in form, with a relatively immovable band of resilient tissue 5 to 12

mm distal to a line drawn across the distal edge of the tuberosities.

Class I

Class 2: Medium size and normal in form, with a relatively immovable resilient band of tissue 3

to 5 mm distal to a line drawn across the distal edge of the tuberosities.

Class II
Class 3: Usually accompanies a small maxilla. The curtain of soft tissue turns down abruptly 3 to

5 mm anterior to a line drawn across the palate at the distal edge of the tuberosities.

Class III

Soft palate:

Classified into three classes

 Class I: Horizontal and extends posteriorly with minimum muscular activity. Wide

posterior palatal seal area. Most favorable configuration. This type of palate is suited for

extended palatal form

 Class III: Most acute in relation to the hard palate (70 degrees). Marked muscular

activity. Associated with ‘v’ shaped palatal vault. Narrow posterior palatal seal area.

 Class II: Lies in between the class I and class III(40degr/ees)

Gag reflex :

Palatal Sensitivity: Classify sensitivity according to House:

Class 1: Normal

Class 2: Subnormal (hyposensitive)

Class 3: Supernormal (hypersensitive)

Maxillary tuberosity :

Classified into three classes

 Class I: No undercuts present

 Class II: Small undercuts present, over which denture can be placed by changing the

path of insertion or by reliving the denture

 Class III: Prominent bilateral undercuts present. Unilateral or bilateral surgical

intervention may be required

Maxillary tori :

Classified into three classes

 Class I: Tori absent or very small

 Class II: Tori present but offers very little difficulty for adaptation. Surgical intervention is

optional

 Class III: Extensively large tori. Surgical intervention may be required

Saliva:
 The type of saliva can be examined by placing the index finger on the palatal side of the

maxillary denture, which has been just removed, (or) by wetting the flat surface of a mouth

mirror with saliva and by drawing a thin column from it. Thin serous type of saliva is more

commonly seen.

Resting saliva volume may be determined by noting the amount absorbed by two cotton

wool rolls placed in the sublingual area for two minutes. Weighing gives an accurate

assessment but the degree of wetness of the rolls on removal affords an approximation.

Normal resting salivary flow is about 1ml / min.

Classified into three classes according to engelmeier:

 Class I: Moderate flow of serous type of saliva

 Class II: Excessive flow of thin watery saliva or thick ropy saliva. Difficulty in impression

making and reduced retention can be seen

 Class III: Insufficient amount of saliva. Reduced amount of retention. Tendency to

ulceration is high.

According to House:

Class 1 is normal in quantity and quality. The cohesive and adhesive qualities of Class 1 saliva

are ideal as a sealing medium.

Class 2 is an abundance of semiviscid, ropy, saliva.

Class 3 is excessive in amount contains much mucus.

Accoidring to quality-

Based on the quality-

 • Serous Gland- thin, watery secretion rich in enzymes e.g. Parotid gland

• Mucous Gland- thick, viscous secretion for protection and lubrication. e.g. Sublingual

salivary gland

• Mixed Gland (seromucous)- both watery and viscous material.e.g. Submandibular

salivary gland

Xerostomia: It may be permanently present after irradiation of the head and neck or after

removal of one or more of the salivary glands .It can also be because of vitamin B deficiencies,

diabetes mellitus, diabetes insipidus and after menopause. A temporary xerostomia may be due

to drug therapy especially tricyclic anti depressants.

Sialorrhoea: Persistent and excessive flow of saliva may occur in parkinsonism epilepsy and in

mentally retarded patients. A temporary sialorroea may be seen in many patients during the

treatment procedure because of the presence of the foreign body in the mouth.

INVESTIGATION:

Radiographic examination:

Check for the presence of root stumps, foreign body, exostosis, cyst and any other pathosis like

osteoporosis. The vertical contour is best studied with penoromic X –ray. The horizontal contour

is best studied with occlusal view .A lateral jaw view is usually sufficient for T.M .J unless any

pathosis exists.

The interpretation of the panoramic radiograph should follow a five-step analysis as outlined by

Chomenko
1. Screen jaws for defects in structure and reactive new bone formation, bone enlargement, and

displacement of jaw parts. The screening should also include any unerupted teeth or retained

root fragments, foreign bodies, radiolucencies, radiopacities, rarefaction or sclerosis, expansion

or bulging, and any welldefined or ill-defined lesions. The TMJ can be screened, although

positive findings should correlate with the history and physical examination. If positive results

are found, the dentist should decide if the patient requires a TMJ tomographic series for

definitive diagnosis. In addition, the maxillary sinus can be checked for inflammation, cysts,

polyps, or tumors. Infection or inflammation can be correlated with the patient’s history. Cysts

or tumors are usually silent and any suspicious lesion should be followed with additional

diagnostic radiographs such as the Waters view.

2. Describe the appearance of the lesion as well as any bone changes adjoining the lesion. This

should be confined to the physical bone changes and include location, size, shape, number, and

a description of the radiographic pattern.

3. Correlate the radiographic findings with the clinical, historical, and laboratory findings.

4. Perform a differential diagnosis which includes all the diseases that could explain the findings.

5. Estimate the growth of the lesion by the appearance of jaw structures bordering the lesion.

Slow-growing lesions show sclerosis, expansion, and displacement of adjacent structures. Rapid

growth features gross bone destruction with a lack of proliferative response.

Any positive finding as well as its immediate or long-term management should be reported to

the patient. If the lesion or finding cannot be diagnosed or appears to be of a serious nature,

the patient should be referred to an oral pathologist or oral surgeon.

 The panoramic radiograph is also an aid in documenting the amount of ridge resorption.

A very useful system of classifying the amount of resorption was described by Wical and

Swoope. They found that the lower edge of the mental foramen divides the mandible into thirds

in normal dentulous panoramic radiographs. If the distance is measured from the inferior

border of the mandible to the inferior margin of the mental foramen and then multiplied by 3,

the resulting product is a reliable estimate of the original alveolar ridge crest height.

The amount of resorption can be calculated and classified as follows

class I (mild resorption) is a loss of up to one third of the original vertical height,

class II (moderate resorption) is a loss of from one third to two thirds of the vertical height, and

class III (severe resorption) is a loss of two thirds or more of vertical height.

The alveolar ridge can be classified according to the radiographic density in to three classes.

Class I: Dense bone. Provides optimum bone support for denture. The trabacula is compact and

the medullary spaces are few and the over all picture is one of opacity. The cortex is solid and

well defined.

Class II: Cancellous bone. It can give adequate support if occlusal loading is within physiological

limits. It may not withstand excessive forces. The overall picture is lighter and great contrast.

The trabaculae and medullary spaces are eventually balanced. The cortex is defined but little in

contrast.

Class III: No cortical bone. The bone is radiolucent. There is no definite cortex. The margins are

feathery thin and trabaculated. It offers poor support for the denture unless the occlusal loading

is reduced. There fallows an endless history of discomfort.

V. EXISTING DENTURES

- Anterior Tooth Shade, Mold, and Material

- Posterior Tooth Shade, Mold, and Material: Existing dentures should be evaluated to

determine physical, esthetic, and anatomic characteristics. Shade, mold, and material should be

recorded for both anterior and posterior teeth. If the mold cannot be determined, the general

shape of the teeth should be recorded (e.g., square, square-tapering, tapering, ovoid, etc.).

- Esthetics, phonetics, retention, stability, extensions, and contours: Existing esthetics,

phonetics, retention,, stability, extensions, and contours should be evaluated. These attributes

should be rated (1) good, (2) fair, and (3) poor.

- Centric Relation and Vertical Dimension of Occlusion: Centric relation and vertical dimension

of occlusion should be assessed and rated "acceptable" or "unacceptable," If unacceptable, it

should be noted whether the existing VDO is "inadequate" or "excessive."

- Occlusal Plane Orientation: The orientation of the occlusal plane should be noted. Improper

orientation as a result of tooth setting or changes in bony architecture often creates a "reverse

smile line." This condition is characterized by teeth that slope downward as one progresses

posteriorly. Consequently, the anterior teeth assume a curvature that does not follow the arc of

the lower lip.

 REVERSE SMILE LINE DESIRED SMILE LINE

- Palate: The palate of the existing maxillary denture should be examined. The denture base

material and thickness should be noted. Anatomic features should be assessed. The practitioner

should note the presence or absence of rugae on the cameo surface of the denture base.

Denture wearers may have become accustomed to a particular palatal form, and may resist

change. The practitioner should listen to speech patterns, and determine whether appropriate

"valving" is taking place. Placement of rugae or a change in thickness may affect pronunciation.

- Post dam: The posterior border of the maxillary denture should be examined. Likewise, soft

tissues in the vicinity of the "vibrating line" should be observed. The seal of the existing

maxillary denture should be evaluated clinically. Often, deficiencies in retention of the maxillary

denture may be traced to improper post-damming. The post dam should be rated "acceptable"

or "unacceptable."

- Base Adaptation: The fit of maxillary and mandibular bases should be assessed using an

appropriate disclosing medium, Adaptation should be rated "acceptable" or "unacceptable."

- Midline: Maxillary and mandibular midlines should be observed. Although discrepancies

between maxillary and mandibular midlines, may be present, it is critical that the maxillary

midline coincide with the facial midline. Discrepancies in midline placement create noticeable

facial disharmonies. The existing maxillary midline should be evaluated using intraoral (e.g.,

incisive papilla) and extraoral landmarks (e.g., nasion, filtrum, middle of the chin). The midline

should be rated "acceptable" or "unacceptable.' Deviations of the maxillary midline should be

recorded by direction and amount (e.g., maxillary midline 2 mm to the right of the facial

midline).

- Buccal Vestibule: The buccal vestibule is an important esthetic and functional component in

complete denture service. Consequently, this space should be assessed carefully. The buccal

vestibule should be judged "acceptable" or "unacceptable." Corrective actions should be

proposed.

- Crossbite: The presence of a unilateral or bilateral crossbite often presents a challenging

situation. Crossbites should be noted and their effects on tooth placement anticipated. This

information may be entered into the diagnostic record using the categories "none “, “

unilateral," or "bilateral."

- Characterization: Characterization or staining of existing denture bases should be evaluated

and recorded. Existing denture bases may be classified as "characterized" or ' 'uncharacterized."
- Comfort: The patient should be questioned regarding the comfort of maxillary and mandibular

dentures. Comfort for the respective arches should be classified as "acceptable" or

"unacceptable." Patients who experience discomfort should be questioned to determine the

nature and source of the discomfort.

- Hygiene: The patient's ability and motivation to clean the dentures should be assessed during

the clinical evaluation. The patient also should be questioned about his or her denture cleansing

regimen. These factors may affect denture-base contouring (e.g, closed interdental contours

versus open interdental contours) and tooth arrangement (e.g., presence or absence of

diastemata). Hygiene should be classified as (1) good, (2) fair, or (3) poor.

- Wear: Wear often is an indicator of parafunctional habits or an abrasive diet. The wear

process must be assessed with respect to time. With these factors in mind, wear should be

classified as (1) minimal, (2) moderate, or (3) severe.

- Attachments and Hardware: Attachments and hardware usually are limited to overdenture

situations. When working under these constraints, it is important to know the specific system in

use and the availability of components.

PRETREATMENT RECORDS

Diagnostic Casts

On occasion, ridge relationships, interridge distance, or ridge shape and form cannot be

adequately determined by clinical examination alone. It may be necessary to make preliminary

impressions and a maxillomandibular relation record to mount the casts on an articulator. The

centric relation and occlusal vertical dimension records must be relatively accurate to make a

proper assessment. The interridge distance, because it often varies, must be viewed around the

entire arch. Sufficient space may not be available for both denture bases between the

tuberosities of the maxillae and retromolar pads of the mandible.

The making of diagnostic casts and a preliminary recording is time-consuming, but may help the

dentist avoid a potential problem. An experienced operator can detect whether space is at a

premium during the oral examination. This is difficult, however, because the patient has a

tendency to change the relationship of the jaws when the lips are parted and an attempt is

made to view the available space, especially in the posterior region. It may aid the dentist to

construct an interocclusal wax stop on the anterior aspect of the ridge at the proper occlusal

vertical dimension and have the patient close on this stop while the posterior region is

examined for space.

Preextraction Records

Old diagnostic casts are invaluable aids in determining tooth size, position, and arrangement.

Old radiographs are also helpful in determining tooth size and bony changes. If the patient had a

former dentist or was referred by a dentist, a request should be made for any previous records.

Photographs showing natural teeth, no matter, how old, can also relay much information

regarding tooth size, position, and display during facial expression. The photograph can be an

extremely effective tool in achieving proper esthetics and patient satisfaction.

Diagnosis:
 Diagnosis is a process of evaluating the patient’s health, as well as the resulting opinions

formulated by the clinical

A thorough evaluation of the patients, his extra oral, and intra oral findings should be

taken care of before formulating the diagnosis.

The ideal condition:

Philosophical patients with no systemic complication with a broad square ridge devoid of

under cuts and bony abnormalities. Broad palate with uniform depth of vault in maxillary arch.

Broad buccal shelf and firm retromolar papillae in the mandibular arch. Frenum attachment

high in maxilla low in mandible. A clearly defined and well-developed lingual sulcus. Firm

mucosal covering over denture bearing area. A normally related maxilla to mandible, good

muscle tonus, and co-ordinated mandibular movement. Adequate inter ridge space for

favourable placement of teeth mixed saliva.

Any deviation from these should be noted in examination so that appropriate procedure

can be incorporated in treatment plan.

VI. TREATMENT PLANNING

- Tissue conditioning: List proposed therapy as finger massage, prescribed medications, type of

tissue treatment material to be used and frequency of soft reline changes, etc.

- Preprosthetic surgery: List any proposed preprosthetic procedures along with the staging of

these procedures.
Articulator:

- Instrument Number and Manufacturer

- Control Settings:

Horizontal condylar guidance (right and left);

lateral condylar guidance (right and left);

incisal guide anterior angle (right and left);

and incisal guide lateral angle (right and left).

-Tooth Selection: The shade, mold, and material of the maxillary anterior,

mandibular anterior, maxillary posterior, and mandibular Posterior should

be selected.

- Denture Base Material: Available materials include microwave resin, gold,

heat-cured resin, soft base, etc.

- Denture Base Shade: Base shade depends on the brand of acrylic.

- Anatomic Palate: Yes or no.

- Characterization: Establish the stains to be used; draw a "map" of the proposed stain

placement.
- List items to improve on in the new dentures, such as inadequacies of the existing dentures

(e.g., items from Section V).

- List items not to be changed in the new dentures, such as good features of the existing

dentures (e.g., items from Section V).

CONCLUSION:

The knowledge obtained by the above procedure is applied for the evaluation of two important

factors.

1. The patient education and 2. the treatment plan

The patient’s behavioral pattern during the examination serves as a yardstick to asses for the

patents education required. The operator must make use of the opportunity to familiarize and

create awareness about the importance of various procedures involved and the patient’s role in

it.
 BIBLIOGRAPHY

1. Dewey, H. Bell: Diagnosis in complete denture prothodontics. Third Ed. J.J Sharry,

Editor. New York McGraw-hill Book Company Inc 1974.

2. Friedman Sameul : diagnosis and treatment planning , Essentials of complete

denture prothodontics , Sheldon Winkler , Editor . W.B Saunders co. Philadelphia inc. 1984.

3. Heartwell, C.M.jr.: Diagnosis, syllabus of complete dentures 4 th edition. Heartwell,

C.M.Jr Editor. Lea and Febtger Philadelphia .inc 1979.

4. Judson , C.Hickey : diagnosis , and treatment planning for patients with some teeth

remaining Boucher’s Prostodontic treatment for edentulous patients . 9 th edition. Judson

C. Hickey editor, C.V. mosby co. St. Louis 1980

5. Engelmeier R.L. and Phoenix R.D. Patient evaluation and treatment planning for

complete-denture therapy. DCNA. 1996:40(1).

6. M. M. House. The relationship of oral examination to dental diagnosis. J Pros Dent

1958:8:2:208-219.

7. Laney W.R. Diagnosis and treatment in prosthodontics. 1983

Dent Clin North Am. 1996 Jan;40(1):1-18.