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J Orofac Sci, 2(3)2010

Journal of
OROFACIAL SCIENCES

Review Article
Examination, Diagnosis and Treatment Planning for Complete Denture Therapy – A Review
Sandeep Chiramanaa*, Ashok .Ka
a
Department of Prosthodontics, SIBAR Institute of Dental Sciences Guntur, Andhra Pradesh, India.

ARTICLE INFO ABSTRACT

Article History : Each patient is an individual, different in his own way from other individual
Received : 18 Oct, 2010 and each edentulous oral environment presents conditions peculiar to it alone.
Received in revised form : 5 Nov, 2010 Inorder to arrive at a proper diagnosis and plan the treatment a thorough extraoral
Accepted : 26 Nov, 2010 and intraoral examination combined with physical and psychological evalua-
tion of the patient is of utmost importance. This article is aimed towards a
Key Words : proper diagnosis and treatment plan for a successful complete denture therapy.
Personal data
Medical history
Dental history
General history
Extraoral and Intraoral examination
Radiographic examination
Diagnosis and Treatment planning ©2010 SIDS.All Rights Reserved

INTRODUCTION :
INTRODUCTION
A successful complete denture therapy begins with a
thorough assessment of the patient’s physical and
psychological condition and determining a treatment that
will deliver a functional complete denture that will satisfy
the expectations of the patient. This article will be helpful
to undergraduate students in general and post graduate
students in particular to arrive at a proper diagnosis and
treatment plan for complete edentulous patients.
Name : It is useful for establishment of patient’s identity.
Addressing by name gains patients confidence.
Age : Age influences denture success. Tissues of the older
patients are less resilient and the oralmucosa and
submucosa are thinner. Repair potential of tissues are
* Corresponding author :
Dr. Sandeep Chiramana,
Professor,
Department of Prosthodontics,
SIBAR Institute of Dental Sciences Guntur, (A.P)
e-mail : chiramanasandeep@gmail.com
altered. Frush and Fisher suggested guidelines for selection
and arrangement of anterior teeth based on age, sex and
personality5.Some age related diseases like - Congenital
cleft lip and palate, Acute rheumatic fever, Scleroderma ,
Rheumatoid arthritis,Hypertension, Diabetes,
Climacteric etc.
Sex : Generally appearance is of high priority for women
and men are more concerned with comfort and function.
Women during 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. A
more masculine appearance is achieved by a more square
or cuboidal tooth form.Some of the sex related disorders
which have significant role in complete denture therapy
are –Heamophilia, Osteomalacia, Iron deficiency anemia.
Occupation : A patient’s job and social standings often
determine the value he or she places on oral health, as
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J Orofac Sci, 2(3)2010
well as the esthetics and other qualities desired in denture.
Tooth position is very important for a musician who
plays a wind instrument. Some occupational habits like
nail biting of tailors and cobblers may cause attrition of
anterior teeth. Occupations like public speakers, teachers
and singers are more particular about the phonetics with
their new dentures.
Address : Helps in future communication, knowledge
of patient’s social status and setting up of appointments.
Chief Complaint : According to DeV an
eVan
an, “ the dentist
should meet the mind of the patient before he meets the
mouth of the patient.”3The chief complaint should be
written in patient’s own words, patient should be
questioned regarding his chief complaint.
Out P atient N
Patient umber : Helps to maintain the statistical
Number
analysis and hospital data.
Medical History : Provides important insights regarding
patient’s dental prognosis. Systemic factors that may affect
complete denture therapy include
Diabetes Mellitus : It is associated with poor wound
healing, increased bone resorption, muscle atrophy and
decreased salivation. Appointments should be short and
not interfere with meals time. Minimal pressure
impression techniques should be used ,care should be
taken in teeth selection and type of occlusion. The tissues
need functional rest so patients should be advised of less
denture wear. Frequent relining and rebasing of dentures
may be required
Nutritional D isor
Disor ders : Avitaminosis lowers the defence
isorders
mechanism of the body and mucosal structures,
Anaemias : Iron deficiency causes anaemia, atrophic
mucosa, purpura and burning sensation of mucosa
Pernicious anaemia and Iron deficiency anaemia patients
have fragile mucosa so the dentures should be as smooth
as possible.
Diseases of the joints :
Osteoarthritis : When terminal joints of fingers are
arthritic it is difficult for the patient to insert and clean
the dentures. When it affects TMJ the mouth opening
will be restricted and painful movements of the jaw
necessitates the use of special impression trays.
Scleroderma: Lips become rigid and the aperture
narrows, and presents mask like facial expression.
Restricted mandibular movements are seen. Management
includes improving the mouth opening by stretching
exercises and sectional trays for impression making.
Dentures can be designed with midline hinge, so that
they are collapsible and can be easily inserted and removed.
Car diovvascular disor
dio
Cardio ders : These conditions include
disorders
hypertension, angina pectoris, myocardial infarction,
previous cardiac bypass surgery, Congestive heart failure,
presence of cardiac pacemaker and infective endocarditis.
Proper care and treatment planning are necessary for such
patients.
Hypertension
Hypertension: Morning dental appointments were once
suggested for hypertensive patients, however recent
evidences indicate that blood pressure levels generally
increases around awakening and peaks at mid morning,
therefore afternoon dental appointments maybe
preferred2.
Pulmonary diseases :
Bronchial asthma : The asthmatic patients should be
questioned about concerned precipitating factors,
frequency and severity of attack, medications used and
response to medications
Diseases of the skin : Skin diseases like pemphigus have
oral manifestations which may vary from ulcers to bullae,
such painful conditions make the denture use impossible
without medical treatment. Constant use of prosthesis
should be discouraged for these patients.
Neur ological disor
eurological ders : Diseases like epilepsy, Bell’s
disorders
palsy, Parkinson’s disease can influence the denture
retention, jaw relation records and impression making
procedures. Use of anxiety reduction protocol and stress
levels should be minimized.
Oral malignancies and radiation therapy : High dose
radiation therapy results in hypovascularity, reduction in
wound healing capacity and stress bearing capacity of the
tissues. Saliva may become extremely viscous or non
existent depending on the dose of radiation. Xerostomia
may cause a decrease in the normal salivary cleansing
mechanisms. Sialogogues and use of denture adhesives
may have to be considered. Here posterior occlusion
should be such that there is reduced stress.
A waiting period should elapse between the end of
radiation therapy and beginning of complete denture
construction.
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J Orofac Sci, 2(3)2010
Medication : Side effects that occur due to various
medications are - Xerostomia, changes in the oral
microflora, mucosal changes, Sialorrhea, dysphagia,
postural or orthostatic hypotension, behavioural changes
or confusion etc. Should be taken care during prosthesis
fabrication.
Climacteric : Climacteric condition like menopause
can cause glandular changes, osteoporosis and psychiatric
changes in the patient. These can influence treatment
planning and the efficiency of the complete denture.
Personal H istor
istoryy : It includes oral hygiene maintenance
Histor
by the patient, habits like smoking, alcohol etc., type of
diet and nutritional status of the patient which may help
in posterior teeth selection
DENT
DENTAL AL HIST
HISTOR ORY:
ORY
Reasons for loss of teeth : The amount of bone loss
would be more for the patient with a long history of
progressive periodontal disease than for the patient with
a history of caries.
Questioning should also include the general order
of teeth loss. If all the posterior teeth were extracted prior
to the anterior teeth a habit of eating with front teeth
may lead to unstabilized effect on full dentures.
Pre extraction records : Includes pre extraction
radiographs, photographs, diagnostic casts. They can be
helpful to reproduce anterior esthetics in complete
denture fabrication.
Previous denture experience : Questions should be
directed towards the length of time she or he has worn
the current dentures, the number and types of previous
dentures, reasons for replacement .
The existing dentures should be examined for tooth
shade, mold, and material, esthetics, phonetics, retention,
stability, extensions and contours, vestibule, Centric
relation and vertical dimension of occlusion and
orientation of occlusal plane.
Characterization or staining , comfort of existing
dentures should be examined. The patient’s ability and
motivation to clean the dentures should be assessed during
clinical evaluation.
Mental Attitude : M.M.House classified patients as
Philosophical/ Exacting/ Indifferent / Hysterical patients4
Patient
atient’’s Expectations And A
Expectations ttitudes : The reason the
Attitudes
patient seeks prosthetic treatment is of critical importance.
His or her expectations must be evaluated to determine
if they are realistic and attainable. The practitioner must
be cognizant of patient’s personality classification and
should not make unrealistic promises regarding treatment
outcomes.
Examination : It includes –extra oral examination and
intra oral examination.
Extra Oral Examination :
Facial symmetr
symmetryy : Should observe for the symmetry of
the face, whether it’s bilaterally symmetrical or not
Facial form : Leon Williams claimed classified the form
of the human face in to 3 types – Square/Tapering/
Ovoid6
Facial P
Prr ofile : Angle classified facial profile into
Normognathic/Prognathic/Retrognathic
The lateral surface of the tooth viewed from the mesial
aspect should show a contour similar to that when viewed
in profile.
Complexion : Complexion helps in shade selection of
the teeth.
Lips : Restoration of the lip support and vermillion
border width must be considered during placement of
the anterior teeth.
Lips can be- Supported/unsupported
Lip thickness: Can be thick /medium/ thin in patients
with thin lips any slight change in the labio lingual
position of teeth makes an immediate change in the lip
contour
Thick lips give little more room for alteration in the
teeth position before obvious changes occur in lip contour.
Lip length : Lip length plays an important role in
esthetics. Can be classified as- Long / normal or medium
/ short
A long lip reveals very little of the anterior teeth, where
as a very short upper lip leads to display of the denture
base. Mold selection and denture characterization can be
critical factors in these cases.
Health of the lips : Angular cheilitis may occur in cases
of decreases vertical dimension. Should observe for
fissures, cracks or ulcers at the corners of the mouth.
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J Orofac Sci, 2(3)2010
Temporo mandibular joint examination :
emporo
Temporomandibular joint should be thoroughly
examined. The range of movements and the amount of
deviation must be noted.
Any pain on palpation or during mandibular
movements must be observed. Muscles of mastication
must be examined for any tenderness. Joint sounds like
crepitus, clicking or popping sounds must be investigated.
These could be encountered due to severe discrepancy
of vertical dimension of occlusion or due to loss of
posterior teeth which causes the load to shift anteriorly.
Muscle tone : The tone of the facial tissues may indicate
the limitations to improve the patient’s facial contours.
The muscle tone of the patient can be classified as
Class 1: the patient exhibits normal tension, tone and
placement of the muscles of mastication and facial
expression. No degenerative changes are apparent , usually
only immediate denture patients have normal muscle
tone.
Class 2 : the patient displays approximately normal
function but slightly impaired muscle tone.
Class 3 : the patient exhibits greatly impaired muscle
tone and function.
Muscle dev elopment : Classification according to
development
M.M.House- Class 1 : heavy/Class Class 3: light4
Class 2: medium/Class
Neuromuscular evaluation : Classification – Normal/
Affected
Coor dinatio
Coordinatio
dination n : Patients with good neuromuscular
coordination can be expected to learn to manipulate
dentures relatively quickly and likewise adapt readily to
new dentures. Classification – Excellent/Fair/Poor
Intra Oral Examination :
Mucosa : Normal color of the mucous membrane is
coral pink , any variation must be investigated. Common
prosthetic causes of irritation are - Over extension of the
periphery of the denture, ill fitting dentures, continuous
wearing of the denture,. faulty articulation of the teeth,
rubber suction discs, traumatic injury, allergy, small
spicules of alveolar bone etc.
Mucosal Condition: Classification according to
M.M.House - Class 1: healthy/Class 2: irritated/Class 3:
pathologic4
Thickness of mucosa and tissue resiliency : A mucosa
of medium thickness and uniform resiliency offer the
most favorable prognosis. If the oral mucosa is excessively
thick stability becomes more of a problem than retention.
If the mucosa is inflamed it should be treated before
impression procedures are started. Thickness of mucosa
is classified according to M.M.House as - Class1: normal
or uniform/Class 2: twice the normal/Class 3 : excessively
thick4
Arch Size :
Classification Class 1(large) : The alveolar ridge of
adequate height gives support and to resist lateral
movement of the denture.
Class 2 (medium) : The alveolar ridge would have
undergone some resorption
Class 3 (small ) : the alveolar ridge is almost or
completely resorbed. There is no resistance to lateral
movement of the denture
Ar ch F
Arch orm : Arch form is generally classified as square,
Form
tapering, or ovoid.
Class 1 : Square arch form is the best form to prevent
rotational movements
Class 2 : The tapering form offers some resistance to
movement but to a lesser degree than the square arch
Class 3 : The ovoid form offers little or no resistance to
rotational movements
Ridge Contour : System of six orders of ridge form
The maxillary residual alveolar ridge and vault form
should be classified as follows
Class 1- Square or gently rounded/ Class 2 - Tapered or
V shaped/ Class 3- Flat
Mandibular ridge form
Class 1- Inverted ridge form, with parallel walls & broad
crest
Class 2- Inverted U shaped , short with flat crest
Class 3- Unfavourable-inverted W or short inverted V
or with undercuts
High ridge with a flat crest and parallel walls is ideal
which give maximum support and stability. The knife
edge ridge with multiple bony spicules offer the poorest
prognosis because they are incapable of withstanding
much occlusal force. Relief has to be provided for this
ridge type in the impression procedures. The flat ridge
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J Orofac Sci, 2(3)2010
also has a poor prognosis because of the lack of vertical
height affords little resistance to horizontal movement.
Inter arch space : Classified as
Class 1- Ideal interarch space to accommodate the
artificial teeth
Class 2- Excessive interarch space leading to poor stability
and retention of dentures because of increased leverage
action.
Class 3- Insufficient interarch space to accommodate
artificial teeth, enchances the stability of the dentures since
the occlusal surface of the teeth are close to the ridge
minimizing tilting leverage but decreases retention.
Ridge P arallelism : When teeth are gradually lost the
Parallelism
residual ridges will diverge from each other. If the ridges
are not parallel to the occlusal plane, dentures will slide
over the basilar tissues when occlusal forces are applied
to them.
Classified as :
Class 1 - Both ridges are parallel to the occlusal plane
Class 2 - Either the mandibular or maxillary ridge
diverging anteriorly
Class 3 - Both ridges diverge anteriorly
Ridge Relationship : Jaw relationship can be Normal
(Angle class1): Anterior segment of the mandibular ridge
is directly below or slightly posterior to the maxillary
ridges
Retrognathic mandible (Angle class2) : Anterior
segment of the mandibular ridge is retruded beyond the
normal position as related to the maxillary anterior ridge
segment.
Prognathic (Angle class 3): Anterior segment of the
mandibular ridge is protruded beyond the normal
position as related to the maxillary anterior ridge
segment.
Lateral Thr oatform : N
Throatform eil
eil’’s Classification :
Neil
Class1 : Indicates that the anatomical structures will
accommodate a fairly long and wide flange; minimal or
no pressure is exerted on the finger , can be classified as
deep.
Class 2 : It is about half as long and narrow as the class1
and twice as long as class3. it can be classified as moderate.
Class 3 : This form has minimum length and thickness.
Heavy pressure is placed on the finger. This is important
for ascertaining the border extension in this area. This
form can be classified as shallow
Maxillar
axillaryy Tuberosities : Classified as-normal/Pendulous
uberosities
or bulbous
Large pendulous or bulbous tuberosities may present
a number of problems like encroachment on the interridge
distance.
Sometimes maxillary tuberosities may be fibrous that
hangs pendulously. They should be surgically reduced as
they contribute to excessive vertical and horizontal
movement seriously jeopardizing the stability of the
denture.
Shape of The H ar
Har dP
ard alate : Classified as flat/rounded/
Palate
U shaped / V shaped.
A flat palate resists vertical displacement but easily
displaced by lateral or torquing forces. The rounded and
U shaped palate has the best resistance to vertical and
horizontal forces. The V shaped palate is the most difficult
one because any vertical or torquing movement tends to
break off the seal easily.
Relationship of the SSoft
oft Palate to the H
Palate ar
Har dP
ard alate:
Palate:
Classified as:
Class 1 : It is horizontal, makes 100 angle to the hard
palate and demonstrates little muscular movement. In
this case more tissue coverage is possible for posterior
palatal seal
Class 2 : Soft palate makes 450 angle to the hard palate
Class 3 : Soft palate makes 700 angle to the hard palate.
Shape of the SSoft
oft Palate: MM House classified it as
Palate:
Class 1 : More than 5mm of movable tissue available
for post damming. Ideal for retention
Class 2 : One to five mm of movable tissue available for
post damming. Good retention is usually possible
Class 3 : Less than one mm movable tissue available for
post damming. Retention is usually poor
The patient with the class 1 will be more comfortable
with a fairly thin posterior border of 1 to 2 mm. The
patient with class 2 throat form can tolerate a posterior
border of moderate thickness. The patient with the class
3 has little or no area for a posterior seal, so the posterior
border can be made thicker.
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J Orofac Sci, 2(3)2010
P alatal SSensitivity
ensitivity : Classification according to
M.M.House-4
Class 1 : normal/ Class2: subnormal (hyposensitive)/
Class3 : supernormal (hypersensitive)
Bony U nder
Under cuts:
ndercuts:
Class1 : bony undercuts are absent
Class2 : small undercuts, the denture can be placed by
altering the path of insertion
Class 3 : prominent bilateral undercuts, must be corrected
surgically.
Tori : A torus palatinus or lingual tori are occasionally
present. Extremely large tori must be removed surgically.
Small or moderate tori can be managed by altering the
impression procedures, since the thin mucosal covering
of these tori cannot tolerate pressure. Adequate relief must
be planned for tori in the impression and the denture.
Fr enal A ttachments: Classification according to
Attachments:
M.M.House4
Class 1: high in the maxilla as low in the mandible with
respect to the crest of the ridge
Class 2 : medium
Class 3 : freni encroach on the crest of the ridge and may
interfere with the denture seal , surgical correction may
be required.
Inadequate clearance may result in pain and ulceration
of mucosa or displacement of the denture. Over clearance
may result in a loss of seal and a loose denture.
Tongue : Classification according to M.M.House4:
Class 1 : normal in size, development and function.
Class 2 : teeth have been absent long enough to permit a
change in the form and function of the tongue.
Class 3 : excessively large tongue. All teeth have been
absent for an extended period of time allowing for
abnormal development of the size of the tongue.
A small narrow tongue contributes to the ease of
impression making , but jeopardizes the lingual seal for
the mandibular denture.
A broad thick tongue always is in the way during
impression making, provides an excellent seal for the
denture.
An extremely large tongue poses additional problems
during impression making and impairs denture stability.
Tongue P osition : Classification according to Wright
Position
Normal or Class1: the tongue fills the floor of the
mouth and is confined by the mandibular teeth.
Retracted or Class2 : the tongue is retraced. The floor
of the mouth is pulled downward is exposed back to the
molar area.
Class 3 : the tongue is very tense and pulled back ward
and curled upward.
Saliva: Saliva is classified as follows:
Class1 : normal quality and quantity of saliva, cohesive
and adhesive properties of saliva are ideal.
Class 2 : excessive saliva, contains much mucous
Class 3 : xerostomia, remaining saliva is mucinous
Copious thick ropy saliva interferes with impression
procedures and often provokes nausea and increased
hydrostatic pressure leads to loss of retention of maxillary
denture. Scanty thin saliva interferes with the seal of the
dentures and provides poor protection against scuffing
and chafing.
Mylohyoid Ridge : Should examine by palpation, it
can be sharp or normal. The mucous membrane over a
sharp or irregular mylohyoid ridge will be easily
traumatized by the denture base, unless relief is provided
in the denture base.
Genial Tuber cles : May be sharp or normal. The genial
ubercles
tubercles become prominent with resorption of the
ridges.
Investigations :
Radiographic Examination :
A complete radiographic study furnishes information
as to the presence of retained roots, foreign bodies,
pathologic areas and generalized osteoporosis in the bony
support.
A panoramic radiograph is useful in assessing the
amount of ridge resorption.
Wical and Swoope found that in panoramic
radiographs if the distance from the inferior border of
mandible to the lower border of the mental foramen was
measured and multiplied by three, it gives the actual height
of the alveolar ridge crest11.
Classification : Class 1: mild resorption with loss of
ridge upto one third of the vertical height.
Class 2: which is moderate resorption with loss of ridge
from 1/3 to 2/3 of original vertical height.
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J Orofac Sci, 2(3)2010
Class 3: severe resorption with loss of ridge more than
2/3 of the original vertical height.
Other Investigations : Blood investigations - Blood
glucose levels for diabetics, Hb % of blood for anemic
patients is important for any preprosthetic surgery desired.
Treatment P lanning : Evaluation of the patient includes
Planning
assessment of mental as well as physical conditions.
Treatment planning should include: Tissue conditioning,
Preprosthetic surgery, Articulator type, Tooth selection,
Denture base material, characterization of the denture etc.
The treatment and expected level of achievement, fees,
manner of payment, duration of treatment, any necessary
tissue preparation in conditioning should be discussed.
Prognosis : Prognosis in denture service is an opinion of
the prospects for success of a restoration A number of
factors affect the prognosis are - gross appraisal of the
patient, patient’s needs and expectations, medical,
psychological and behavioral considerations, anatomic
factors, physiological factors etc.
It can be rated as - most favourable prognosis/ integral
/ least favourable prognosis
CONCLUSIONS : Dentists must have a sense of real
concern for the health comfort and welfare of the patients
to establish necessary mutual confidence. A “tender loving
care” approach towards dental patients should be taken
before treatment is started and continued throughout the
treatment planning and the treatment itself.
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considerations for complete denture patients; Journal of Indian
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2. Robert L.Engelimeier, Rodney D.Phoenix. Complete dentures.
The Dental clinics of North America1996;40: 1-19
3. DeVan MM. Methods and procedures in a diagnostic service to
the edentulous patients. Journal of American Dental Association
1989; 29:29-38
4. House MM: The relationship of oral examination to dental
diagnosis, Journal of Prosthetic Dentistry 1958; 8:208.
5. Frush JP,Fisher RD: Introduction to dentogenic restorations,
Journal of Prosthetic Dentistry 1955; l 5: 586:
6. Williams JL: A new classification of human tooth forms with
special reference to a new system of artificial teeth, Cosmos 1914;
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7. Charles M Heartwell, Arthur O. Rahn. Syllabus of complete
dentures: 4th edition 1984;573
8. Essentials of complete denture prosthodontics by Sheldon
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9. Alexander Halperin. Mastering the art of complete dentures
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11. George Albert Zarb, Charles L Bolender, Steven E. Eckert .
Prosthodontic treatment for edentulous patients, 12th edition
Mosby Publications, 2004:73-93
12. Harold Robert Blackwell Fenn, Liddelow KP, Gimson AP.
Clinical dental prosthetics. 3rd edition. Staples Press.1961-838.
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Source of Support : Nil, Conflict of Interest : None declared.
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