DIAGNOSIS & TREATMENT

PLANNING OF
EDENTULOUS PATIENTS

Dr Saransh Malot
Dept of Prosthodontics
 CONTENTS:
• Introduction
• Definition
• General introduction to the patient
• Principles of perception & Diagnostic procedure
• House classification
• Observation of the patient
• Health history
• Clinical & radiographic examination
• Pretreatment records
• Treatment planning
• Conclusion
• Bibliography
 INTRODUCTION:
• Successful complete denture therapy:
Thorough assessment of patients physical and psychological
condition.
Determining a treatment plan that will satisfy patient’s
expectations.

Above all, treating the patient instead of just constructing

complete dentures for them.
 DEFINITIONS:

• According to HEART WELL

Diagnosis is
The act or process of deciding the nature of the diseased
condition by examination

A careful investigation of facts to determine the nature of

a thing

The determination of the nature, location and causes of a

disease.
• According to BOUCHER
Diagnosis consists of planned observations to determine
and evaluate the existing conditions, which lead to
decision making based on the conditions observed.
• In short, DIAGNOSIS can be summarized as:

Recognizing the problem

Formulating the plan

Carrying out the necessary examination

Finally, interpreting the result.

 GENERAL INTRODUCTION
TO THE PATIENT:

• First appointment  most important

time
Fact finding

Development of mutual trust &

understanding
• Familiar with the overall condition of
the patient.
• New patients + patients with previous experience 
complete history taking & thorough examinations in which
perceptive abilities of the dentist play an important role.
 PRINCIPLES OF
PERCEPTION:
• Detection: noticing something
• Discrimination: Distinguish that which we have noticed
from something else.
• Recognition
• Identification
• Judgement
 DIAGNOSTIC
PROCEDURES
 Preferably carried out in two
appointments:

THE FIRST APPOINTMENT:

Acquainted with the patient

Beginning of evaluation of the

process involved in diagnosis &
treatment plan
Obtain essential information from the patient:

•Thorough history

•Radiographic survey •Diagnostic casts

A thorough history should include:
• Personal Data:
 Name
 SSN
 Age
 Sex
 Race
 Occupation
 Cosmetic index: Class I- High cosmetic index
Class II- Low cosmetic index
 Personality
• Medical History
 General health
 Pathology

 Denture History
 Chief complaint
 Expectation
 Edentulism
 Existing or current dentures
 Pre extraction records
• Clinical Evaluation

 Facial form according to House & Loop

Square Square Tapering Ovoid

tapering
 Facial profile according to Angle

Class I Class II Class III

Normal Retrognathic Prognathic
 Muscle tone according to House
Class I : Normal muscle tone
Class II: Slightly impaired muscle tone
Class III: Greatly impaired muscle tone

 Muscle Development according to House

Class I: Heavy
Class II: Medium
Class III: Light

 Complexion
Hair
Eye
Skin
 Lip Examination

Cracking, fissuring at corner & ulceration: indicative of

vitamin B-complex deficiency, candida infection,
overclosure of existing denture or neoplasm.
Lip support
Lip thickness
Lip length
 Temporomandibular Joint

Clicking, crepitations
Pain & tenderness on palpation
Temporomandibular arthralgia
Impaired mandibular mobility
Irregularity or deviation on opening & closing of
mandible
Locking of mandible.
 Neuromuscular Evaluation
Class I: Excellent
Class II: fair
Class III: poor

 Arch Size
Class I: Large
Class II: Medium
Class III: Small
Determines the amount of basal seat available for
denture foundation.
Greater the size, more the support
Greater the contact surface, greater the retention.
Discrepancy in size of the maxilla and mandible can
present a problem of stability in the smaller arch.
  Arch Form

Class I Class II Class III

Square Tapering Ovoid
  Ridge Form:

Maxillary Mandibular

Class I

Square Inverted U-shaped

Class II

V-shaped Flat

ClassIII
Tall Short Inverted
Flat
Inverted Inverted W
  Inter ridge space

Excessive inter ridge space: poor stability and retention

because of increased leverage.
Small inter ridge distance: difficulty in setting teeth and
maintaining proper freeway space.

Ideal Excessive

Insufficient
 Ridge relationship according to Angle

Parallel Divergent Mandibular

Divergent Maxillary & Mandibular

  Ridge Contour:

Type I: High, well rounded bone profile

+ve resistance

Type II: Narrow, knife edge ridge

-ve resistance

Type III: Rounded but lowered residual ridge

-ve resistance

Type IV: Terminal stage

-ve resistance
Most ideal is a high ridge with a flat crest and parallel or
nearly parallel sides  maximum support & stability.
Knife edge ridges or ridges with multiple bony spicules
offer the poorest prognosis  incapable of with standing
much occlusal force.
Best determined by careful palpation.
 Lateral Throat Form [mandibular]: Neil

Class I

Class II

Class III
 Palatal sensitivity according to House
Class I: Normal
Class II: Hyposensitive
Class III: Hypersensitive

 Mucosal Thickness according to House

Class I: Normal uniform density (1 mm)
Class II: Thin investing membrane
Class III: Thick investing membrane
 Mucosa condition according to House
Class I: Healthy
Class II: Irritated
Class III: Pathologic

 Saliva
Class I: Normal
Class II: Excessive
Class III: Xerostomia
Deficient saliva: retention of denture will
be affected.
Excess of saliva: complicates impression
making.
Thin serous saliva is the best to work with.
Thick saliva makes dentures more difficult
to wear.
  Colour of Mucosa:

Ranges healthy pink to angry red.

Redness indicative of inflammation:
related to ill fitting denture,
underlying infection, systemic
disease or chronic smoking.
Pigmented spots or lesions.
White patches  keratotic areas
caused by denture irritation.
  Tongue:

If patient has been without teeth for a long time: tongue

becomes enlarged & powerful. This will create a problem
in impression making & may contribute to denture
instability.
A small tongue: may jeopardize lingual seal.
Tongue position is very important to the prognosis of the
mandibular denture.
 Wright classified tongue positions as follows:

Class I: Tongue lies in the floor of the mouth with the tip
forward & slightly below the incisal edges of mandibular
anterior teeth. Most favourable prognosis.
Class II: Tongue is flattened and broadened but the tip is
in the normal position.
Class III: Tongue is retracted & depressed into the floor of
the mouth with the tip curled upward, downward or
assimilated into the body of the tongue. Least favourable
prognosis.
  Hard palate:

U-shaped palatal vault; most

favourable for retention & lateral
stability.
V-shaped vault: less favourable for
retention.
Flat palatal vault: also unfavourable.
  Soft Palate:

Classified according to configurations based on the degree

of flexure the soft palate makes with the hard palate and
the width of the seal area.

Class I: Horizontal & demonstrating little muscular

movement. Most favourable condition as it allows for
more tissue coverage for posterior palatal seal.
Class II: Turns downward forming a 45o angle to hard
palate. Potential tissue coverage is less than for class I.
Class III: Turns downward sharply at 70o angle just
posterior to hard palate. Least favourable soft tissue form.
V- shaped vault: associated with Class III soft palate
Flat palatal vault: usually associated with Class I or Class
II soft palate.
  Gag Reflex:

Normal defense mechanism developed by the

body to prevent foreign bodies from enetering the
trachea.

Can be caused by:

Systemic disorders,
Psychological factors,
Extraoral & intraoral physiological factors
Iatrogenic factors.

Controlled by glossopharyngeal nerve.

 Management of gag reflex:

Clinical techniques, pharmacological measures,

psychological intervention.
Identify the existence of gag reflex with a thorough
conversation with the patient.
Careful handling of impression procedure and constant
reassurance of the patient will suffice.
In severe cases, a specialist maybe needed to treat the
problem at a psychological level.
  Redundant tissue:

Excess amount of flabby tissue: cause denture base to

shift & move as force is applied, due to instability of
denture foundation.
Surgical excision may improve the condition before
impression making.
  Hyperplastic tissue:

When present under ill fitting dentures it may present as

an epulis fissuratum, papillary hyperplasia or
hyperplastic folds.
Patient should be instructed to rest the tissues by not
wearing the existing denture.
Proper oral hygiene and tissue massage.
Existing denture should be refitted with a tissue
conditioning or temporary relining material. Occlusion
should be improved if possible.
Last resort is surgical correction.
  Bony undercut:

Frequently found on both maxillary &

mandibular ridges.
Usually pose no problem in denture
insertion.
Rule should be selective relief of denture
rather than surgical reduction.
On mandibular ridge, the only undercut
that can pose a real problem is a
prominent sharp mylohyoid ridge.
  Tori:

Torus palatinus & lingual tori frequently present.

Torus palatinus: range from a small prominence in the
midline to one that covers the entire hard palate.
Adequate relief must be planned.
Lingual tori: interfere with denture construction & unless
very small should be surgically removed.
  Muscle & frenum attachments:

Should be examined for favourable & unfavourable

positions in relation to the crest of the ridge.
Attachments most often corrected are maxillary labial
and mandibular lingual frena.
Unfavourable frenal attachments may necessitate
surgical correction to ensure border seal.
  Floor of the Mouth:

Near the ridge crest or when magnitude of movement is

great, retention and stability of the denture
Sublingual gland & mylohyoid areas are concern where
floor of the mouth is high  cannot be selectively
displaced by the denture flange, the prognosis of the
mandibular denture will be poor.
Retromylohyoid space maybe partially or totally
obliterated by tongue movement.
 Since success & failure of treatment depends greatly on
mutual confidence & rapport between the dentist &
patient, the first appointment is extremely important.

THE SECOND APPOINTMENT

The dentist discusses the
- Proposed treatment plan
- The sequence in which the treatment will be carried out
 PATIENT MADE RECENTLY
EDENTULOUS:
• Completely unaware of difficulties
• Assume to continue same eating habits
as with their natural teeth

Patient education is of paramount

importance and must begin with the
second examination appointment and
continue throughout the entire treatment
sequence.
• Expect their new teeth to last for a life time  not
possible as changes occur in the basal seat causing
position of dentures to change i.r.t their foundation & to
each other.
• “Green Ridge”:
- Tooth sockets do not completely fill with new bone
- Socket edges not rounded off as desired
- Bony spicules remain from extraction site
- Bony undercuts with a thin mucosal covering.
• Alveolar ridges recently made edentulous  subject to
large, rapid changes during the first year.

The dentist must inform the patient of these potential

changes before beginning, to avoid problems later on.
 PATIENT EDENTULOUS FOR A LONG
TIME:
• The problems they present are more difficult to treat
especially if they have been previous denture wearers.
• These problems must be recognized before adequate
treatment procedures are planned
• Most important among this group are the difficult
denture wearers  Personality characteristics should be
assessed.
 THE HOUSE CLASSIFICATION

• Proposed by Dr. Milus M. House

• General classification of patient’s mental attitude
They can be classified as:
Philosophic
Exacting
Indifferent
Critical
Skeptical
Hysterical
 PHILOSOPHIC:

• Willing to accept the dentist’s judgement without

question.
• Best mental attitude for denture acceptance.
• Motivation is generalized.
• Ideal attitude for successful treatment, provided the
biomechanical factors are favourable.

Dr Saransh Malot
Dept of Prosthodontics
 EXACTING:

• All good attributes of philosophic patient.

• Require extreme care, effort and patience on the part of
the dentist.
• Methodical, precise and accurate and at times make
severe demands.
• Like each step of the procedure to be explained.
• If intelligent and understanding  they are the best

or else extra hours must be spent, prior to treatment,

in patient education until an understanding is reached.
 HYSTERICAL:

• Emotionally unstable, excitable, apprehensive and

hypertensive.
• Prognosis is often unfavorable.
• Additional professional help (psychiatric) is required
prior to and during treatment.
 Hysterical

DEPT.Of Prosthodontics 56
 INDIFFERENT:

• Questionable or unfavorable prognosis.

• Little concern for their teeth or oral health.
• Seek treatment because of the insistence of family.
• Pay no attention to instructions, are uncooperative &
give up easily if problems are encountered with their
new teeth.
• Require more time for instruction on value and use of
their dentures.
Indifferent

58
 OBSERVATION OF THE PATIENT:

• Begins when the patient enters the dental clinic.

• Aspects to be observed
Motor skills
Facial features
Attitude and adaptive response.
 (i) Motor Skills:
• CVA, Bell’s Palsy, nerve blocks for
trigeminal neuralgia  hemiplagia and
dyskinesia.

• Facial tremors/spasms indicate Parkinson’s

disease, nervous habits or possibly drug
induced tardive dyskinesia.

• Psychotropic drug therapy may show

Uncontrollable chewing movements
Licking and smacking of lips
Uncoordinated tongue movements
Twitching of the nose
Puffing of cheek
These complications often result in
prosthetic failure.

DIAGNOSIS:
• Check fluency and quality of patient’s
speech
• Best judged during casual conversation
 (ii) Facial features:
• Dentist must note
Length of face
Labial fullness
Apparent support of lips
 Observe for hollowness/puffiness in
Philtrum
Nasolabial fold
Labiomental groove
• Texture of skin  determines the
tone for anterior teeth setup

Rough textured skin deserves a

more rugged tooth arrangement
than smooth, light coloured skin.
• Size of oral cavity, activity of
lips and width of vermilion
border  directly related to
degree of tooth display.

• Profile view indicates position

of maxilla to mandible  first
indication of patient’s occlusal
classification.
(iii) Attitude & Level of Expectation:

• Factors producing adaptive response to complete

dentures:
Acceptance of & confidence in dentist
Previous favourable experience & capacity to cope
favourably with change
Favourable physical conditions
Realistic expectation of the patient
Good learning capacity
Desire to please the doctor
• Factors that produce a maladaptive response to
complete dentures
Lack of trust in the dentist
Poor dentist-patient communication
Negative previous experience
Unrealistic expectations on the part of the patient
Resistance to change
Inadequate tissue tolerance
Muscle in coordination

Chronic dissatisfaction

The wish to fail, since the patient craves

for attention from the doctor

Disapproval of the dentures or of the

individual with the dentures by people
important to them.
 HEALTH HISTORY:

• Patients today have a more complex health history than

ever before.
• More likely to involve the dentist in medicolegal
challenge.
• Therefore a complete health history is an extremely
important part of the patient’s overall diagnosis and
treatment planning.
 (i) Systemic Status of the Patient:

• DEBILITATING DISEASES
They must be kept under medical control
Eg. Diabetes, Blood Dyscrasias and TB

Require
 Extra instruction in oral hygiene, eating
habits & tissue rest
 Physician consultation
 Frequent recall appointments to check the
status of underlying bone and thus occlusion
• DISEASES OF THE JOINTS

Primary osteoarthritis:
 Familial disease
 More common in females
 “Heberdens nodes” involving
terminal joints of fingers  difficult
for patient to insert & clean dentures
Osteoarthritis of TMJ:

 Painful mandibular movements  difficulty in

construction of dentures
 Special impression trays  accommodate reduced
mouth opening
 Difficulty in recording jaw relations
 Occlusal corrections have to be made often
• CARDIOVASCULAR
DISEASES

 Consultation with patients

cardiologist is indicated
 Surgical procedure of any nature
maybe contraindicated
 Short appointments with pre-
medication
• DISEASES OF SKIN

 May have oral

manifestations Eg.
Pemphigus & lichen planus
 Oral mucosa is very painful
 Medical treatment may or
may not give comfort
 Constant use of dentures is
contraindicated  their use
is primarily for mental
comfort
 NEUROLOGICAL
DISORDERS:
Eg. Bells palsy
Parkinson’s disease
Added Problems:
 Denture retention
 Maxillo-mandibular relation
records
 Supporting musculature
• ORAL MALIGNANCIES:

 Most often detected by the dentist

 Treatment of choice = eradication of
lesion by surgery or radiotherapy.
 Prosthodontic treatment therein is
best handled by a maxillofacial
prosthodontist.
 Radiation therapist must be consulted  if tissues lack
tonus & have a bronze colour denture construction should
be delayed.
 Observe for signs of radiation necrosis
 Dentures should be used on a limited basis
• MENOPAUSE:

 Bone changes: generalized osteoporosis

 Mental disturbances: mild irritability to complete nervous
breakdown
 Oral symptoms: hot flushes, burning tongue, burning
palate and vague area pains.
 Tranquilizers and psychotherapy may help.
 Patient should be made aware of these conditions and
their possible effect during the period of denture
adjustment.
 RADIOGRAPHIC EXAMINATION

• The interpretation of the panoramic radiograph should

follow a five step analysis:
 Screen jaws for defect in structure and bony enlargement,
displacement of jaw parts, unerupted teeth or retained
root fragments, foreign bodies, radiolucencies as well as
radio opacities. TMJ can be screened and findings
correlated with history and clinical examination.
 Describe the appearance of the lesion as well as any
bony changes adjoining the lesion
 Correlate the radiographic findings with the clinical,
historical and laboratory findings.
 Perform a differential diagnosis which includes all the
diseases that could explain the findings.
 Estimate the growth of the lesion by the appearance of
the jaw structures adjoining the lesion.
• Panoramic radiographs also aid in determining the
amount of ridge resorption.
• Wical & Swoope advocated measuring the distance from
the inferior border of the mandible to the inferior margin
of the mental foramen and then multiplying it by 3, the
resultant product is a reliable estimate of the original
alveolar ridge crest height.
• Class I: Mild resorption, is a loss of upto one third of the
orignal vertical height.
• Class II: Moderate resorption, is a loss from one third to
two thirds of vertical height.
• Class III: Severe resorption, is a loss of two thirds or more
of vertical height.
 PRETREATMENT
RECORDS:

• Diagnostic casts:
 Helps dentists avoid a potential problem
 Time consuming
 Aid in determining the inter ridge space, ridge
relationships, ridge shape and form that cannot be
adequately determined by clinical examination alone.
• Pre extraction records:
 Old diagnostic casts: determining both size, position &
arrangement of teeth.
 Old radiographs: determining tooth size & bony
change.
 Photographs: relay information regarding tooth size,
position & display during facial expressions. Forms an
effective tool in achieving proper esthetics & patient
satisfaction.
 TREATMENT
PLANNING:
• Process of matching possible treatment options with
patient needs and systematically arranging the
treatment in order of priority but in keeping with a
logical or technically necessary sequence.
• Must have a parallel process of developing a prognosis.
• Driven by the diagnosis but must take other factors such
as prognosis, patient health and attitudes into account.
 WHY TREATMENT
PLAN?
Treatment Plans Informed
consent
Addresses patient
needs Treatment
Lists specific Enables patient to
Time
treatment give

Specific logical Fees

sequence
Enables dentist to
Estimate
Operating time
Laboratory time
Calender time Dentist delivers &
Fees patient recieves
Patient specific
care
• Treatment planning determines the patients problems by
way of a thorough case history as previously described

Thus making selection of the treatment option that is

most ideally indicated for the particular case at hand.

 By placing a primer on determining patient problems, it

also places a primer on the various treatment options
that are best suited for those particular conditions.
 PROSTHODONTIC CARE

 Edentulous Patient
 Complete denture

Immediate or conventional
Definite or interim
Tooth, implant or tissue supported.
 ADJUNCTIVE CARE

 Elimination of infection
 Elimination of pathoses
 Surgical improvement of denture support & space
 Tissue conditioning
 Nutritional counselling
• Thus it is seen that diagnosis and treatment planning help
both the dentist as well as the patient understand the:
 Diagnostic procedures
 Diagnostic results
 Treatment plan
 Use of prosthesis
 Continuing care
 Fees
 BIBLIOGRAPHY
• Boucher’s: Prosthodontic treatment for edentulous patients, 11th edn.
• Winkler: Essentials of complete denture prosthdontics, 2nd edn.
• J.J. Sharry: Complete denture prosthodontics, 2nd edn.
• Bouchers: Prosthodontic Treatment for edentulous patients, 10th edn.
• Rahn & Heartwell: Textbook of complete denture, 5th edn.
• The dental clinics of North America, Jan 1996;40(1)
• The Dental Clinics of North America, Apr 1977;21(2)
• Radiographic examination of edentulous mouths, JPD 1990;64:180-182.
• Psychological aspects of prosthodontics, JPD 1973;30:736-744
• Wical K.E. & Swoope C.C., Studies pf residual ridge resorption. Part I Use
of panoramic radiographs for evaluation and classification of
mandibular resorption, JPD 1974;32:7-12
• Also courtesy to some unknown authors from whome I copied some of
slides….!!
 Dr Saransh Malot
Dept of Prosthodontics

THANK YOU