Chapter I

Examination, Diagnosis
and Treatment Planning
for Complete Denture
Patients

Dr. Majdi Seghayer

 Diagnosis :
The determination of the nature location and causes of a disease.

Treatment plan:
The sequence of the procedures planned for the treatment of a patient after diagnosis
 THE DIAGNOSTIC
PROCEDURE
 Include:
 I. Patient interview.

 II. Patient's history which

include:

 1. personal history.
 3. medical history.
 3. dental history.
 III. Clinical examinations of the patient:

 1. extra-oral examination.
 2. intra-oral examination.

 IV. Investigations

 1. radiographic evaluation.
 2. evaluation of mounted diagnostic casts.

 IV. Treatment plan.

 Procedures Carried Before Denture Treatment

 General information
 Chief complaint & patient expectations
 Medical history & current medication
 Dental history
 Visual & manual examination of the mouth
and head and neck
 Radiographic examination
 Procedures Carried Before Denture Treatment

 Referring for additional tests or medical

consultation
 Referring for second opinion
 Making alginate impressions & preparing
mounted study models
 Discussion of diagnosis, treatment planning &
prognosis with patient
 Finalizing the fees & obtaining a signed
consent
 The First Meeting

 The First Meeting Most important

 Prior to meeting, you should review general
information
 Your confidence is as important as the
treatment itself
 You should be a good listener
 Your communication should be in a simple &
truthful manner
 Recording General
Information
 Name
 Race
 Occupation
 Address and telephone no.
 Previous dentist
Age
 With advancing age*:
 Decrease capacity of tissue to tolerate stress
 Tissue takes longer time to heal
 Many diseases are prevalent in older age
 Men at old age may be concerned with only
comfort & function (indifferent)
 * It is not necessary that chronological age
match with physical age of the patient. Maybe
an 75 ys old individual having the health,
energy, and appearance of a 50 ys old one
 Psychological Evaluation (House
Classification of Denture Patients)
 Philosophical patient: well motivated, cooperative,
calm & composed even in difficult cases.
 Exacting (critical): likes each step in detail, makes
alternative treatment for dentist, makes severe
demands.*
 * Extra care and patience are required on the part
of the dentist. This pt can be a good pt if he is
intelligent and understanding. With less intelligent
exacting pts, the dentist should listen to their
demands but must not respond to them especially
if they are unreasonable
Continue
 Indifferent: not very interested in treatment,
blames the dentist for any mishap, not follow
instructions, been coerced to come by friend,
relative….*
 *Management: difficult to manage, the trick is
to identify such a patient before treatment is
started. An attempt is made to educate the pt
and improve his interest, but if this fails, it is
best to postpone or refuse treatment until
improvement is observed.
Continue

 Hysterical: easily excited, highly apprehensive, unrealistic

expectations*
 Skeptical: bad results from previous treatment, doubtful,
often have severely resorbed ridges and poor health, might
have psychological disturbances from recent personal trajedy
#
 *Management: a lot of time and effort is needed, often
medical consultation is required, these pts must be made
aware that many of their problems are primarily systemic
and not the result of dentures. Avoid making immediate
dentures with them.
 #Management: psychological management is as important as
the denture treatment. This pt can be made into excellent pt if
handled with care and sympathy.
 Chief Complaint & Patient
Expectations
 Patient’s own words
 Why he is seeking prosthodontic treatment
 You should assess if patient expectations are
realistic or not
 If not realistic, you should educate pt and scale
them down
 Medical History
 Diabetes Mellitus Cardiovascular diseases
 Diseases of joints: osteoarthritis
 Diseases of skin: pemphigus ?
 Neurological disorders (Bells balsy and
Parkinson)
 Sjogren’s syndrome
 Transmissible diseases
 Medical History
 *Diabetes is not a contraindication for denture treatment.
However, it may affect wound healing especially if
preprosthetic surgery is planned.
 Osteoarthritis: special impression trays are needed if pt is
not able to open his mouth wide, and jaw relations may be
difficult to record.
 Pemphigus: constant wearing of dentures is contraindicated.
 Neurological disorders (Bells balsy and Parkinson): denture
procedures are more difficult because of the patients’
inability to cooperate completely, also they have difficulty in
maintaining denture hygiene so they need assistance in
cleaning their dentures.
 Sjogren’s syndrome causes xerostomia.
 Radiation Therapy Vs.
Dentures
 *# Dentures can be a source of trauma to thin
friable dry soft tissue, so it is recommended to
postpone construction of complete denture for
pt who has received radiation therapy in head
and neck region 6-12 months from radiation
therapy.
 Denture Fabrication in Radiation
Therapy Patient
 Avoid impression material that dry tissue
(impression plaster) or heavily flavored
materials (ZOE)
 Consider non-anatomic teeth
 Teeth set in neutral zone
 Slight reduction in vertical dimension
 Soft liners are controversial due to porosity and
possibility of candida
 Current Medication
 Insulin *
 Anticoagulants
 Antihypertensive: dryness & postural
hypotension
 Corticosteroids: dryness, confusion & behavioral
changes
 Antiparkinson agents like Norflex and Akineton:
dryness, confusion & behavioral changes
 *hypoglycemic shock may be induced by local
anasthetic injection so the dentist must enquire if
pt has eaten a meal after his insulin injection
 Dental History
 History of tooth loss: cause, time* Edentulous
period
 Cause: poor ridges can be expected if teeth were
lost due to periodontal diseases
 Time: teeth lost at different time intervals would
result in different ridge levels.
 The most rapid rate of resorption occurs in the
first 6 months after extraction, so rapid loosening
can be expected if dentures are constructed soon
after total extraction and relining or remaking
may be necessary within a short period of time.
 Beware of Patients Who Have A
“Bag of Dentures”
 *The dentist should refrain from treating such a
pt unless it is possible to determine ways in
which new prostheses can be made
significantly better than previous attempts
 Extraoral Examination
 General appearance (healthy, signs of proper
nourishment?)
 Facial symmetry
 Skin: color, deep wrinkles
 Palpation of the head & neck (lymph nodes &
masses
 Extraoral Examination
 Neuromuscular coordination*
 * Pts with poor neuromuscular coordination
(CVA, parkinson, paralysis) may find it
difficult to adapt to new dentures. The pt is
asked to perform various mandibular
movements to determine neuromuscular
coordination.
Extraoral
Examinati
on
 TMJ
examination
Classification of Frontal Face Forms
(House, Frush & Fisher)
 This is important for selection of tooth shape
Classification of Lateral Face Forms
 Normal
 Retrognathic
 prognathic
 Lips
 Length*
 Thickness
 Mobility
 Smile line
 Short lips show more of the denture base when pt
smiles or talks, longer teeth may have to be selected.
 Long lips would hide the denture base and most of the
teeth during facial expressions. Tooth visibility as a
guide to anterior teeth positioning would be
impractical
 Thin lips are very sensitive to small changes in anterior
teeth position
Lip (smile) line
*the greatest height
to which the inferior
border of the upper
lip is capable of
being raised by
muscle function.
High smile line
Normal smile line
Low smile line
 Intraoral Examination
 Cheeks,
 tongue,
 floor of the mouth (FOM),
 maxillary tuberosity,
 hard palate,
 soft palate,
 arch relationship,
 residual ridge form,
 saliva,
 undercuts
 Cheeks
 Draping of the cheeks over the buccal flanges
essential for peripheral seal
 Opening of Stenson’s duct
 Location for many lesions (lichen planus,
submucosal fibrosis, leukoplakai, malignancies
as sqauamous cell carcinoma (SCC))
 The Tongue
 Favorable tongue is average sized, moves
freely, covered by healthy mucosa
 Normally, it should rest in a relaxed position
on lingual flanges, this will retain denture &
contributes to denture stability by controlling it
during speech, mastication & swallowing
 Tongue Size
 Normal or Large
 An edentulous pt who has not been wearing a
mandibular denture lead to enlarged toungue,
It may slowly regain its normal size after a
period of wearing complete dentures.
How to Manage Large Tongue?
 Lower the occlusal plane
 Use narrower teeth
 Increase the intermolar distance
 Grind off the lingual cusps
 Avoid setting a second molar
Tongue
Position
 Normal: Lateral
borders rest at
level of
mandibular
occlusal plane,
while dorsum is
raised above it.
Apex rests at or
slightly below
the incisal edges
of mandibular
anteriors
 Tongue Position
 Retruded tongue position deprives pt of border
seal of lingual flange in sublingual crescent and
also may produce dislodging forces on distal
regions of lingual flange
 Tongue Mucosa
 The specialized mucosa covering the tongue is
said to be a “window” on systemic diseases. *
 Aided by a gauze, the dentist can hold the
tongue while using a mirror to examine it. The
sides and ventral surface of tongue are
common locations for carcinogenic lesions. An
ulcer like lesion should be viewed with
suspicion
 Diagnostic Procedures
1. History Taking:
 1. Patient’s history
 2. Past medical history
 3. Past dental history

2. Clinical examinations:
 1. Extra-oral examination
 2. Intra-oral examination
 3. Pre-extraction record and helpful aids
 4. X-rays
 5. Models
 7. Biopsy

 3. Treatment plan
 I. History taking
 1. Patient’s History:
 A. Personal and social details.
 1. name, Address and telephone number..
 2. age of the patient…
 3. sex….
 4. occupation…
 Psychological evaluation
 Types of patient in the dental clinic:
 1. The philosophic patient (Truth-seeking)
 2. Exacting Patients (Demanding)
 3. Indifferent Patients (Uncaring, cool)
 4. Skeptical antagonistic or Hysterical Patients
(Panic-stricken)
 I. History taking
 B. Reason for Attendance and patient
expectations
 Restore appearance
 Restore function
 I. History taking
 2. Past Medical History:
 Diabetes
 Blood dyscrasias
 Avitamminosis
 Hormonal disorders such as Acromegaly
and hyper parathyrodism Frequent
denture adjustment or even new dentures
 Parkinson's disease (brain disorder) that affect
movement, loss of muscle control, and balance.
Usually, the first symptoms include a tremor (hand,
foot, or leg), also termed a "shaking palsy)
it affects the ability of patients to wear and control
dentures
 I. History taking
3. Dental History
1. History of tooth loss
2. Experience with old denture
3. Edentulous period
 II. Clinical Examination

 1. Extra-oral examination

1. General look of the patient
 2. Facial form and profile
 3. TMJ examination
 4. Pathological lesions
 II. Clinical Examination

 1. Extra-oral examination

1. General look of the patient
 II. Clinical Examination

 1. Extra-oral examination
 2. Facial form and profile
2. Facial form and profile
2. Facial form and profile
 3. TMJ examination
 Signs of TMJ
dysfunction:
 Pain, Limited and
deviated mouth
opening, Clicking
sound, headache and
tenderness
 Palpitation of the TMJ
and facial muscles
 Pain or tenderness
over the joint is an
indication of an
inflammation in the
joint capsule or within
the joint
 Radiographic methods
as Panoramic x-ray,
computerized
tomography, MRI, and
cone beam
 1. Extra-oral examination

 4. Extra-oral pathological lesions:

 Examination of any pathological lesions as
abscesses, cysts, herpes, ulcers, or any facial
asymmetry.
 Intra-oral examination
 Visual and digital intra-oral examinations and
Radiographic examination are necessary to detect
the following:
 1. Arch size and form:
 The larger size of the mandibular and maxillary
arches the more support and better retention and
stability.
 2. The oral mucosa:
 A. Denture bearing area:
 Healthy denture supporting tissues are firm, non-
edematous, even thickness, pink color mucosa with
1-2 mm resilience.
 Palpation is necessary to detect the resiliency and
B. Border tissues
 Examine the oral vestibule

 Overextended labial flange leads

to hyperplastic tissue.
C. Frenuli:
A broad frenum occupying a position near the ridge
crest requires Frenectomy
Excessive relief by deep and wide V-shaped notch
in this area causes loss of peripheral seal and
results in a weak denture base prone to midline
fracture.
 Intra-oral examination
 3. Types of alveolar ridge:
 The residual alveolar ridge may be:
 A. U-shaped
 B. V-shaped or tapered
 C. Knife edged
 D. Flat
 E. Inverted
 F. Undercut