Casehisory, Examination, diagnosis &

Treatment Planning For Complete Dentures.

Complete Denture Prosthodontics involves the replacement of the lost

natural dentition and associated structures of the maxilla and mandible for
patients who have lost all their remaining natural teeth or are soon to lose
them.

The basic objective of the C.D. prosthodontics is the restoration of

function, facial appearance and the maintenance of the patients health.

The C.D. patient should be able to speak distinctly and experience oral
comfort.

Diagnosis

Diagnosis is defined as determination of nature of disease.

Boucher diagnosis consists of planned observation to determine & evaluate
the existing conditions, which lead to decision making based on the condition
observed.

Treatment Planning

Treatment planning is defined as the sequence of procedures planned for

the treatment of a patient after diagnosis

Prognosis
Prognosis depends on both diagnosis and treatment planning.

Factors Affecting Diagnosis:

Local Biological Factors:

Local Physical Factors:

Systemic Factors:

Mental Attitude:

Prosthodontic Approach

Getting Acquainted:

Technical Analysis:

Importance Of Case History

Patients should be received well by the receptionist, comfortably seated in

a well lit area that is tastefully decorated. It should provide the patient
with a sense of ease and security that will allow them to communicate
honestly and completely about their problems.

If the patient has previously been to the dentist, he should not proceed on
assumptions, both new and returning patients need their complete
medical history taken or reviewed and need to undergo thorough
examination.

Location

Tells about certain endemic disorders such as flourosis.

Race

Race can be critical factor in the characterization of dentures i.e., choice of

denture base shade, teeth Shade, denture base stains.

Nutritional Status

Vegetarian:

Non Vegetarian:

Chief Complaint

Own Words

Primary reason the patient consults the dentist.

History of Present Condition

The duration of the edentulous state is of importance in ascertaining a

proper diagnosis and treatment plan for the patient. Also the manner in
which there was a loss of teeth helps to understand the patients personal
interest in his or her oral hygiene and other habits.

Personality

Mental Attitude
House Classification:

1. Philosophical

Best mental attitude for denture acceptance.

Ideal, co-operative, optimistic .Prognosis good.

2. Exacting
Asks dentist each & every procedure. If motivated hell be the best to cooperate in dental procedures.

3. Hysterical
Poor health, nervous, unrealistic expectation, poor prognosis. Pt education
& motivation.

4. Indifferent

Least concerned about their oral health not co-operative, avoid treatment.
Prognosis poor.

Patients may also be classified according to the following :

Cooperative
-Open minded and are amenable to suggestion

Apprehensive
-Anxious.
-Frightened.

-Obsessive or exacting.
-Chronic complainers.
- Self-conscious.

Uncooperative
- General attitude is negative

Habits

Expectations

The reason the patient seeks prosthetic treatment is of critical

importance. The patients expectations should be determined and
evaluated to see if they are realistic and attainable.

Examination

Extraoral

IntraOral.

The medical and dental history should be reviewed before the examination
begins .

Diseases affecting success in wearing dentures

Infectious diseases

Metabolic diseases.

Bleeding disorders

Anemia

Cardiovascular disorders

Pulmonary disorders

Endocrine disorders

Diseases of the bones and joints

Diseases of the skin

Oral malignancies

Neurologic disorders

DIABETES MELLITUS

Anemia

Oral Manifestation: changes in the mucous membrane, Pallor of the

tongue and lips, burning, smooth, glossy tongue, usually pain in tongue
and supporting areas.

The patient should be placed under good medical care. Dentist must
achieve good oral hygiene, efficient dentures, i.e, small food table with
maximum supporting area to keep supporting tissues from being over
stimulated. Careful patient instruction should be given.

DISEASE INVOLVING WBC`S

DISEASES OF PLATELETS

Multiple myloma

When involves the oral cavity, it is usually a late secondary manifestation

of lesions within the jaws, most often the mandible. Cause swelling of the
jaws, pain, numbness mobility of teeth, and pathologic fractures. Punched
out lesions of the skull and jaw are characteristic radiographic findings. As
multiple myeloma results in immunosuppression, a variety of infections
may be present, including oral hairy leukoplakia and candidiasis.

INFECTIOUS DISEASES

DISEASES OF BONE & JOINTS

Rheumatoid arthritis

Paget`s disease

Achondroplasia

CENTRAL NERVOUS SYSTEM

Bell`s palsy

Parkinson`s disease

Trigeminal neuralgia

DISEASES OF SKIN WITH ORAL MANIFESTATIONS

Systemic sclerosis

Oral Complications:

Infection .

Spontaneous gingival bleeding.

Ecchymosis.

Petechiae .

Climacteric

Dental History

An understanding of the etiology of tooth loss by a patient will contribute

to the prognosis for Prosthodontic success.

Considerable information can be gained from observations of dentures

being used by patients.

Reasons for Tooth Loss

Periodontal:

Caries:

Congenital:

Trauma:

Surgical Intervention:

Duration Of Edentulousness

Even loss of bone natural teeth are lost simultaneously or with in short
period.

Uneven ridge configurations Uneven loss of teeth in different quadrants.

Loss of teeth on onside chewing on other side deviation of jaw to the

side of last tooth extracted.

Combination syndrome.

No Posteriors No RPD Patient tends to eat with anteriors effect on jaw

relations (Stability ).

Previous Denture Experience

RPD

CD

Pre extraction records:

Photographs , radiographs- for anterior esthetics, guide the jaw relations.

Diagnostic casts:

When intra oral exam is unsatisfactory or inaccurate, tentative jaw relation

to assess the inter arch space ridge form.

Information regarding Natural teeth

If teeth not extracted by prosthodontist, information of extractions,

Radiographic examination has to be carried out.

Clinical Examination

Extra oral

Intra oral

Neuro Muscular Skill Examination.

Speech.

Coordination.

Posture and walking pattern. ( gait )

Built and Nourishment.

Extra Oral

Facial examination

Feature of the face to be carefully examined.

Facial Symmetry

Disproportions, asymmetrical Facial features

Facial Form

Helps in selection of teeth.

Loop, Frush Fisher & Williams : classified facial form based on the out line
of the face as:

Facial Profile

Angle Classified Facial Profile as :

Facial Expression

An absence of facial expression may indicate a loss of muscle tonus. A

mask like expression may be due to numerous surgical procedures. It can also
occur in patients with CNS disorders like paralysis agitans or endocrine disorders
like hypothyroidism.

Complexion

From the patients complexion, the dentist can know about the shade of
the teeth.

Hair

May be black, blond, brown, brunette, white.

Eyes

May be black, blue, brown, gray hazel. The shade of hair and
eyes in selection of teeth is irrelevant.

Skin texture

Rough.

Smooth.

Wrinkles

Due to age.

Loss of vertical dimension.

Vermelion Border

Lip

Vary in size: thin, tight, Short to tense and Taut.

Tense : nervous individuals.

Examine lips for: support, thickness, length, fullness, mobility.

Lip Mobility:

Muscle Tone

Class I : Normal tension, muscle tone.

Class II : Normal muscle function, slightly decreased muscle tone.

Class III : Decreased muscle tone and function

Muscle development

Class I : heavy.

Class II : Medium.

Class III : Light.

Muscles of mastication

Class I muscles of mastication are normal in tone and function.

Class II muscles of mastication are near normal.

Class III muscles of mastication are subnormal in function and tone.

Examination of muscles of mastication

Masseter

The TEMPORALIS is palpated in much the same manner and Intra orally
along the upper aspect of ascending ramus to detect lateral interferences.

Pain reffered toTMJ ,orbital regions

LATERAL PTERYGOID

In patients with nonworking side interferences, the muscle on the opposite

of the interference is sometimes painful.

In addition, this muscle will be painful whenever there is a centric slide

with an anterior component and the patient is bruxing or clenching in
this anterior position.

The lateral pterygoid, despite its commonality in displaying a spasm,

cannot be palpated intraorally.

Pain reffered to the TMJ

MEDIAL PTERYGOID

Palpation at the insertion of Muscle is at medial of angle of mandible .

Can be done intraorally also with two fingers placed externally Muscle
should be palpated bilaterally and simultaneously (to compare left and
right side

The muscle is not usually involved in gnathic dysfunctions but when they
are hypertonic, the patient is usually conscious of a feeling of fullness in
the throat and, occasionally pain on swallowing.

Pain reffered to to maxillary teeth,gonial angle,ascending ramus.

The DIGASTRIC muscles are usually not involved.

The STERNOCLEIDOMASTOID muscles may be involved in mandibular

dysfunction patients and they may be painful near their superior or inferior
attachments.

Temporomandibular Joint Examination

Diagnosis of Temporomandibular disorders requires an understanding and

examination of the articulatory system.

The Articulatory System is comprised of three components:

1. The Temporomandibular joints,

2. The muscles of mastication ,
3. Occlusion.
Their is such an intrinsic interdependence between the components of the
Articulatory System, that any change in one is almost certain to effect one or
more of the others.
Tenderness to palpation

The TMJ is palpated on both sides of the face with the mouth open wide
and closed.

Pain or tenderness over the joint is an indication of an inflammation in the

joint capsule or within the joints. The uppermost portion of the condyle
normally rotates and moves forward as the mouth is opened wide. A finger
should be placed in the immediate pre-auricular area, gently applying
pressure on the lateral pole / head of the condyle while the jaw is closed.

The level of pain and discomfort on each side should be assessed and
compared.

Joint sounds

There are 2 types of joint sound to look out for:

CLICKS - single explosive noise .
CREPITUS - continuous 'grating' noise.

CREPITUS

Crepitus is the continuous noise during movement of the joint,

caused by the articulatory surfaces of the joint being worn.

This occurs most commonly in patients with degenerative joint disease.

The joint sounds should be listened to with a stethoscope, preferably a

stereo one, as the two sides can be more easily compared.

Range of motion

This is the only truly measurable parameter, as the others are more
subjective. It is just as important to record jaw movement as a means to
assess the rate and degree of improvement as it is to determine the
severity of symptoms.

Movements to be measured are:

Incisal opening - pain free limit .

Incisal opening - maximum (forced).

Lateral mandibular excursions .

Mandible deviations on pathway of opening.

The incisal opening is measured from the upper incisal tip to the lower,
with the patient first of all opening to the limit of their comfortable, pain
free range.

This is then compared to the normal range of motion (normal is 35-50

mm).

Their maximum (forced) limit is also recorded. It is important to determine

whether a limitation of vertical movement is due to pain or a physical
obstruction.

If it is pain, then it may be a muscular problem, if an obstruction, then disc

displacement is most likely.

Lateral Excursions

The lateral movement should be measured from mid-line to mid-line, the

patient moving the mandible to their maximum extent, from one side to
the other.

Mandibular deviation

When the jaw is opened, the path it follows should of course be straight
and consistent. Deviations from the norm are either lasting or transient,
and are all suggestive of internal derangements of different sorts.

Mandibualr movments

Protrusive

Right lateral.

Left lateral.

Transient deviations

Transient deviations occur when the joints are moving as far but at
different rates. This is often caused by disc displacement with reduction.

Salivary Glands

Examination of the Lymph Nodes

Intra Oral Examination

Residual alveolar ridge

Arch size.

Arch form.

Ridge form.

Height of the residual ridge.

Ridge relations.

Inter arch space.

Ridge parallelism.

Irregularities of the ridge.

Arch Size

Denture bearing area increases with arch size in turn increases retention.

Discrepancy of arches lead to difficulties in teeth arrangement, stability of

the denture in the smaller arch is effected.

Class I : Large ( ideal retention and stability ).

Class II : Medium ( Good retention and Stability ).

Class III : Small ( Retention and stability poor ).

Arch form

House Classified arch forms as :

Ridge Form / contour

High ridge with flat crest and parallel sides ( ideal ).

Flat ridge.

Knife edge ridge.

Classification of maxillary ridge contour :

Classification of Mandibular Ridge Contour:

BONY UNDERCUTS

May be an aid to retention.

Cause loss of peripheral seal.

Selective relief sufficient.

Maxilla anterior ridge & lateral to tuberosities.

Mandibular under mylohyoid ridge.

If undercuts severe - Require surgical intervention

Class I :- bony undercuts are absent.

Class II :- There are small undercuts over which the denture can be placed
altering the path of insertion.

Class III :- Prominent bilateral undercuts are present that must be

corrected by surgery.

Tori

Abnormal bony prominences.

Mid palatal in maxilla.

Lingual side of mandible. Premolar region.

Surgical intervention not necessary unless they are big & interfere.

Require relief due to thin mucosal covering.

Class I : Tori absent or small, will not interfer with denture construction or
use.

Class II : Tori present, mild difficulties for adaptation of the dentures,

surgical intervention is optimal.

Class III : large tori, extend up to PPS, surgical intervention is necessary.

Inter arch space

Increased inter arch is due to excessive resorption, with reduced retention

and stability

Reduced space cause problem in teeth arrangement, with increased

retention due to decrease in leverage forces

Parallelism of ridges

Relative parallelism between planes of ridges.

Denture stability enhanced by parallel ridges.

Teeth arrangement is easier in parallel ridges.

Relation between arch size and aperture

Relation between size of the opening and arch size and shape are critical
for patient and dentist.

Ridge relation

Relationship of the mandibular ridge to the maxillary ridge.

Related to resorption pattern.

Anterior posterior relation .

Class I- normal

Class II

Class III

Cross bite A

Anterior ridge relation is normal, posterior ridge relation is prognathic.

Cross bite B

Posterior ridge relation is normal, anterior ridge relation is prognathic.

Class A: Most of the alveolar ridge present.

Class B: Moderate alveolar ridge resorption has occurred.

Class C: Advanced alveolar ridge resorption has occurred, only basal bone
remains.

Class D: Some resorption of the basal bone.

Class E : Extreme resorption of basal bone.

Soft palate

Important to observe the relation of soft palate to hard palate.

Called palatal throat form.

Class I :

Found on a line drawn between the two hamular notches

GAG REFLEX

Normal defense mechanism.

Initiated by-systemic disorders, psychological, extra oral, intraoral and

iatrogenic factors.

Management : psychological, pharmacological

Classified as :- normal, hyposensitive, hypersensitive.

Class I : No response on palpation, Normal.

Class II : Minimal response, indicates patient is sensitive, Sub normal.

Class III : Violent response, indicates patient is hypersensitive, Super

Normal.

Shape of the Hard Palate

Shape of vault examined

U shaped ideal for retention and stability with well defined incline of
rugae.

Maxillary tuberosity

Often enlarged, covered by movable fibrous mucosa, or With bony

undercut.

Class I : No Undercut.

Class II : Small undercut, place denture with changing the path of insertion
or relieving in that area.

Class III: Prominent bilateral undercuts, need surgical correction,

correction limited to one side.

Mucosa

Colour -

1. coral pink,
2.

redness indicates inflammatory change, - inaccurate impression.

3. Pigmented lesions- light to dark brown or blue.

4. White patches frictional keratosis, cheek biting.

5. Fordyce's granules.

Color of the mucosa

Healthy mucosa - pink.

Common causes for irritation:

Condition of the mucosa

Classified as :

class 1 healthy.
class 2 irritated.
class 3 pathologic.

2. Thickness of mucosa

Varying in thickness make it difficult to equalize the pressure under the

denture and to avoid soreness.

Ideal oral conditions.

Mucoperiosteum uniform thickness. approximately 1mm, firm but not

tense.

Tissue can be displaced approximately by 2mm.

Cushion like effect. Will not produce gross positional defects.

Class 2

Mucoperiosteum with smooth surface, susceptible to irritation from

pressure.

More than 1 mm in thickness.

Increased tendency of denture to shift.

Condition is poor for developing adhesion and border seal.

Muscle and Frenal Attachments

Examined for favorable and unfavorable position in relation to the crest of

the ridge.

If too close to the crest , require surgical correction.

Cause displacement of dentures during action.

Saliva

Major glands orifices should be examined for patency

Viscosity determined

CLASS I: normal quality and quantity saliva with ideal cohesive and adhesive
properties
CLASS II : excessive saliva, too much mucus
Class III: Xerostomia, poor retention and tissue irritation

Thick ropy saliva alters seat of denture

Tongue

Examination of position, size, shape and coordination.

SIZE
Large Tongue - decreases the stability of denture and hinders impression
making,
- tongue biting.
Small Tongue - leads to inadequate peripheral seal.
Movement & Coordination
Good movements for peripheral tracing.
Maintaining denture during functional activities.

Smith Described two anatomic tongue types:

Floor of the mouth

Critical for prognosis of lower denture.

If raised too high, upto crest of the ridge especially in sublingual and
mylohyoid regions the retention and stability is reduced.

Can be measured with Williams probe.

Touch upper lip with tongue to activate the muscles.

Alveolingual sulcus

Extends posteriorily from lingual sulcus to retromylohyoid curtains on

either side.

Space for lingual flange.

Can be divided in to three parts :

Anterior third : lingual frenum to the place where the mylohyoid ridge
curves down the level of the sulcus Pre mylohyoid fossa.
Middle third : Extends from the premylohyoid fossa to the distal end of the
mylohyoid ridge.
Posterior third : retromylohyoid space or fossa extending from end of
mylohyoid ridge to the retromylohyoid curtain.

EXAMINATION OF EXISTING DENTURES

Mucosa examined for pathological changes.

Evaluation of

Denture cleanliness.

C R & CO, premature contacts ,sliding.

Vertical dimension.

Denture extensions.

Type of teeth.

Retention ,stability.

Esthetics.

Phonetics.

SPECIFIC INVESTIGATIONS

Radiographs:

Panoramic radiographs play an important role in diagnosis &treatment

planning in completely edentulous patients.

Study the residual alveolar ridge resorption.

Mandibular RAR resorption can be classified.

Class IUpto 1/3rd of original vertical height lost

Class II-From 1/3rd to 2/3rd of original vertical

lost.

ClassIII-2/3rd or more of original vertical height lost.

Radiographic examination for the bone density.

Study the location of anatomic structures.

RADIOGRAPHIC EXAMINATION TMJ

height

Panoramic projection bilateral view of condyle& fosssa relation,

oblique posterior ,anterior view of the joint .
To rule out gross intra
osseous defects.

Transcranial projectionlateral view of TMJ.Spicules &erosions of lateral

surface

Transorbital projection---medial & lateral surface.

Submento vertex view---the surface of condyles

Tomography: Specialized technique that allows detailed images of

structures in a predetermined plane ,while blurring the
unwanted
structures.

Classic tomography: Several exposures of selected area at orbitrary

intervals or section.Lateral, medial, central parts of joint as separate
images.

Computed tomography: Scanning of well defined area.

-The computer analyses X-ray absorption at many different points &

converts them into an image on a video screen.

-Gross determination of condyle disk relation

Arthrography:

Magnetic resonance imaging:

Bone scintigraphy:

Diagnostic casts

Aids in the evaluation of anatomy & relationships in absence of patients.

Evaluation of following

Ridge relationship

Diagnose missed findings

Conform clinical findings

Measuring & determining relation to other structures

Decision about preprosthetic surgery

Undercut surveying.

Pre extraction records:

Photographs showing natural teeth.

Old radiographs.

Diagnostic casts & radiographs obtained from other dentist.

EXISTING DENTURES

Using the patient`s existing dentures impression made

casts made.

With tentative CR & face record mount the maxillary cast on to the
adjustable articulator, orient the mandibular casts with CR.

Check vertical dimension ,CR &CO.

OTHER INVESTIGATIVE PROCEDERES

To Rule Out DM

RBS

FBS

PPBS

& diagnostic

Patients BP should be recorded.

BT

CT

Prothrombine time

Hb gm%.

If any Intra or Extra Oral lesion advise for Biopsy Histopathological

Examination .

TREATMENT PLAN

The treatment plan should specify regarding the treatment

procedures,operating time,laboratory time,calender time & fees such that
patient informed consent regarding the same can be obtained.

Treatment plan for completely edentulous patients includes:

Adjunctive care---Pt education &motivation.

----Elimination of infection.
----Elimination of pathoses.

----

Treatment of abused tissues.

conditioning.
counseling.

----Tissue
----Nutritional

Prosthodontic care Conventional complete denture.

--implant supported complete denture.

ADJUNCTIVE CARE

Patient education:

Information about their dental health &it`s effect on the treatment

outcome.

Limitation of complete denture.

Problems associated with complete denture initially.

Importance of oral & denture hygiene.

Need for regular check up.

Convincing about the Rx procedure, need for the surgical Rx, time
required, fees.

Motivation of the patient.

Diet counseling: Diet rich in proteins, calcium, vitamins, minerals, low

calorie diet.

If required referred to dietician, physician.

SURGICAL METHOD

1)Correction of hyperplastic ridge tissue, epulis fissuratum,

papillomatosis ,hyperplastic pendulous tuberosity.

Indicationno response to nonsurgical Rx procedures.

--interferes with stability .

Excision of the tissues with vestibuloplasty. Electro surgery.

2)Frenal attachments-maxillary labial frenum broad fibrous band, lingual

tongue tie, prominent buccal freni

Indicationsnear to crest of ridge.

Frenectomy.

3)papillary hyperplasia-Small lesion with sharp curettes electro

surgery.
-Large lesion split thickness supra
periosteal flap.

4)Vestibuloplasty-Restores the ridge height

attachments & attached mucosa.

by lowering the muscle

OSSEOUS ABNORMALITIES

Ridge undercuts.

Prominent mylohyoid & Internal oblique ridge-surgical recontouring

repositioning of muscle attachment.

Prominent genial tubercle-surgically removed & genioglossus muscle

sutured to geniohyoid muscle.

Bony tuberosities.

Residual ridge sharp, spiny.

Torus palatinus.

Torus mandibularis.

Discrepancies in jaw size.

Mental foramen with sharp extended margins.

Ridge augmentation.

FABRICATION OF COMPLETE DENTURE

Conventional complete denture.

Implant supported.

Previous h/o failures with conventional complete dentures

Good health, affordable.

Patient with compromised motor skills, advanced residual ridge

resorption.

If dose not like to wear dentures.

Free way space.

CL 1: 2mm

Cl 2: more than 2 mm.

Cl 3: Less than 2mm.

In the premolar region.