EXAMINATION & DIAGNOSIS OF

EDENTULOUS PATIENTS
Presented by:
Dr. Jehan Dordi
1st Yr. MDS

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 CONTENTS
• Introduction
• Social Information
• Medical History
• Dental History
• Radiographic Examination
• ACP classification for complete edentulism
• Treatment plan
• References
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 INTRODUCTION

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According to Winkler

“Successful CD therapy begins with a thorough assessment of

patients physical & psychological condition & determining a
treatment that will condition the expectations of the patient.”

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 DEFINITION
Diagnosis-
• According to Winkler it is the examination of physical state,
evaluation of the mental or psychological setup & understanding the
needs of the each patient to ensure a predictable result.

• According to Zarb & Bolender it involves identifying & making

judgement about departures from a healthy site.

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• According to Rahn & Heartwell it is :-

The act or process of deciding the nature of a diseased condition

by examination .
A careful investigation of facts to determine the nature of a thing.
Determination of the nature , location & cause of disease.

Examination:
• It is scrutiny or investigation for the purpose of making a diagnosis
or assessment.
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Treatment Planning
• According to Rahn & Heartwell it is consideration of all of the
diagnostic findings (systemic & local), which influence:-
• The surgical preparation of the mouth
• Impression making
• Maxillo-mandibular relation records
• Occlusion to be developed
• Form & material in the teeth
• The denture base material &
• The instructions in the use & care of dentures .

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• According to Winkler it means developing a course of action that
encompasses the ramification & sequelae of treatment to serve the
patient’s needs.

• According to Zarb & Bolender it is the process of matching

possible treatment options with patient needs & systematically
arranging the treatment in order of priority but in keeping with a
logical or technically necessary sequelae.

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 PRINCIPLE OF PERCEPTION
• Visual perception is primary mode of data gathering in any type
of examination. It is like seeing by eyes and interpreting by
brains.

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According to Zarb & Bolender there are 5 typical principles of these
perceptions
1. Detection-determining its presence.

2. Discrimination-distinguishing that, which has been noticed from

something else.

3. Recognition- deciding whether these or atleast something similar has

been perceived on some previous occasion.

4. Identification-it is process of specificity.

5. Judgement- allows something that has been observed , to be placed

within a spectrum of knowledge.
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 According to DCNA case history should include

Personal data:-

• Name

• Age

• Sex

• Occupation

• Cosmetic index

12 • Personality
Medical History:- Denture History :-

• Systemic factors • Chief complaint

• Expectations
• Localized lesions • Years of Edentulousness
• Previous / existing dentures
• Pathology • Experience with dentures
• Pre extraction records

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Clinical Evaluation:-
• Facial form
• Muscle tone
• Muscle development
• Complexion
• Lip
• TMJ
• Neuromuscular evaluation
• Arch size
• Lateral throat form
• Palatal throat form
• Palatal sensitivity
• Mucosal thickness
• Mucosal condition
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• Ridge form
• Undercuts
• Defects
• Tori
• Interarch space
• Ridge parallelism
• Ridge relation
• Border attachments
• Frenum attachments
• Muscle attachment
• Saliva
• Tongue size
• Tongue position
 Data Collection

• Data must be:-

• Easily retrievable
• In a logical sequence
• Be kept confidential

• Data / information gathering can be done in any of the 3 ways:-

• Direct interrogation by the dentist
• A comprehensive questionnaire
• A combination of both
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Direct interrogation
• Offers a greatest information regarding patients.
• Questions asked are brief & general in nature.
• Can be probing and overlapping on points, dentists deem important.
• Helps developing rapport with patient.
• Helps evaluating patient’s attitude towards treatment.

Disadvantage
• Time consuming.
• Relies heavily on skills & experience of dentist.
• Necessary questions might not be asked if forgotten.
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A comprehensive questionnaire
• It is quick & is filled by patient in waiting room.

Disadvantages:-
• Patient may not read properly.
• May overlook important information.
• May give it to companions to fill which will lead to errors.

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A combination of both
• Added advantages of both direct & comprehensive technique.

• Form filled by patient can be verbally reviewed.

• Any +ve / -ve response may be noted & clarified.

• Chance to correlate between examination observation & patient

health history.

• Any conflicting information may be thoroughly probed.

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 SOCIAL INFORMATION

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Name (must for ) –
• Identification
• Building rapport
• Gaining confidence of patient
• For data record keeping

Age: indicates ability to wear dentures successfully from prosthodontic point of

view.
In 4th decade we see :-
• Rapid healing of tissues.
• More resilient tissues.
• Ease in patient adaptation to denture.
• Patients are more esthetically concerned.
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• In 5th decade onwards:-
• No rapid healing.
• Tissue not much resilient.
• Menopausal hormonal changes make women patients more exacting or
hysterical type for esthetics.
• Longer learning period because of muscle insufficiency.
Sex
• Women have high priority for esthetics.
• Young men though have high priority for looks, older men grow indifferent for
the looks.
• However men shift their concern more towards comforts & function.
• Osteoporosis is more seen in women above 50 years of age. This may lead to
more bone resorption & less support for the denture.
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Race:
• They are useful for characterization of denture like shades & stains.

• Blacks may require slight whiter shade of teeth than the white race
people

Habit:
• It helps identify conditions responsible for present condition & those
which may affect future success or failure of treatment (smoking)

• It may give idea about oral hygiene habit/denture cleansing habit

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Occupation:
• It influences the degree of importance of factors like esthetics,
phonetics & general appearance.
• Job & social standing determines the value patient gives on his/her
dental health/esthetics.
• Professionals having direct people contact prefer appearance/retention
more often then efficiency.
• Public speaker / singer need perfect retention as well as proper palatal
shape/base thickness for phonetics.
• Wind instrument player need special modification for instrumental
playing
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Cosmetic Index
• It is basically about esthetics expectations.

• Class 1 – (High Cosmetic Index)- they are often exacting but usually
appreciate & co-operative

• Class 2 –(Moderate Cosmetic Index)-they are the patient with

nominal expectations.

• Class 3 – (Low Cosmetic Index)-patient are indifferent, un-

cooperative & place little value on the effort of prosthodontists.
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Personality:
• It consists of mental health, patient attitude towards new denture,
patients adaptive response.

• Analyzing personality gives opportunity to dentist to peep inside his

brain.

• Patients mental attitude may be classified According to Dr. MILUS

MARYLSON HOUSE (1960).

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 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
favorable.

 Exacting:
• All good attributes of philosophic patient.
• Require extreme care, effort and patience on the part of the dentist.
• Immaculate appearance and dress.
• Methodical, precise and accurate and at times make severe demands.

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• Likes 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:
• Submit to treatment as a last resort, have negative attitude, often poor health,
unfounded complaints.
• Emotionally unstable, excitable, apprehensive and hypertensive.
• Unrealistic expectations.(demand equals to natural teeth)
• Prognosis is often unfavorable.
• Additional professional help (psychiatric) is required prior to and during
treatment.
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 Indifferent:
• Questionable or unfavorable prognosis.
• Little concern for their teeth or oral health.
• Without dentures or worn out dentures for years.
• 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.
• Do not value the efforts or skills of the dentist.
• Require more time for instruction on value and use of their dentures.

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 New M.M. HOUSE Classification

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MM HOUSE MENTAL CLASSIFICATION REVISITED : INTERSECTION OF PARTICULAR PATIENT
30 TYPES & PARTICULAR DENTIST’S NEEDS(J Prosthet Dent 2003;89:297-302.) SIMON
GAMER,TUCH,GARCIA
 Medical history

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A complete health history should include:

• Name of the physician, including data & reason for last appointment.
• A record of status of all major systems of body.
• A record of all medications the patient is currently taking.
• A record of any hospitalization.
• A record of any complication that was result of previous dental
treatment.
• A record of patient opinion of his/her general health.
• Space to update health history whenever patient is recalled

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Many systemic diseases might or might not have oral manifestation but
some have a direct relation to denture success these are:-

Debilitating disease
• Debilitating diseases includes diseases like diabetes , tuberculosis ,
blood dyscrasias etc.
• These patients require extra instructions in oral hygiene, eating habits
& tissue rest.

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DIABETES
• An uncontrolled or poorly controlled diabetics may pose problem of:

• Bacterial viral & fungal infections including candidiasis.

• Xerostomia- it causes dry atrophic oral mucosa accompanied by mucositis,

ulcers, desquamation & opportunistic infection.
• Inflamed , depapillated painful tongue.

• Difficulty in lubricating , masticating & swallowing are the complications

that make denture wearing a bad experience.
• Poor wound healing / multiple abscess

• Burning mouth syndrome

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Hypoglycemia:
• Most common dental complication seen in patients taking insulin.
• Shakiness / tremors
• Dizziness
• Confusion • Unconsciousness
• Agitation / anxiety • Seizures
• Sweating
• Tachycardia

Treatment:
• Prevention-instruct the patient to take regular diet & then insulin.
• Schedule the appointment in morning.
• Keep treatment visit short.
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Tuberculosis:-
• Immunity is low
• Clinician should find whether disease is active/passive
• Precaution in sterilization/protective gear should be worn.

Blood Dyscrasias:-
• Anemia- most commonly found
• Results in mucosal ulceration / infection
• Tongue becomes atrophic, inflamed & sore

• Other blood dyscrasias are like leukemia, neutropenia which may affect
denture success.

• In all cases care should be taken not to bruise oral mucosa while
extending
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or recording border tissues
Cardiovascular disease:
• Consultation with cardiac physician is a must.

• If CVD is present, denture procedure of any type may be

contraindicated.

• Short appointment with pre-medication is necessary.

• Patient with history of rheumatic fever & RHD are susceptible to

infective endocarditis.

• So prophylactic antibiotic coverage for all dental procedure is

indicated mainly in surgeries.
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Other Precautions In Case Of CVD

• Reduce stress or anxiety.

• Make patient free to express.
• Keep short appointments & in morning.
• Premedication with diazepam 5-10 mg to decrease apprehension.
• In case of angina pain Tab. nitroglycerine sublingually

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 DISEASES OF JOINTS
Osteoarthritis:
• Occurs under 45 yrs. of age, men are twice more susceptible then
women.
• 45-65 yrs. women affected more.
• >65 yrs. both affected equally.
• Normally affects weight bearing joints & secondarily TMJ.

Prosthodontic considerations
• If terminal finger joints become arthritic, it is difficult to clean or
insert dentures.
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• Osteoarthritic TMJ presents problems in CD construction as
mandibular movements are painful & jaw relation records are
difficult to record & repeat.

• Occlusion correction must be made often because of subsequent

change in joint.

• Special impression trays are necessary due to limited access from

reduced mouth opening.

• In extreme cases surgery may be required.

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 Disease of Skin
• Dermatological conditions like pemphigus, erosive oral lichen planus
may make oral mucosa extremely painful.
• The constant use of denture is contraindicated

Neurological disorders
• Bell’s Palsy & Parkinson’s Disease
• Patient may be given normal prosthetic treatment but denture
retention, Maxillo-mandibular relation record & supporting
musculature pose denture problems
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 Radiations
• Patients treated with radiations may develop:-
• Mucositis • Trismus
• Xerostomia • Secondary infection ( candidiasis )
• Loss of taste • Osteoradionecrosis

• Before radiation treatment is started:-

• Infection should be treated
• Extraction of all remaining teeth should be done if CD is planned
• Pre-prosthetic surgeries should be performed
• Accurate casts are made before surgery/radiation that later aid in treatment.
• Denture bearing area should be carefully watched for Osteoradionecrosis.
• Denture should be used on limited basis.
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 Hormonal Disturbances
Acromegaly- increase in growth hormone.

• Patient need frequent adjustment and/or new denture.

Hyperthyroidism-decrease salivary flow.

• Inflammed mucosa.

• Thyrotoxic crisis may get precipetated by stress/trauma during

prosthodontic treatment.

• Osteoporosis also might get developed.

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Hypothyroidism-may develop to hypothyroid coma under stress
• Increase tongue size & gingival edema leads to poor denture design &
stability.
• Hyperparathyroidism- incresed alveolar resorption.

Allergies.

• Allergy to any drug or denture material is noted.

• Avoid all allergic factors.

• In case of emergency- 0.3-0.5 ml of epinephrine 1:1000 IM should be

given
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 Disease Of Respiratory System
• Asthma /COPD/ Pneumonia.

• Consult physician.

• Short morning appointments.

• Keep inhaler in handy.

• Avoid NSAID( IBUPROFEN)

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 Drug History
• Dentist should know all the medicines patient takes because:-

• It indicates systemic diseases the patient is suffering from & this

could alter dental treatment

• Compatibility of dentist’s prescribed medicines & physician should

be there.

• Conditions which affect the prosthodontic treatment & the drugs

causing them.
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 DENTAL HISTORY

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Chief complaint:

• The dentist should meet the mind of the patient before he meets
mouth of the patient
• This helps in determining the factor for which the patient is
seeking treatment
• If not asked, chief complaint may be overlooked by dentist which
should not happen
• Dentist can access whether the expectation is realistic or
attainable.

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Expectations:
• Patients expectations must be determined, then it should be evaluated
whether it is realistic or attainable.
• Dentist must be able to classify patients personality & accordingly
should not make unrealistic promises.

• Years of Edentulousness:
• It provides information regarding bone resorption pattern &
progression as well as timing of tooth loss.

• Patient should be questioned for reason of tooth loss.

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Detailed information should be obtained & this should contain:-
• Cause of tooth loss.

• History of difficult extraction.

• Order of tooth loss.

• Length of edentulous time- gives idea of resorption.

• History of healing-sufficient / incomplete.

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Denture experience/history:

• Information to be recorded are:-

• No. of dentures the patient has used.

• Length of time each has been used & reason for replacement.

• Denture adhesive / suction cup if used.

• Type of material used.

• Degree of satisfaction with Mastication, Retention, Stability, Esthetics,

Comfort, VD, & Phonetics
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Existing Or Current Dentures
• Length of time patient is wearing.
• Satisfaction.
• Point on denture care ability should be noted.
• Problems associated with current denture, its nature, type, & whether it
can be corrected.
• Distribution of tissue contact can be revealed by pressure indicating
paste.
• Occlusion in harmony with jaw relation should be evaluated.
• Esthetics whether acceptable & whether should be altered or duplicated in
new denture should be determined keeping in mind its possibility/
patient’s desires.
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• Pre-extraction records
• Pre extraction photographs.
• Radiographs.
• Casts & Facial close up is always helpful in denture therapy for
recreation of esthetics & support as well as evaluation of VD.
• Cast is most valuable among all because of its 3-D information.

• Pre extraction records can be used to reproduce the anterior

esthetics. They can also be used to guide jaw relation.

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 CLINICAL EXAMINATION

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 Extra-oral Examination
• Head & neck region should be examined in general.
• Nodules, nevi, ulcerations if any should be noted.

• Face Ideally face can be divided in thirds

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 FACIAL EXAMINATION
Facial form:-
• Leon Williams classified facial form into 4 types:-
• Square
• Tapering
• Square tapering
• Ovoid

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• To determine the type, clinicians imagine two lines, one on either
side of the face, running about 2.5 cm in front of the tragus of the ear
& through the angle of the jaw.

• If these lines are almost parallel:- SQUARE

• If they converge towards the chin:-TAPERING

• If they diverge at the chin:- OVOID

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Facial profile
• According to angle
• Class 1- Normal
• Class 2- Retrognathic
• Class 3- Prognathic

• Consider line joining forehead and edge of the upper lip and upper
lip to chin.

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According to profitt:-
• Line joining the forehead, bridge of
nose, & border of upper lip.
• Line joining upper lip to chin (soft
tissue pogonion ).
• 3 points are choosen: Glabela,
Subnasion & Pogonion

• When joined, if these 2 lines are :-

• Straight- class 1
• Convex- class 2
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• Concave- class 3
Muscle Tone
• House Classification-
• Class 1 – patient exhibits normal tension, tone, & placement of
muscles of mastication & facial expression. No degenerative
changes. Normally seen in immediate denture patient only.

• Class 2-patient displays approximately normal function but slightly

impaired tone. Seen in recently edentulous patient

• Class 3- greatly impaired muscle tone & function. This is associated

with poor health, inefficient dentures, loss of VD, wrinkles,
decreased biting force & drooping commissure.
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Muscle development
• According to house classification
• Class 1 – Heavy
• Class 2 – Medium or normal
• Class 3 – Light

Complexion
• With age, skin becomes thinner and melanin pigmentation accumulates in skin
and hair leading to darker in shade with age. (Heartwell)

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• Hair, eye and skin color provide useful guides in shade selection.

• Yellow is dominant with fair hair ,blue eyes and fresh complexion

• Grey tinged with blue is dominant with dark hair brown eyes and
dark complexion

• Opal is dominant with clear, pale complexion irrespective of color of

hair and eyes.

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Smile architecture

Type 1(based on lip component)

• Straight smile
• The lower margin of upper lip is straight
horizontally

• Smile space is seen as having a hemisphere

like outline and having a straight upper
border and usually concave lower border

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Concave smile
• Lower margin of upper lip is concave
horizontally with concavity upward.
• Smile space is seen as having a crescent
shape outline and concave upper border and
usually concave lower border.

Convex smile
• Lower margin of upper lip has to be convex
horizontally.
• Smile space is seen as having a convex upper
64border and concave lower border.
• Type 2 (tooth and soft tissue
component)
• Tooth smile
• Papilla smile
• Gingival smile
• Mucosal smile

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• Slope of forehead (classified as)
• Steep
• Protruding
• Flat

• For steep ---- dental base will be

more prognathic than the flat one

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 Lip
• Lip should be examined for cracking fissure and ulceration because
these changes are seen in vitamin B complex deficiency, infection
such as herpes labialis candida , or neoplasia.

• Lip should then be examined for lip support, fullness, thickness and
length.

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Lip support:
• Lack of proper lip support can lead to a collapsed appearance and
wrinkling.
• How to find out lip support?
• If only tissues around mouth is wrinkled and rest of the face is
normal then lack of support is suspected.

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• If this lacking is due to too palatal positioning of anterior teeth it can
be confirmed by adding wax

• However too far anteriorly placed teeth to support the lip may cause
leverage on maxillary denture causing loss of stability.

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• Another way is by assessing nasolabial angle.

• If nasolabial angle is increased after wearing denture --means

drooping of lip and loss of lip support occurs.

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Lip fullness
• It is related to the support lip gets from
mucosa or teeth or denture base.

• Denture with thick labial flange may

make the lip appear too full.

• An obliterated philtrum or mentolabial

fold suggests excessive support.

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Lip thickness
• It is because of intrinsic structure of lip itself.
• Two types of lip thickness
1. Thin lip
2. Thick lip

• In Thin lip type any change in labiolingual position of teeth can alter
fullness/support or drape of thin lip.

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• Lip length

• Classified as
• Long
• Normal
• Short

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• Length of the lip will affect how much the teeth will be exposed
during rest and function

• Short lip
More exposure of the teeth or sometimes denture base also.
Seen in incompetent lip

• Long lips hide denture base and most of the teeth

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How to check lip length?
• Vertical lip relation: In lower facial height, length of upper lip is
equal to one third. Length of lower lip plus chin should be two third.

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Horizontal lip relation (lip step)

• It is A-P relationship of upper to lower lip

• Can be classified as
• Normal-lip step is slightly negative
• Positive -lip step positive (seen in class III case)
• Marked negative - seen in class II cases

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Nasolabial angle
• Normal is 110 degree
• It is measured line joining subnasale and anterior most point of
collumella and subnasale and upper lip border.
• In class II or protrusion of upper lip angle is decreased.
• In class III or retrusive position of upper lip nasolabial angle
increases.

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Mouth opening
• Normal mouth opening is 40-45 mm (rakosi)
• Decrease is called as trismus.

• Causes of trismus are:

• Trauma
• Tumor
• Localized inflammation
• TMJ disorders
• Pericoronitis
• Myositis ossificans
• Scleroderma
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 Palpation Of Muscles Of Mastication
Temporalis
• It is palpated bilaterally and extra orally in isometric contraction.
• Tendon of temporalis is palpated intraorally when mouth is half open
in the posterolateral region of buccal vestibule near coronoid process

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 Lateral pterygoid

• Palpated intraorally in close proximity to neck of condyle and joint

capsule behind maxillary tuberosity.
• Examination is carried out with mouth open and mandible displaced
laterally.

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Medial Pterygoid
• It can be palpated by placing the finger on the lateral aspect of the
pharyngeal wall of the throat, this palpation is difficult and sometimes
uncomfortable for the patient.
• Functional manipulation is done when the muscle becomes fatigued
and symptomatic. The muscle contracts as the teeth are coming in
contact Also stretches when the mouth is open wide

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Masseter
• Examined extraorally in isometric contraction.
• Superficial muscles are palpated beneath the eye inferior to
zygomatic arch.
• Deep portion is palpated two fingers width in front of the tragus

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 Temporomandibular Joint
• Examined by visualization/palpation and auscultation .

Temporomandibular joint disorder symptoms

• Pain and tenderness at TMJ and muscles of mastication
• Sound during condylar movement
• Limitation of mandibular movements

• TMJ problem affects mandibular movement and masticating efficiency.

• This can be checked by asking patient to open mouth about half way and
move the lower jaw from left to right then to put the tongue into right
cheek and then to left cheek, to stick it out and to back and up inside
mouth.
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Lateral palpation
• Exert slight pressure on condyloid process with index figure.
• Palpate both sides together
• Register any pain/ tenderness /irregularity in movement while closing
or opening
• Co ordination between left and right TMJ should be noted

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 Posterior palpation
• Position little finger in external auditory meatus and palpate posterior
surface of condyle during opening and closure.
• Palpation should be carried out in such a way that the condyle
displaces the little finger when closing in full occlusion.

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• Auscultation done by stethoscope

Types of clicking
• Initial movement –sign of retruded condyle in respect to disc
• Intermediate—sign of unevenness of condyle and disc
• Terminal – occurs most commonly results in condyle being moved
too far anteriorly on maximum opening
• Reciprocal – occurs during opening and closing and expressed in
coordination between disc and condyle

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Neuromuscular control
• House classification
• Class 1 Enough muscular control to use denture effectively and not
to exceed physiologic tolerance of denture bearing tissues by putting
excessive pressure on teeth.

• Class2 Patient chews with great force. Heavy force can cause sore
mouth as tissue tolerance limit exceeds.

• Class 3 Slight deviation of muscle coordination .They are light

chewers and can not control dentures effectively.
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 Intraoral examination

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 Mucosa
• Examine for color/ texture / contour and continuity.
• Normal color—healthy pink.
• Angry red indicates inflammation caused by mechanical / chemical /
bacterial irritation

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Causes of abnormally thick mucosa
• Excessive load in A-P or lateral direction e.g natural lower anteriors
against upper CD causes resorption of the ridge which then gets
covered by bunched rugae from palatal mucosa/submucosa

• Hyperplasia: It may occur from resorption and excessive load e.g.

papillary hyperplasia in center /fibrous hyperplasia in peripheral
tissue

• Adverse periodontal disease: Results in loss of bone and after

extraction of teeth excess gingival tissue may lead to thick flabby
tissues.
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• Thin mucosa gets ulcerated and not good for developing PPS and
hence retention is difficult.

• Thick mucosa leads to lack of stability ,less tissue tolerance and jaw
relation will be difficult to obtained. In this case non anatomic teeth
should be preferred.

• Inflamed and abused mucosa should be treated first, etiology should

be determined and stopped before impression procedure.

• For existing denture 5-7 days of rest is recommended. Unusual slow

recovery indicates low general health index.
91
 Common prosthetic cause of irritation of mucosa

• Overextension of denture periphery

• Dry ill fitting denture
• Continuous wearing of denture
• Faulty occlusion of denture
• Rubber suction discs
• Traumatic injury
• Small spicules of alveolar ridge
• Denture stomatitis
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 Basal seat examination
 Arch size
• The size is determine by amount of basal seat available for denture
foundation
• Classification
• Class 1 – Large (best for retention and stability)
• Class 2 – Medium (good for retention and stability but not ideal)
• Class 3 - Small (difficult to achieve good retention and stability)

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Greater the size more support

Large contact surface retention

Better prognosis
(winkler)

• Smaller arch bad retention poor prognosis

• Size provides a quick estimate of teeth size to be used

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• If arch size is small and arch size and face size is not in harmony
,esthetic will be jeopardized.

• If arch size is smaller than head size and muscle of mastication is

well developed, the functional demand of denture may cause injury.
Hence in this case patient training might be required.

• Smaller arch size may be due to genetics ,trauma, early tooth loss,
severe class II and III malocclusion.

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Arch form
• Class 1 square
• Class 2 tapering
• Class 3 ovoid

• The arch form affects support of the denture.

• It helps in proper stock tray selection as well as teeth selection and
arrangements

96
Ridge form
Maxillary
• Class 1 square to generally round
• Class 2 tapering or v-shaped
• Class 3 flat

• Ideal is high ridge with flat crest and parallel side – this gives max
support and stability
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Mandibular
• Class 1 Inverted U- shaped, Parellel walls ,high to medium height with
broad crest.
• Class 2 Inverted U-shaped with short flat crest
• Class 3 Unfavourable
• Inverted w
• Short inverted v
• Ridge with undercut (results from lingual or buccally placed teeth)

98
 Inter arch space
• Class 1 - Ideal interarch space to accommodate the artificial teeth
• Class 2 - Excessive interarch space
• Class 3 - Insufficient interarch space

• Interarch space is usually difficult to determine during initial

period of diagnosis unless the cast is properly mounted on the
articulator, but an early attempt should always be made for proper
diagnosis

99
Procedure
• Have the patient rest the jaw and carefully part the lips to examine
the distance. To stabilize the mandible dentist should rest his thumb
under patient chin. (Sharry)

• Inter ridge distance should be examined around entire arch as it

varies in different part of the ridge. Most frequent problem is seen
in retro molar tuberosity area.

• Small inter ridge distance in contrast to larger distance enhances

retention and stability (sharry)
100
• Retention is enhanced because the tongue contacting the lingual and
palatal surfaces of denture more completely fills the oral cavity
providing an excellent seal

• Stability increases because occlusal surfaces of the teeth are more

close to the ridge --- minimizes undesirable tilt and tongue forces.

• Disadvantage of small ridge distance is difficulty in teeth

arrangement.

• Large inter ridge distance caused by the marked resorption of the

ridge is a threat to retention and stability.
101
Ridge parallelism
• Class 1 Both ridges are parallel to occlusal plane
• Class 2 Mandibular ridge is divergent from occlusal plane
anteriorly.
• Class 3 Maxillary ridge is divergent from occlusal plane or
Both the ridges are divergent occlusally.

102
• To observe this relation tell patient to position jaw at VDO and part
the lip with finger and mouth mirror, or mounted diagnostic cast can
be used.

• Denture stability is enhanced by parallel ridge. In Natural dentition

the ridges are parallel

• To overcome un-paralellism implant supported denture should be

considered.

103
Ridge relation
• Class I Normal
• Class II Retrognathic
• Class III Prognathic

104
Bony undercut

• Class 1 : Bony undercut absent

• Class 2 : Small undercut over which denture can be placed either by
changing path of insertion or selectively relieving
• Class3 : Prominent bilateral undercut to be corrected by surgery(one
side/two side)

105
Exostosis/Tori
• Tori are benign bony enlargement covered by thin mucoperiosteum.
• Class 1 - Tori absent or minimal size. They do not interfere with
denture construction
• Class 2- Tori of moderate size. Such tori offer mild difficulties but
surgery is not required
• class 3- Large tori. Compromises function and fabrication of CD.
Surgery is required.

106
• In most of the cases of maxillary tori, relief can be provided in the
denture base.

• Mandibular tori should always be removed because seating the

denture will always be difficult. (Shafer)

• However maxillary tori if extended to soft palate beyond the

vibrating line should be reduced or removed.

• If surgery is opted, the thin cortical plate of tori which is removed

naturally, get replaced in 2-6 months (Zarb)
107
Maxillary tuberosity (sharry)

• Large tuberosity offer best option for success permitting wide areal
coverage and providing fine bearing surface.
• But they may pose problems such as
• Encroached inter ridge distance
• Large or opposing undercuts
• Pendulous unstable bearing surfaces

108
Lateral throat form (Retromyelohyoid fossa)
According to Neil
• Class 1 -Deep : 0.5 inch space exists between myelohyoid ridge
and the floor
• Class 2 -Moderate : Less than 0.5 inch space exists
• Class 3 - Shallow : Myelohyoid fold is at the same level as
myelohyoid ridge. Retention is difficult

109
Palatal throat form
• Class 1 - Large and normal. Relatively immovable band of resilient
tissue 5-12 mm distal to line drawn across distal edge of tuberosity
• Class 2 - Medium in size and normal in form. 3-5 mm of band of
tissue posteriorly.
• Class 3 - Soft tissue turns down abruptly 3-5 mm anterior to line
drawn across palate distal to tuberosity. It is seen in smaller maxilla

110
• Soft palate classification (Winkler)
• Class 1 - Soft palate rather horizontal with minimum muscular
activity. Here PPS area is maximum and not deep. Most favorable
for retention
• Class 3 indicates most acute contour of soft palate with hard palate.
Usually seen in V shaped palatal vault. PPS area is smaller and
deeper. Least favorable for retention
• Class2 in between class 1 and class3

111
Hard palate(winkler)

• U shaped- Most favorable for retention and lateral stability.

• V shape- Less favorable for retention. Slight movement of denture

base may cause break in seal.

• Flat palate- Unfavorable because accompanied by resorbed ridge.

Although retention is good, lateral stability is very poor.

112
• U shaped hard palate (Mc greggor)- It is well developed normally
thick ridges with moderate vault

Advantage
• Centre of palate presents almost flat horizontal area leading to good
retention
• Sulcus allows development of good peripheral seal
• Well developed ridge resist lateral and AP movement

113
High v shaped palate
• It is associated with thick bulky ridge which is unfavorable
• This is because forces of adhesion and cohesion is not at right angle
to the surface when counteracting the normal displacing forces of
gravity. In this case peripheral seal is essential.

• Flat palate with small ridge and shallow sulci are unfavorable
because ill developed ridge do not resist movements in lateral and AP
direction. Sulci do not provide good peripheral seal

114
Palatal sensitivity(gag reflex)
House classification
• Class 1 Normal response to palpation
• Class 2 Subnormal response(hyposensitive)
• Class 3 Supernormal response(hypersensitivity)

115
 Borders attachment
House classification
• Class 1 – Attachment high in maxilla or low in mandible in respect to
ridge crest (0.5 inch or more between level of attachment and ridge
crest)
• Class 2 - Attachment height is between 0.25 – 0.50 inches
• Class 3 - Attachment height is less than 0.25 inch from the ridge crest.

116
 Frenum attachment:
• House classification

• Class 1-High in maxilla low in mandible with crest ridge

• Class 2 -Medium (notch required)
• Class 3 -Freni encroach on the ridge crest and interfere with the seal.
Surgery needed.

• Mostly maxillary/mandibular, labial /lingual frenum require surgery.

Buccal frena rarely need correction

• In mouth exhibiting very poor retention the removal of all frenum

increases peripheral seal.
117
 Tongue Size
House classification
• 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

form and function

• Class 3- Excessively large tongue. Extended period of complete

edentulism allowing for abnormal development of size of tongue.
(Insufficient denture can lead to class 3 tongue development.)
118
• Wright’s classification of tongue position (winkler)

• Class 1 Tongue lies in the floor of mouth with the tip forward and
slightly below the incisal edges of mandibular anteriors.

• Class2 Tongue is flattened and broadened but tip is in normal

position

• Class 3 Tongue is retracted and depressed into floor of the mouth

with tip curled upward downward or assimilated in body of the
tongue.

119
• Class 1 is most favourable prognosis. Floor of mouth will be high
enough for proper border seal

• Class 2 and 3 are unfavorable. Because retracted tongue deprives

patient of border seal in sublingual crescent and may produce
dislodging force on distal region of lingual flange.

Prosthodontic consideration
• In edentulous cavity tongue can be enlarged.
• Increased instability of denture and difficulty in impression making.
• Small tongue – Decreased border seal.
120
Saliva
• Class 1 - Normal quality and quantity of saliva. Cohesive and
adhesive properties are ideal
• Class 2 - Excessive saliva, contains much mucous
• Class 3 – Xerostomia. Saliva is mucinous.

Quality
• Thin watery
• Mucinous(mixed)
• Thick mucous

Quantity
• Normal
• Sialorrhea
121 • Xerostomia.
 Saliva collection
• Methods include draining/spitting/suction/absorbent swab method.

• Draining---passive saliva is collected in Pre-weighed test tube or

graduated cylinder for a timed period

• Spitting ---Patient allows saliva to accumulate in oral cavity and

expectorate into pre-weighed graduated cylinder usually every 60 sec for
2-5 min

• Suction --- Use aspirator or saliva ejector to collect saliva(carlson-

crittenden collector for parotid)

• Absorbent--- Use pre-weighed gauze sponge for a period of time.

122
Materials used to stimulate saliva
Chewing unflavored gum , paraffin wax, rubber band or 2% citric
acid.

Salivary secretion

• Normal salivary secretion is 1 ml/min (Zarb)

0.38 -/+ 0.21 ml/min Unstimulated

4.3 +/- 2.1 ml/min Stimulted (Budtz jorgensen)

123
 Radiographic examination

124
• Interpretation of OPG should be in a 5 step analysis as outlined:
Step 1-
• A)Screen jaw for defect in structure, reactive bone formation, bone
enlargement and displacement of jaw parts.
• B) Unerupted tooth, retained root , foreign bodies should be noted
• C)Radiolucency/Radio-opacicty /rarefaction or sclerosis /expansion
or bulging or any well/ill defined lesion should be noted
• D)TMJ finding (correlate with history plus examination).Decide if
more specific investigation is required
• E)Maxillary sinus for inflammation ,cyst , Polyp, Tumor

125
Step 2-
Describe appearance of lesion as well as any bone changes
adjoining lesion .This should be confined to physical bone change
and include location, size, shape, number and description.

Step 3 –
Correlate R/f with clinical/ history and lab finding.

Step 4-
Perform differential diagnosis.

126
Step 5-
• Estimate the growth of lesion by appearance of jaw structure
bordering the lesion
• Slow growth-sclerosis/Expansion/Displacement
• Rapid growth-Bone destruction ..

If cannot be diagnosed refer to Pathologist/Surgeon

127
 Assessment of Ridge resorption
• Wical and Swoop classified the amount of resorption. They found
lower edge of mental foramen divides the mandible into thirds in
normal dentulous OPG.
• Means if the distance between the lower border of the mandible and
inferior margin of Mental foramen is multiplied by 3 ,original crest
ridge height can be estimated

128
• Class I –mild resorption -
Loss of up to 1/3rd original height

• Class II –Moderate resorption

1/3rd to 2/3rd loss of height

• Class III -Severe resorption

2/3rd or more loss

129
• Bone Quality (Lekholm- Zarb)
• Class I- homogeneous compact bone.

• Class II – thick cortical/dense trabecular

• Class III – thin cortical/dense Trabecular

• Class IV – thin cortical/Fine Trabecular

130
• Misch bone density classification

131
Bone Quantity
• According to Branemark

• Class A-- normal bone

• Class B Loss of alveolar bone
• Class C Complete loss of alveolar bone
• Class D Resorption of basal bone
• Class E Rudimentary bone present (advanced loss of basal bone)

132
 ACP CLASSIFICATION FOR
COMPLETE EDENTULISM

133
 Residual Bone Height Classification
• Type I – Most favorable- Residual bone height (vertical height
of mandible) 21 mm or greater

• Type II - 16-20 mm

• Type III – 11-15 mm

• Type IV – 10 mm or less

134
 RESIDUAL RIDGE MORPHOLOGY-MAXILLA
ONLY
Type A –
• Labial & buccal vestibule depth and palatal morphology resisting
vertical & horizontal movement
• Sufficient tuberosity
• Well define hamular notch
• No tori & exostosis

135
Type B –
• Loss of buccal vestibule
• Palatal vault morphology resist vertical & horizontal movement
• Tuberosity & hamular notch poorly defined
• Compromised PPS
• Palatal tori &/or exostosis rounded & do not affect posterior
extension

136
Type C –
• Loss of labial vestibule
• Palatal vault morphology offer minimum resistant to vertical & horizontal
movement
• Maxillary palatal tori &/or lateral exostosis with bony undercut that do
not affect the posterior extension.
• Hyperplastic mobile anterior ridge offer minimum support & stability
• Reduction of posterior molar space by the coronoid process during
mandibular movement

137
Type D –
• Loss of anterior labial & posterior buccal vestibule
• Palatal vault morphology do not resist vertical & horizontal
movement.
• Palatal tori &/or lateral exostosis interfere with denture border
extension
• Hyperplastic redundant anterior ridge
• Prominent anterior nasal spine

138
 MUSCLE ATTACHMENT - MANDIBLE ONLY
Type A –
Attached mucosal base without under muscular attachment
during normal function in all region.
Type B –
Attached mucosal base in all regions except labial vestibule.
Mentalis muscle attachment near crest of alveolar ridge.

139
Type C –
• Attached mucosal base in all region except in vestibule – canine to canine.
• Genioglossus & mentalis muscle attachment near crest of alveolar ridge
Type D –
Attached mucosal base only in posterior lingual region.
Mucosal base in all other regions detached.
Type E – No attached mucosa.
• No discernible vestibular anatomy remains

140
 MAXILLOMANDIBULAR RELATION
• Class I – most favorable
Allows tooth position that has normal articulation with teeth
supported by residual ridge

• Class II –
Tooth position outside normal ridge to attain esthetic, phonetics &
articulation

• Class III –

141
Tooth position outside normal ridge eg. crossbite
• CLASSIFICATION OF
EDENTULISM
Class I –
• Bone height - Type I
• Ridge Morphology Type A
• Muscle attachment Type A or B
• Maxillo-mandibular relation-
class I

142
Class II –
• Bone height type II
• Ridge morphology type B
• Muscle attachment type A or B
• Class I maxillomandibular relation
• Minor modifiers ( psychosocial,
mild systemic disease with oral
manifestion)

143
Class III –
• Bone height type III
• Ridge morphology type c maxilla
• Muscle attachment type c mandible
• Jaw relation class I/II/III
• Condition require- Preprosthetic
surgery
- Soft tissue minor surgery
- Alveoplasty
- Simple implant without
augmentation
144
Class IV
• Bone height type IV
• Residual ridge shape type D maxilla
• Muscle attachment type D, E mandible
• Class I/II/III jaw relation
• Major pre prosthetic surgery
-complex implant with augmentation
-surgical correction of dentofacial abnormality
-hard tissue augmentation required
-major soft tissue revision required
-vestibular extension with or without soft tissue
grafting
-history of paresthesia /dysesthesia

145
 TREATMENT PLAN

146
• The primary objectives for prosthetic treatment of the edentulous
patient are restoration of ESTHETICS, FUNCTION, and
HEALTH.

• Basic criteria for long term success

Retention
Physiologi
Stability c comfort
rigidity
biocompatibilty Long
term
success
Psychological
Esthetics
comfort
TREATMENT SEQUENCE
SYSTEMIC PHASE
• The purpose of this phase is to protect the patient and to protect the
operator.
• Medical risk factors are screened for, and any necessary precautions
are taken prior to therapy. This mainly includes control of the
following aspects:
• Coronary heart conditions and blood circulation, risk for infection,
including infective endocarditis, diabetes, hepatitis and HIV,
Conditions leading to haemorrhage, Toxic and allergic reactions.
• Close cooperation with the patient's physician is recommended.
148
HYGIENIC, INITIAL OR PREPARATORY PHASE
• The purpose of this phase is to establish clean and healthy conditions
in the oral cavity.
It includes:
• Motivation of the patient
• Instruction in adequate oral hygiene practices
• Removal of soft and hard deposits from the teeth and appliances
• Removal of plaque-retaining factors, such as calculus,overhanging
margins of restorations, and open carious lesions
• Elimination of ('hopeless') teeth not to be preserved
• Temporary reconstructions
149
CORRECTIVE PHASE
• In this phase, the sequelae of the oral diseases are treated. It should
always follow the hygienic phase and represent the traditional
approach of dental therapy.
It includes, in a logical sequence, if indicated:
• Periodontal surgery,
• Implant placement
• Endodontic therapy
• Control of the functional aspects, such as checking the occlusion
and eventually incorporating bite planes
• Occasional orthodontic therapy
150
• Prosthetic reconstruction.
MAINTENANCE PHASE AND SUPPORTIVE CARE
• The objective of maintenance care is continuously to preserve health
and prevent re-infection.
• Removal of Supragingival plaque by the patient is a prerequisite for
a good long-term prognosis.
• Regular clinical re-evaluation, with appropriate interceptive
treatment, continued mental support and encouragement of the
patient and a life-long commitment by the therapists are required.
• Maintenance phase normally starts immediately after cause-related
therapy.

151
• In CD treatment planning ,following must be considered:
(1) Basic criteria:
(a) Retention
(b) Stability
(c) Rigidity of prosthesis
(d) Good masticatory function
(e) Biocompatibility of dental materials.

(2)Esthetics and other factors for physical & psychological comfort

(3) Direct Treatment sequelae with regard to patient general

health considered
152
 (4) Failures and complications
Mechanical failures – loss of retention, fracture
Biologic and detoriation of esthetics

(5) Cost in maintenance is also considered

153
 Treatment modality (Zarb)
• Adjunctive care
• Elimination of infection /pathosis
• Surgical correction of denture base support
• Tissue conditioning
• Nutritional counseling
• Prosthodontic care
Yet to be edentulous
• RPD conventional interim
• Hybrid CD/RPD
• Immediate/Transitional denture
Edentulous
• CD- soft tissue supported
• Implant supported CD/FPD
154
 Patient education

Purpose
• Inform patient of their dental health and significance
• Making patient understand the significance of edentulism
• Match patients expectations with reality of treatment potential
• Explain nature, use and shortcomings of prosthesis
• Identify alternative treatment plan

155
 It will help patient understand:
• Diagnostic procedure
• Diagnostic results
• Treatment plan
• Treatment to be provided
• Use of prosthesis
• Continuing care and fees
It should facilitate:
• Acceptance of treatment
• Acceptance of fees
• continuing care
156
 References
• Sharry JJ. Complete denture prosthodontics. McGraw-Hill Companies;
1974 May 1.
• Rhan AO, Heartwell CM. Textbook of complete denture. Lea and Febriger,
USA. 1993:59-109.
• Winkler S, editor. Essentials of complete denture prosthodontics. Year
Book Medical Pub; 1988.
• Fenn HR, McGregor AR. Fenn, Liddelow F and Gimson’s Clinical Dental
Prosthetics.
• Zarb GA, Bolender CL, Carlsson GE. Boucher's prosthodontic treatment
for edentulous patients. St. Louis: Mosby; 1997 Jan.
• Rakosi T. An atlas and manual of cephalometric radiography. Lea &
Febiger; 1982.
• Misch CE. Contemporary implant dentistry. Implant Dentistry. 1999 Jan
1;8(1):90.
157
• Rajendran R. Shafer's textbook of oral pathology. Elsevier India;
2009

• DCNA - complete denture 1996,40,1;1-9

• ACP classification of complete edentulism. Jprosthodont 1999;

8,1:27-39

• Owall B, Käyser AF, Carlsson GE. Prosthodontics: principles and

management strategies. Mosby Inc; 1996.

• Lamb DJ. Problems and solutions in complete denture

158
prosthodontics. Quintessence Pub Co; 1993.
159