The Prosthodontic Diagnostic Index

The Prosthodontic Diagnostic Index
A presentation by:
Dr. Rabie M El huni. BDS, MSc, Advanced Education in Implant

Dentistry.
• Department of Prosthodontics, Faculty of Dentistry University of Benghazi.
• Lecturer at Libyan International Medical University.
Demographics of Edentulism
 2025: Global population over 65 years will double

(2005 levels – 820 million people)
 Europe, 40 – 50% of the population will be over 65 years – 2050
 USA, 37.8 million edentulous Americans – 2020
Spence D. Because home is where the health is. Health Magazine-i Financial Times. December 2009
Chester W. Douglass, Annie Shih, Larry Ostry. J Prosth Den 2002; 87(1): 5-8
 The prosthodontics diagnostic index (PDI) for edentulism is an
excellent tool to use to evaluate the patient, determine the level of
difficulty, and to establish effective communication with other
members of the dental team. J Prosthodont 1999;8:27-39
 In general, there are 4 classifications with Class I being the most ideal
situation, and Class IV being the most difficult.
 The classification is usually increased to the next higher level when
any pre-prosthetic surgery, implant surgery, or re-establishment of
the vertical dimension is warranted

Intraoral Examination
 This classification was first established in 1994 as a subcommittee of

the Prosthodontic Care Committee :
1) Thomas J. McGarry, DDS, Chair

2) Arthur Nimmo, DDS
3) James F. Skiba, DDS
4) Christopher R. Smith, DDS
5) Robert H. Ahlstrom, DDS, MS
6) Jack H. Koumjian, DDS, MSD
7) Ronald P. Desjardins, DMD, MSD
 It was then presented at:
 The Annual Sessions of the American Dental Education
Association in Chicago in 2001 and
 The American College of Prosthodontists in New Orleans in 2001
and Orlando in 2002.
 This project was funded by the American College of Prosthodontists.
 It was published twice:
1) McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH. Classification system for
complete edentulism. Journal of Prosthodontics. 1999 Mar;8(1):27-39.
2) McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Guichet GN. Classification system
for the completely dentate patient. Journal of Prosthodontics: Implant, Esthetic and Reconstructive
Dentistry. 2004 Jun;13(2):73-82.
 Potential benefits of the system include:
1) Improved intraoperator consistency.
2) Improved professional communication.
3) Improved screening tool for dental school admission clinics.
4) Standardized criteria for outcomes assessment and research.
5) Enhanced diagnostic consistency.
6) Simplified aid in the decision‐making process associated with
referral.
The prosthodontics diagnostic index (PDI)
1. Mandibular Bone Height

 The objectivity of residual bone height measurement is
affected by the magnification and variance of
radiographic procedures and equipment of different
manufacturers.
 In order to minimize variance in techniques, the
measurement should be made at that portion of the
mandible of the least vertical height.
1. Mandibular Bone Height
Class I: Residual bone height of 21mm or greater

measured at the least vertical height of the mandible.
Class II: Residual bone height of 16-20 mm measured

at the least vertical height of the mandible.
Class III: Residual alveolar bone height of 11-15 mm
Class IV: Residual vertical bone height of 10 mm or

less
2. Residual Ridge Morphology (Maxilla)
Residual ridge morphology is the most objective criteria for

the maxilla since measurement of the residual bone height
by radiography is not reliable.
Class II Class I
Loss of posterior buccal Anterior labial and posterior buccal Anterior Maxilla
vestibule vestibular depth that resists vertical and
horizontal movement of the denture
base.
Tori are rounded and do not Palatal morphology that resists vertical Hard Palate form
affect the posterior extension and horizontal movement of the denture
of the denture base. base. No tori or exostosis.
Tuberosity and hamular notch Sufficient tuberosity definition that Maxillary

are poorly defined. resists vertical and horizontal movement Tuberosity
of the denture base. Well defined
hamular notch.
Class IV Class III
Loss of anterior labial and Loss of anterior labial vestibule. Anterior Maxilla
posterior buccal vestibules. Hyperplastic, mobile anterior ridge that
Hyperplastic, redundant offers minimum support and stability of
anterior ridge the denture base
Tori-rounded or undercut that Palatal vault morphology that offers Hard Palate form
interferes with the posterior minimal resistance to vertical and
border of the denture horizontal movement of the denture base
Palatal vault morphology that Prominent midline suture.
does not resist vertical or Tori with bony undercuts that do not
horizontal movement of the affect the posterior extension of the
denture base denture base
Prominent anterior nasal Reduction of the post malar space by the

spine coronoid process
3. Muscle Attachment (Mandible)
• Class I: Adequate attached mucosal base without undue

muscular impingement during normal function in all regions.
• Class II: Adequate attached mucosal base in all regions

except anterior labial vestibule i.e. cuspid to cuspid (High
mentalis muscle attachment).
• Class III: Adequate attached mucosal base in all regions

except anterior labial and lingual vestibule i.e. cuspid to
cuspid (High genioglossus and mentalis muscle attachments).
• Class IV: Adequate attached mucosal base only in the

posterior lingual region (All other regions are detached).
3. Muscle Attachment (Mandible)
Class V: No attached mucosa in any region (Cheek and lip movement =
tongue movement)
4. Maxillomandibular Relationship
Class I: Maxillomandibular relationship allows tooth position that

has normal articulation with the teeth supported by the residual ridge.
Class II: Maxillomandibular relationship requires tooth position

outside the normal ridge relation in order to attain phonetics and
articulation; i.e., anterior or posterior tooth position not supported by
the residual ridge/anterior vertical overlap that exceeds the principles
of articulation.
Class III: Maxillomandibular relationship requires tooth position

outside the normal ridge relation in order to attain phonetics and
articulation; i.e., crossbite— anterior or posterior, tooth position not
supported by the residual ridge.
5. Conditions requiring Pre-prosthetic Surgery
Any situation requiring pre-prosthetic surgery are considered

in class III and class IV of classification system
• Class III
 Minor soft/hard tissue surgical procedure
 Implant placement without graft
5. Conditions requiring Pre-prosthetic Surgery
Any situation requiring pre-prosthetic surgery are considered

in class III and class IV of classification system
• Class IV
 Implant with bone-graft complex
 Hard tissue augmentation
 Correction of dentofacial deformity
 Major soft tissue revision
6. Limited Inter-arch Space

• Class III
 18-20 mm
• Class IV
 Surgical correction required
7. Tongue Anatomy
• Class III
 Large and occludes interdental space
• Class IV
 Hyperactive with retracted position
8. Modifiers
 Oral manifestation of systemic diseases
 Mild (Class II)
 Moderate (Class III)
 Severe (Class IV)
 Psychosocial conditions warranting professional

intervention
 Moderate (Class III)
 Severe (Class IV)
 Temporo-mandibular dysfunction symptoms (Class III).

8. Modifiers
 History of Paraesthesia or Dysesthesia (Class IV).
 Maxillofacial defects (Class IV).
 Maxillomandibular ataxia (incoordination) (Class IV).
 Refractory Patient (Class IV).

Guidelines for use of (PDI)
 In those instances when a patient’s diagnostic criteria are
mixed between two classes, any single criteria of a more
complex class will move the patient into that respective
class.
 Utilization of this system is indicated for pre-treatment
evaluation and classification of patients.
 Retrospective analysis on a post-treatment basis may
alter a patient’s final classification
PDI Class I
 This classification level describes the stage of edentulism
that is most appropriate to be successfully treated by
conventional prosthodontic techniques with complete
denture prosthesis.
 All four of the diagnostic criteria are favorable.
PDI Class I
 Residual bone height of 21 mm or greater measured at the least

vertical height of the mandible (Class I MBH)
 Residual ridge morphology that resists horizontal and vertical
movement of the denture base (Class I Maxilla).
 Location of muscle attachments that are conducive to denture
base stability and retention (Class I or II Muscle attachment).
 Class I maxillomandibular relationship.
PDI Class I
PDI Class II
 This classification level distinguishes itself with the noted
continuation of the physical degradation of the denture
supporting structures.
 In addition, it is characterized with the early onset of systemic
disease interactions, localized soft tissue factors and patient
management/lifestyle considerations.
 Minor modifiers, psychosocial considerations, mild systemic
disease with oral manifestations and localized soft tissue
conditions
PDI Class II
 Residual bone height of 16-20 mm measured at the least vertical
height of the mandible (Class II MBH)
 Residual ridge morphology that resists horizontal and vertical
movement of the denture base (Class I Maxilla).
 Location of muscle attachments that are conducive to denture
base stability and retention (Class I or II Muscle attachment).
 Class I maxillomandibular relationship.
PDI Class III
 This classification level is characterized by the need for

surgical revision of denture supporting structures to allow for
adequate prosthodontic function.
 Additional factors now play a significant role in treatment
outcomes.
PDI Class III
 Residual bone height of 11-15 mm measured at the least
vertical height of the mandible (Class III MBH)
 Residual ridge morphology has minimum influence to resist
horizontal or vertical movement of the denture base(Class III
Maxilla).
 Location of muscle attachments with moderate influence on
denture base stability and retention (Class III Muscle
attachment).
 Class I, II, or III maxillomandibular relationship.
PDI Class III
 Minor pre-prosthetic surgery is required.

 Limited inter-arch space (18-20 mm).
 TMD symptoms present.
 Hyperactive gag reflex
PDI Class III
PDI Class IV
 This classification level depicts the most debilitated

edentulous condition.
 Surgical reconstruction is almost always indicated but can not
always be accomplished due to the patient’s health, desires,
past dental history and financial considerations.
 When surgical revision is not selected, prosthodontic
techniques of a specialized nature must be used in order to
achieve an adequate treatment outcome.
PDI Class IV
 Residual bone height of least vertical height of the mandible

(10 mm or less)
 Class II and III maxillomandibular relationships
 Residual ridge offers no resistance to horizontal or vertical
movement ( Class IV Maxilla )
 Location of muscle attachments with significant influence on
denture base stability and retention (Class IV and V
Mandibular Muscle Attachment)
PDI Class IV
 Implant placement (complex) augmentation required

 Surgical correction of dentofacial deformities
 Hard tissue augmentation
 Major soft tissue revision, i.e., vestibular extensions with or
without soft tissue grafting
 History of paresthesia or dysensthesia
 Insufficient inter-arch space with surgical correction required
 Acquired or congenital maxillofacial defects
PDI Class IV
 Severe oral manifestation of systemic disease or conditions

including squeal from oncologic treatment
 Maxillomandibular ataxia (incoordination)
 Hyperactivity of tongue that can be associated with a
retracted tongue position and/or its associated morphology
 Hyperactive gag reflex managed with medication
 Severe psychosocial conditions warranting professional
intervention
PDI Class IV
Refractory Patient
 A patient who has chronic complaints following appropriate

therapy.
 These patients continue to have difficulty in achieving their
treatment expectations despite the thoroughness or
frequency of the treatment provided.
PDI Class IV
Refractory Patient

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The Prosthodontic Diagnostic Index

Dr. Rabie M El huni. BDS, MSc, Advanced Education in Implant

 2025: Global population over 65 years will double

 Europe, 40 – 50% of the population will be over 65 years – 2050

 USA, 37.8 million edentulous Americans – 2020

excellent tool to use to evaluate the patient, determine the level of

difficulty, and to establish effective communication with other

members of the dental team. J Prosthodont 1999;8:27-39

situation, and Class IV being the most difficult.

 The classification is usually increased to the next higher level when

any pre-prosthetic surgery, implant surgery, or re-establishment of

the vertical dimension is warranted

 This classification was first established in 1994 as a subcommittee of

1) Thomas J. McGarry, DDS, Chair

1) Improved intraoperator consistency.

2) Improved professional communication.

3) Improved screening tool for dental school admission clinics.

4) Standardized criteria for outcomes assessment and research.

5) Enhanced diagnostic consistency.

6) Simplified aid in the decision‐making process associated with

1. Mandibular Bone Height

Class I: Residual bone height of 21mm or greater

Class II: Residual bone height of 16-20 mm measured

Class III: Residual alveolar bone height of 11-15 mm

Class IV: Residual vertical bone height of 10 mm or

2. Residual Ridge Morphology (Maxilla)

Residual ridge morphology is the most objective criteria for

Tuberosity and hamular notch Sufficient tuberosity definition that Maxillary

Prominent anterior nasal Reduction of the post malar space by the

• Class I: Adequate attached mucosal base without undue

• Class II: Adequate attached mucosal base in all regions

• Class III: Adequate attached mucosal base in all regions

• Class IV: Adequate attached mucosal base only in the

Class I: Maxillomandibular relationship allows tooth position that

Class II: Maxillomandibular relationship requires tooth position

Class III: Maxillomandibular relationship requires tooth position

5. Conditions requiring Pre-prosthetic Surgery

Any situation requiring pre-prosthetic surgery are considered

5. Conditions requiring Pre-prosthetic Surgery

Any situation requiring pre-prosthetic surgery are considered

6. Limited Inter-arch Space

 Psychosocial conditions warranting professional

 Temporo-mandibular dysfunction symptoms (Class III).

 Maxillofacial defects (Class IV).

 Maxillomandibular ataxia (incoordination) (Class IV).

 Refractory Patient (Class IV).

 Residual bone height of 21 mm or greater measured at the least

 This classification level is characterized by the need for

 Minor pre-prosthetic surgery is required.

 This classification level depicts the most debilitated

 Residual bone height of least vertical height of the mandible

 Implant placement (complex) augmentation required

 Severe oral manifestation of systemic disease or conditions

 A patient who has chronic complaints following appropriate

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