DIAGNOSIS AND

TREATMENT PLANNING
FOR EDENTULOUS
PATIENTS
INTRODUCTION

Diagnosis is the examination of the physical state, evaluation of

the mental or psychological makeup, and understanding the
needs of each patient to ensure a predictable result
 Diagnosis is the determination of the nature of the disease. (GPT
8)

Treatment planning means developing a course of action that

encompasses the ramification and sequelae of treatment to serve
the patient’s needs
Prosthodontic Approach to edentulous patients

 Examination of edentulous patients should be divided into two

steps:

Getting acquainted: Seat the patient comfortably, let him talk,

one can learn much by listening.

 Establish
rapport with the patient and the spouse or the person
accompanying the patient. Develop mutual understanding.
Technical analysis: Do visual and digital oral examination.

 Make diagnostic impressions for visual explanation to the

patient, guidance for specialization, note correctable
abnormalities

 Record all adverse factors, make plans for their management.

History taking and examination

Name

 Not only helps in maintaining records but also helps in

creating a more personal and ambient atmosphere for the
patient in the dental clinic.

 Gives idea about patients family and community.

 Age
 An indicator of the patient’s ability to wear and use a
prosthesis.
 Fourth decade of life - tissues heal rapidly and are resilient.
 Fifth decade healing is not rapid.
 Sixth is a compromised one.
Sex
Woman facing the physiologic and
psychological problems often present as
exacting or hysterical patients who are
very conscious about esthetics.
Men are pre-occupied and present as
indifferent patients who are concerned
more with comfort or function.
Occupation

A patient’s job & social training often determine the values

he or she places on oral health, as well as the esthetics and
other qualities desired in a denture.

Race

 Criticalfactor in the characterization of dentures i.e., choice

of denture base shade, denture base stains & shade selection.
Chief Complaint

 Thepatient should be questioned regarding his or her chief

complaint such as-
 Inability to chew
 Impaired speech
 Poor appearance
 Others.

 Recorded in patients own words.

Dental History

Reasons For Loss Of Teeth:

 The patient should be questioned regarding the cause of teeth

loss (e.g. periodontal, caries, congenital, trauma etc)

Duration Of Edentulousness

 Proves about bone resorption patterns and progression.

Previous Denture Experience
 The patients made to comment on the reasons for replacement
and should be educated regarding the realistic limitations.
 A patient with a history of several dentures over a short time is
a poor prosthodontic risk.

Existing Or Current Dentures

 The patient should be questioned about the length of time for
which the dentures have been worn.
 Careful clinical observation may provide valuable information
about denture experience, dental care, knowledge,
parafunctional habits etc.
The following factors should be noted on the existing
prosthesis:

◦ The period should be determined.

◦ Ridge resorption should be assessed to determine the amount

of expected ridge resorption after placement of the new
prosthesis.

◦ Anterior and posterior teeth shade, mould and material.

◦ Centric occlusion and also the patient profile in centric

relation.
◦ The tissue surface and the polished of the palate should be
examined. Reproduction of rugae should be noted.

◦ The patient's speech pattern should be noted for any valuing

nasal twang.

◦ The posterior extension & PPS of the maxillary denture

should be noted.

◦ Proper basal seat coverage and adaptation should be noted.

◦ The midline of the denture should be checked.

◦ Presence of cross-bite should be checked. It should be

recorded as none, unilateral and bilateral.

◦ Patient's comfort should be enquired.

Mental Health

De Van stated, “meet the mind of the patient before meeting the mouth
of the patient”.

 Arrivewith an accumulation of experiences and resulting attitudes.

Range from optimistic to resignation to despair.

 Positive – Negative spectrum.

 Personality characteristics of Pt’s who have difficulty wearing

dentures.
Most of the time – narrow & restrictive
 House classified patients as:

Philosophical Patient

 The best mental attitude for denture acceptance is the philosophical

type. Patient is rational, sensible, calm and composed in difficult
situations. Overcomes conflicts and organizes his time and habits in an
orderly manner, he eliminates frustrations and learns to adjust rapidly.

Exacting Patient

 They may have all of the good attributes of the philosophical patient;
however he may require extreme care, effort and patience on
Prosthodontist’s part. This patient is methodical, precise and accurate
and at times makes several demands: if the patient is intelligent and
understanding, he can give the best time.
Indifferent Patient
 They presents a questionable or unfavourable prognosis. They
exhibits little concern if any; he is apathetic and uninterested and
lacks motivation. Pays no attention to instructions, will not cooperate
and is prone to blame the dentist for poor dental health.
 An education program in dental conditions and dental treatment is the
recommended treatment plan before denture construction.

Hysterical Patient
 They are emotionally unstable, excitable, excessively apprehensive
and hypertensive. The prognosis is often unfavorable and additional
professional help (psychiatric) is required prior to and during
treatment. This patient must be made aware that his/her problem is
primarily systemic and that many of his symptoms are not result of
dentures.
Medical History

Debilitating diseases
 Diabetes, blood disorders and tuberculosis.

 Require specific instruction on denture/tissue care.

 Special follow-up appointments to observe response of soft

tissue to the denture.

 Diabetic patients show excessive bone resorption, hence

frequent relining is necessary.
Disease of Bone
 Bone is firm, yet physiologically dynamic, support for teeth and
prostheses. Influenced by systemic & local factors.

 Osteosclerosisrefers to increased amounts of calcified bone.

Assoc with metastatic tumors or hypoparathyroidism.

 Osteomalacia refers to deficiency of amount of minerals

relative to amount of matrix.

 Osteoporosis is a decrease in bone mass but in normal ratio of

minerals and matrix.
Diseases of the Joints
 Most common Osteoarthritis.

 Affecting finger joints may find it difficult to insert and clean

denture.

 Affecting TMJ,has limited mouth opening & painful

movements of jaw.

 Requires special impression trays, repeat jaw relations & post

insertion occlusal adjustments.
Cardiovascular Diseases

 Consultation with the patient’s cardiologist is indicated

 Denture procedures of any kind may be contra-indicated.
 Pre-medication may be required before any procedure.

Diseases of the Skin

 Pempighus have oral manifestations, which vary, from ulcers to

bullae.
 Such painful conditions, make the denture use impossible without
medical treatments.
 Constant use of prosthesis should be discouraged for these
patients.
Neurological Disorders

 Bell’s palsy & Parkinson’s disease can influence denture

retention & jaw relation records.
 Pt should understand the difficulty in denture fabrication and
usage.

Oral Malignancies

 Pt require radiation therapy before prosthetic treatment.

 Tissues having bronze colour & loss of tonoicity are not suitable
for denture support.
 Once dentures are constructed, tissues examined frequently for
Radionecrosis.
Climacteric Conditions

 Like menopause can cause glandular changes, osteoporosis

and psychiatric changes.
 Can influence treatment planning and efficiency of complete
denture.

Habits

 Information regarding the habits such as smoking, pan

chewing etc should be taken.
 Habits such as bruxism can jeopardize the success of the even
properly fabricated denture.
 CLINICAL EXAMINATION
EXTRAORAL EXAMINATION

Facial Form:
 Classification according to House & Loop, Fisher & Williams.

◦ Square
◦ Tapering

◦ Ovoid

◦ Different combinations
Facial Profile

 The facial profile is examined by viewing the patient from the

side.

 Helps in diagnosing gross deviations in the maxillo-mandibular

relationship.

 It determines the jaw relation and occlusion.

 Based on Relationship of these lines

a. Straight/orthognathic

b. Concave/prognathic

c. Convex/retrognathic
Facial Symmetry:

 Examined to determine disproportions in transverse and vertical

plane.
 In most patients, the right and left sides are not identical which is
also termed as normal asymmetry.
 Only gross asymmetries are recorded.

Gross asymmetries can be due to:

a. Congenital defects
b. Hemifacial atrophy
c. Unilateral condylar ankylosis and hyperplasia.
Complexion

 The colour of eye, hair, and the skin guide the selection of
artificial teeth.
 Pale skin colour is indicative of anaemia.

Lip support

 If only tissues around the mouth has wrinkles and face does not,
significant improvement can be done.
 Anterior teeth are set lingually, the lip will lack support and plans
to bring new teeth forward can be made.
 Long standing wrinkles do not disappear at once.
Lip Thickness:

• Thin Lips: Any slight change in the labiolingual tooth position

makes a sudden change in lip contour.
• Even overlapping of teeth may distort the surface of lips.

• ThickLips: Variations in the arch form and individual tooth

arrangement do not make obvious changes.
Lip Length:

 Patients with short upper lips will expose all the upper anterior teeth,
much of labial flange as well.
 Care must be taken to select color and form of denture base.
 Long lip shows less of anterior teeth.

Lip Fullness:

 Related to the support from the mucosa or denture base and the teeth
behind it.
 Denture with thick labial flange could make the lip appear to be too
full rather than displaced.
 If teeth set to far palatally, the new and corrected tooth arrangement
makes the lip too full.
Muscle Tone:

Classification According to House:

Class I
 Thepatient exhibits normal tension tone and placement of the
muscles of mastication and facial expression.

 No degenerative changes are apparent.

 Majorityof edentulous patients have experienced some degree

of degeneration and usually only immediate denture patients
have normal musculature.
Class II

The patient displays approximate normal function but

slightly impaired muscle tone.
Maximum muscle function cannot be used.

Class III

 The patient exhibits greatly impaired muscle tone and function.

 Usually coupled with poor health, inefficient dentures, and loss
of vertical dimension, wrinkles, decreased biting force and
drooping commissures.
TMJ EXAMINATION

 Examined for range of movements, pain, muscles of mastication,

joint sounds upon opening and closing.

 Severe pain indicates increased or decreased VD.

NEUROMUSCULAR EXAMINATION

SPEECH

 Normal – Pt capable of producing an articulated speech with there

existing dentures can easily accommodate to the new dentures.

 Affected– Pt require special attention during anterior teeth

arrangement.
Require more time to adapt to a proper articulated speech in a new
denture.
NEUROMUSCULAR COORDINATION

 Patient’s
gait, coordination of movements, ease with which he
moves & his steadiness are important.

 Abnormality indicate diseases like Parkinson’s diseases,

Hemiplegia, Cerebellar diseases or use of Psychotropic drugs.

 Abnormal facial movements like lip smacking, tongue tremors,

uncontrollable chewing movements influence CD prognosis.

 Normal pt can easily learn to manipulate dentures.

INTRAORAL EXAMINATION

TEETH
 Thecondition of the existing teeth are important for single
complete dentures & tooth supported over denture.

 Valid reasons for extractions include:-

◦ Advanced periodontal disease with severe bone loss around
the teeth.

◦ Severely broken crown that cannot be restored.

◦ Fractured roots.

◦ Periapical or periodontal abcesses that cannot be treated.

◦ Unfavorably tipped or inclined teeth.

◦ Extruded or inclined teeth that interfere with proper location

of occlusal plane.
MUCOSA

Six different edentulous maxilla underscore some of the frequently

encountered variables:-

 Excellent morphological prognosis.

 Residual ridge is irregular with bony undercuts & small exostoses.
 Left tuberosity is pendulous & mobile and large torus is present.
 Denture can be built, but surgical considerations should be
addressed to optimize the basal seat area.
 Anterior localized ridge resorption and replaced by hyperplastic
tissue. Excised before impression making.
 If pt’s health precludes, a modified impression tech employed.
 Home care & regular recall programme were not instituted for these
patient. Basal seat became inflamed & epulis resulted.
 Tissue rest, massage & treatment liner should precede a surgical
assessment in this pt.
 Advanced RRR, with low mobile peripheral tissue attachments
& obliteration of the hamular notches leading to poor prognosis
for retentive & stable denture.
 Rectified by preprosthetic sulcus deepening with skin graft
placement, mainly done in mandible.
Six diverse edentulous mandibular morphological outcomes:-

 Firm, broad & well developed ridge with favorable tongue size &
position suggests good prognosis.
 Alveolar ridge undercuts present , ridge size differs substantially.
 Fig 1 surgical removal avoided by prudent relief of denture base.
 Fig 2 tender areas over the exostoses &/or the tori have to be
treated surgically.
 Hyperplastic replacement doesnot provide a firm denture bearing area.
 Surgical excision result in significantly reduced basal area as in Fig 2.
 Extension of dentures posterior lingual flanges usually allow stable
denture in Fig 2.
 Unfavorably high attachment of floor of mouth.
 Seperated with buccal vestibule by a thin, mobile, fibrous band.
 Preprosthetic surgery for placement of osseointegrated implants
is likely to be needed.
SALIVA

 Mouth is dry– retention of the denture is affected.

- increased potential for soreness.

 Excess saliva – difficulty in impression making.

 The consistency of saliva can range from a thin, serous type to a

thick ropy consistency.

 Best consistency of saliva is serous .

 Thick saliva makes dentures more difficult to wear, and forming
voids in the impression surface.

 Thick , ropy saliva is a factor which causes the patient to gag

during impression making.

 Salivary glands should be examined to ensure they are open and

good salivary flow is present.
RESIDUAL ALVEOLAR RIDGE

ARCH SIZE
 The size of the maxilla and mandible ultimately will determine
the amount of basal seat available for denture formation.

 The greater the size: greater the support, larger the contact
surface, greater the retention.

 If discrepancy is present, leads to difficulties in artificial teeth-

arrangement & decrease the stability of the denture.
ARCH FORM

 Influence the role in support of the denture and in tooth

selection.
 If the arch form is not same in both the arches some problems in
tooth arrangement can be anticipated.

 The arch may be:-

◦ Square
Ovoid

Tapered
 RESIDUAL RIDGE CONTOUR / FORM

Characterized by its cross-sectional contour as a whole arch.

 U shaped arch - Favorable for supporting a denture.

oAs it has broad base for occlusal stresses
oParallel sides that enhance adhesion and resistance to
displacement & encourage border seal.
 V-shaped has a narrow crest that is not conducive to the
reception of masticatory stresses without irritation and
discomfort.
oLess favorable for retention - sloping sides and has a
tendency to progress towards narrowness.
oDifficulty in prosthetic management.

 Flat residual ridge - most difficult for restoration by the

prosthodontist.
o Jaw relationship progresses to cross-bite situations and
complicate the distribution of prosthetic stress to the basal
support.
RIDGE RELATION

 Itis the positional relation of the mandibular ridge relative to the

maxillary residual ridge.
 While examining, the pattern of resorption of arches should be
remembered.

Classification by ANGLE:-

Class I (Normal)
Class II (Retrognathic)

Class III (Prognathic)

INTERMAXILLARY SPACE

 Space between the maxillary and the mandibular arches.

Normally it should be 20mm.
 If the space is less it is difficult to obtain stability of the denture
base, which is compromised as the teeth are set away from the
basal seat.

 ClassI: Ideal interarch space

to accommodate the artificial teeth
 Class II: Excessive interarch
space

 Class III: Insufficient interarch

space to accommodate the
artificial teeth
HARD PALATE
Shape of palatal vault
 U Shaped: It is most favorable for retention and lateral stability.

 V Shaped: Less favorable for retention because slightest movement

of denture base will cause the seal to be broken with a resultant loss of
retention.
 Flat palatal vault: Is unfavorable.
o Usually resorbed ridges and although retention may be
satisfactory in a downward direction.
o Lateral or rotatory forces results in poor resistance and less
retention
SOFT PALATE
CLASS 1 – It is horizontal with little muscular movement.
More tissue coverage is possible for posterior palatal seal.

CLASS 2 – It makes 45* angle to the hard palate. Tissue coverage

is less than class 1 condition.
 CLASS 3 – It makes 70* angle to hard palate. Tissue coverage is
minimum.

Position of the patient:

 The classification of soft palate are determined when the patient
is in upright position and the head is held erect.
PALATAL THROAT FORMS
The relationship between the soft palate and the hard palate is
called Palatal throat form.

CLASS 1 – Large and normal in form, immovable band of tissue

of 5 to 12 mm distal to a line drawn across the distal edge of
tuberosities.
CLASS 2 – Medium sized and normal in form, with relatively
immovable resilient band of tissue of 3 to 5mm distal to line drawn
across the distal edge of the tuberosities.

CLASS 3 – Small maxilla. Curtain of soft tissue turns down abruptly

3 to 5mm anterior to a line drawn across the palate at the distal
edge of tuberosities.
 TONGUE

Classification of tongue size according to

House:
CLASS I: Normal in size, development and
function, sufficient teeth are present to maintain
normal form and function.

CLASS II: Teeth have been absent long

enough to permit a change in the form and
function of the tongue.
 CLASS III: Excessively large tongue. All teeth have been
absent for an extended period of time, allowing for abnormal
development of a class III tongue.
WRIGHT`S CLASSIFICATION OF
TONGUE POSITIONS:

CLASS I:
 The tongue lies in the floor of the
mouth with the tip forward and
slightly below the incisal edges of the
mandibular anterior teeth.

CLASS II:
 The tongue is flattened and broadened
but the tip is in a normal position.
CLASS III:

 Thetongue is retracted and depressed in the floor of the

mouth, with the tip curled upward, downward or
assimilated into the body of the tongue.
Gag Reflex and Palatal Sensitivity

 Exaggerated gag reflex - due to a systemic disorder,

psychological, extraoral, intraoral or iatrogenic factors.

 The management of such patients is through clinical,

psychological and pharmacological means.

 Ifthe patient lacks progress, should be referred to a specialized

consultant.
BONY UNDERCUTS

 Do not help in retention, rather interfere with peripheral seal.

 On the maxilla , undercuts are present on the anterior region
and lateral to the tuberosities.
 On the mandibular ridge , a prominent , sharp mylohyoid ridge
acts as a undercut.
TORI
 CLASS I: Tori are absent or minimal in size and do not interfere
with existing denture.

 CLASS II: Clinical examination shows several tori of moderate

size, often mild difficulties in denture construction and use of
surgery not required.
 CLASS III: Large tori are present. These tori compromise the
function of dentures. These tori require surgical removal.
FRENUM ATTACHMENTS

Classification according to House:

 CLASS I: High in the maxilla or low in the mandible with

respect to the crest of the ridge
 CLASS II: Medium

 CLASS III: Freni encroach on the crest

of the ridge may interfere with the
denture seal. Surgical correction may be
required
DIAGNOSTIC AIDS

Pre-extraction records

 Old diagnostics casts are valuable aid in determining tooth size,

position and arrangement.

 Oldradiographs are also helpful in determining tooth size and

bony changes.

 Photographs showing natural teeth can also relay much

information regarding tooth size, position etc; and be helpful in
achieving proper esthetics and patient’s satisfaction.
Radiographic Examination Of Edentulous Patients

 Advisable prior to the construction of dentures.

 Use of the Orthopantomograph for routine examination of

prosthetic patients.

 Reveal the presence of residual roots, unerupted teeth or other

abnormalities in patients who are otherwise free from signs or
symptoms that might suggest existence of a pathologic
condition.
Diagnostics Casts

 Ridge relationships, inter-ridge distance or ridge shape and

forces cannot be adequately determined by clinical examination
alone.

 Necessary to make a maxillo-mandibular relation record to

mount the casts on the articulator.

 Centricrelation and occlusal vertical dimensions records must

be viewed around the entire arch.
INTERPRETING DIAGNOSTIC FINDINGS

 After all the diagnostic findings, they can be interpreted, and

treatment plan can be developed.

Obvious, Congruent, or Incongruent?

 Isthere congruency between the disease that appears to be

present and the probable etiology?

 Incongruity of information gathered about a patient signals the

need for further investigation.
TREATMENT PLANNING
 GPT: The sequence of procedures planned for treatment of a
patient after diagnosis.

 Boucher: Treatment planning is the process of matching

possible treatment options with patient needs and systematically
arranging the treatment in order of priority but in keeping with a
logical or technically necessary sequence.
 Thisprocess requires a broad knowledge of treatment
possibilities and detailed knowledge of the patients needs, as
determined by a careful diagnosis.

 Otherfactors such as prognosis, patient health and attitude must

be taken into account.

 Accuratediagnosis  Effective treatment plan  Favorable

prognosis.
WHY TREATMENT PLAN?
Treatment plan
Addresses patient’s needs Informed consent
Lists specific treatment Enables patient to Treatment
Specifies logical sequence Time
Fees

Enables Patient
dentist to receive

Estimate
Operating time Delivered care
Laboratory time Patient specific
Dentist delivers
Fees
TREATMENT PLANNING PROCESS

Determining Select
Patient Treatment
MATCH

Requires Requires
Specific Broad
Knowledge of Knowledge
patient from of treatment
complete options,
diagnosis delivery &
management
ADJUNCTIVE CARE

Elimination of Infection:

 Sources of infection like infected necrotic ulcers, periodontally

weak teeth, and nonvital teeth should be removed.

 Infective conditions like candidiasis, herpetic stomatitis, and

denture stomatitis should be treated and cured before the
commencement of treatment.
Elimination of pathology
 Pathologies like cysts and tumors of the jaws should be removed
or treated.
 Some pathologies may involve the entire bone. In such cases, after
surgery, an obturator may have to be placed along with the
complete denture.

Preprosthetic surgery
 Enhance the success of the denture.
 Some of the common preprosthetic procedures are:

Frenectomy, Excision of denture granulomas, Excision of

flabby tissue, Reduction of enlarged tuberosity, Vestibuloplasty,
Alveoloplasty, Alveolectomy etc.
TISSUE CONDITIONING

 The patient should be requested to stop wearing the previous

denture for at lest 72 hours before commencing treatment.

 Should be taught to massage the oral mucosa regularly.

 Special procedures should be done in patients who have adverse

tissue reactions to the denture. Denture relining material should be
applied on the tissue side of the denture to avoid denture irritation.
Nutritional counseling

 Patientsshowing deficiency of particular minerals and vitamins

should be advised a proper balanced diet.

 Patientswith vitamin B2 deficiency will show angular cheilitis.

Prophylactic vitamin A therapy is given for xerostomic patients.

 Nutritionalcounseling is also done for patients showing age-related

changes such as osteoporosis.
PROSTHODONTIC CARE

 Thetype of prosthesis, denture base material, anatomic palate, tooth

material and teeth shade should be decided as a part of treatment
planning.

 Depending upon the diagnosis made, the patient can be treated with
an appropriate prosthesis.

For example:
◦ For a patient with few teeth, which are likely to be extracted an
immediate or conventional, definitive or interim, implant or soft
tissue supported dentures can be given.
◦ For a patient who is already edentulous a soft tissue
supported or implant supported denture can be given.

◦ For patients with acquired or congenital deformities, a

denture with an obturator can be given.
Patient Education

An initial and continuing activity integral to, and supportive of, a

treatment plan.

Purposes

 Inform the patient of there dental health and its significance.

 Give the patient understanding of significance of edentulism.
 Match the patients expectations with reality to treatment potential.
 Explain nature, use and shortcomings of prostheses.
 Identify alternative treatment and their consequences.
Will help patient understand

 Diagnostic procedures
 Diagnostic results
 Treatment plan
 Treatment to be provided
 Use of prostheses
 Continuing care
 Fees
Should facilitate

 Acceptance of treatment
 Acceptance of fees
 Continuing care
CONCLUSION

Treatment plan developed should reflect the dentist’s

best efforts at interpreting the diagnostic findings and
addressing the patients needs in keeping with their
appreciation for dentistry and their ability to accept the
proposed treatment.
REFERENCES

 Prosthodontic treatment for edentulous patients - BOUCHER`S

 Essential
of complete Denture Prosthodontics – SHELDON
WINKLER

 Textbook of complete denture – Heartwell

 Complete dentures. The dental clinics of North America. Jan 1996

40:1- Robert .L. Engelmiur.
THANK YOU