Prosthodontic Diagnostic Index (PDI) for Partially Edentulous and Completely Dentate Patients

The American College of Prosthodontists (ACP) has developed diagnostic indices for partial edentulism24
and for completely dentate patients25 on the basis of diagnostic findings that are summarized here with the
permission and support of the ACP. These guidelines are intended
to help practitioners determine appropriate treatments for their patients. For each index, four categories,
class I to class IV, are defined; class I represents an uncomplicated clinical situation and class IV represents
a complex clinical situation. The indices are designed for use by dental professionals involved in the
diagnosis and treatment of partially edentulous and completely dentate patients. Potential benefits of the
system include (1) improved intraoperator consistency, (2) improved professional communication, (3)
insurance reimbursement commensurate with complexity of care, (4) improved screening tool for dental
school admission clinics, (5) standardized criteria for outcomes assessment and research, (6) enhanced
diagnostic consistency, and (7) simplified decision to refer a patient.
Each class is differentiated by specific diagnostic criteria (ideal or minimal, moderately compromised,
substantially compromised, or severely compromised) of the following (for partially edentulous patients):
1. Location and extent of the edentulous area or areas
2. Condition of the abutment teeth
3. Occlusal scheme
4. Residual ridge
For completely dentate patients, only tooth condition and occlusal scheme are evaluated.
Location and Extent of the Edentulous Areas In the ideal or minimally compromised edentulous area, the
edentulous span is confined to a single arch, and one of the following conditions is present:
• Any anterior maxillary span that does not exceed two missing incisors
• Any anterior mandibular span that does not exceed four missing incisors
• Any posterior maxillary or mandibular span that does not exceed two premolars or one premolar and one
molar In the moderately compromised edentulous area, the edentulous span is in both arches, and one of
the following conditions exists:
• The span includes any anterior maxillary span that does not exceed two missing incisors.
• The span includes any anterior mandibular span that does not exceed four missing incisors.
• The span includes any posterior maxillary or mandibular span that does not exceed two premolars or one
premolar and one molar.
• The maxillary or mandibular canine tooth is missing.

The substantially compromised edentulous area includes

Condition of the Abutment Teeth (Tooth Condition for Completely Dentate Patients)
In cases of ideal or minimally compromised abutment teeth,
• No preprosthetic therapy is indicated.
In cases of moderately compromised abutment teeth,
• Tooth structure is insufficient to retain or support intracoronal restorations, in one or two sextants.
• Localized adjunctive therapy (i.e., periodontal, endodontic, or orthodontic procedures, in one or
two sextants) is required for abutments.
In cases of substantially compromised abutment teeth,
• Tooth structure is insufficient to retain or support intracoronal or extracoronal restorations, in four or
more sextants.
• Extensive adjunctive therapy (i.e., periodontal, endodontic or orthodontic procedures, in four or
more sextants) is required for abutments.
In cases of severely compromised abutment teeth,
• Abutments have a guarded prognosis.
Occlusal Scheme
Ideal or minimally compromised occlusal schemes are characterized by the following conditions:
• No preprosthetic therapy required
• Class I molar and jaw relationships
Moderately compromised occlusal schemes are characterized by the following conditions:
• Necessity for localized adjunctive therapy (e.g., enameloplasty on premature occlusal contacts)
• Class I molar and jaw relationships
Substantially compromised occlusal schemes are characterized by the following conditions:
• Necessity for reestablishment of entire occlusal scheme, but without any change in the occlusal vertical
dimension
• Class II molar and jaw relationships
Severely compromised occlusal schemes are characterized by the following conditions:
• Necessity for reestablishment of entire occlusal scheme, with changes in the occlusal vertical
dimension
• Class II, division 2, and class III molar and jaw relationships
Residual Ridge
The Classification System for Complete Edentulism26 is
used to categorize any edentulous span present in a partially
edentulous patient.
Classification System
The four criteria and their subclassifications are organized into an overall classification system for partial
edentulism; the two criteria provide the system for completely edentulous patients.

Class I
This class (Figs. 1-28 and 1-29) is characterized by ideal or minimal compromise in the location and extent
of an edentulous area (which is confined to a single arch), abutment conditions, occlusal characteristics,
and residual ridge conditions. All four of the diagnostic criteria are favorable.
1. The location and extent of the edentulous area are ideal or minimally compromised:
• The edentulous area is confined to a single arch.
• The edentulous area does not compromise the physiologic support of the abutments.
• The edentulous area may include any anterior maxillary span that does not exceed two incisors, any
anterior mandibular span that does not exceed four missing incisors, or any posterior span that does not
exceed two premolars or one premolar and one molar.
2. The abutment condition is ideal or minimally compromised, with no need for preprosthetic therapy.
3. The occlusion is ideal or minimally compromised, with no need for preprosthetic therapy;
maxillomandibular relationship consists of class I molar and jaw relationships.
4. Residual ridge structure conforms to the class I complete edentulism description.

Class II
This class (Figs. 1-30 and 1-31) is characterized by moderately compromised location and extent of
edentulous areas in both arches, abutment conditions that necessitate localized adjunctive therapy, occlusal
characteristics that necessitate localized adjunctive therapy, and residual ridge conditions.
1. The location and extent of the edentulous area are moderately compromised:
• Edentulous areas may exist in one or both arches.
• The edentulous areas do not compromise the physiologic support of the abutments.
• Edentulous areas may include any anterior maxillary span that does not exceed two incisors, any anterior
mandibular span that does not exceed four incisors, any posterior span (maxillary or mandibular) that does
not exceed two premolars, or one premolar and one molar or any missing canine (maxillary or
mandibular).
2. Condition of the abutments is moderately compromised:
• Abutments in one or two sextants have insufficient tooth structure to retain or support intracoronal or
extracoronal restorations.
• Abutments in one or two sextants necessitate localized adjunctive therapy.
3. Occlusion is moderately compromised:
• Occlusal correction necessitates localized adjunctive therapy.
• Maxillomandibular relationship is characterized as class I molar and jaw relationships.
4. Residual ridge structure conforms to the class II description of complete edentulism.

Class III
This class (Figs. 1-32 and 1-33) is characterized by substantially compromised location and extent of
edentulous areas in both arches, abutment condition that necessitates substantial localized adjunctive
therapy, occlusal characteristics that necessitate reestablishment of the entire occlusion without a change in
the occlusal vertical dimension, and residual ridge conditions.
1. The location and extent of the edentulous areas are substantially compromised:
• Edentulous areas may be present in one or both arches.
• Edentulous areas compromise the physiologic support of the abutments.
• Edentulous areas may include any posterior maxillary or mandibular edentulous area greater than three
teeth or two molars or anterior and posterior edentulous areas of three or more teeth.
2. The condition of the abutments is moderately compromised:
• Abutments in three sextants have insufficient tooth structure to retain or support intracoronal or
extracoronal restorations.
• Abutments in three sextants necessitate more substantial localized adjunctive therapy (i.e., periodontal,
endodontic, or orthodontic procedures).
• Abutments have a fair prognosis.
3. Occlusion is substantially compromised:
• The entire occlusal scheme must be reestablished without an accompanying change in the occlusal
vertical dimension.
• Maxillomandibular relationship is characterized as class II molar and jaw relationships.

Class IV
This class (Figs. 1-34 and 1-35) is characterized by severely compromised location and extent of
edentulous areas with guarded prognosis, abutment conditions that necessitate extensive therapy, occlusion
characteristics that necessitate reestablishment of the occlusion with a change in the occlusal vertical
dimension, and residual ridge conditions.
1. The location and extent of the edentulous areas result in severe occlusal compromise:
• Edentulous areas may be extensive and may be present in both arches.
• Edentulous areas compromise the physiologic support of the abutment teeth, and so the prognosis is
guarded.
• Edentulous areas include acquired or congenital maxillofacial defects.
• At least one edentulous area has a guarded prognosis.
2. Abutments are severely compromised:
• Abutments in four or more sextants have insufficient tooth structure to retain or support intracoronal or
extracoronal restorations.
• Abutment conditions in four or more sextants necessitate extensive localized adjunctive therapy.
• Abutments have a guarded prognosis.
3. Occlusion is severely compromised:
• Reestablishment of the entire occlusal scheme, including changes in the occlusal vertical dimension, is
necessary.
• Maxillomandibular relationship is characterized as class II, division 2, or class III molar and jaw
relationships.
4. Residual ridge structure conforms to the class IV complete edentulism description.
Other characteristics include severe manifestations of local or systemic disease, including sequelae from
oncologic treatment, maxillomandibular dyskinesia or ataxia, and refractoriness (a patient’s presenting
with chronic complaints after appropriate therapy).