Examination, Diagnosis and Treatment

Planning for Edentulous or Partially

Edentulous Patients

Rola M. Shadid, BDS, MSc

Procedures Carried Before Denture Treatment

General information
Chief complaint & patient expectations
Medical history & current medication
Dental history
Visual & manual examination of the mouth and
head and neck
Radiographic examination
Continue

Referring for additional tests or medical

consultation
Referring for second opinion
Making alginate impressions & preparing
mounted study models
Discussion of diagnosis, treatment planning
& prognosis with patient
Finalizing the fees & obtaining a signed
consent
The First Meeting
Most important
Prior to meeting, you should review
general information
Your confidence is as important as the
treatment itself
You should be a good listener
Your communication should be in a
simple & truthful manner
Recording General Information
1. Name
2.

3. Race
4.

5. Occupation
6.

7. Address and telephone no.

8.

9. Previous dentist
 Age
With advancing age*:
1. Decrease capacity of tissue to tolerate stress
2. Tissue takes longer time to heal
3. Many diseases are prevalent in older age
4. Women at postmenopause may have psychological
disturbances (exacting or hysterical)
5. Men at this age may be concerned with only comfort
& function (indifferent)
Psychological Evaluation (House Classification of
Denture Patients)

Philosophical patient: well motivated, cooperative,

calm & composed even in difficult cases.
Exacting (critical): likes each step in detail, makes
alternative treatment for dentist, makes severe
demands.*
Continue
Indifferent: not very interested in
treatment, blames the dentist for any
mishap, not follow instructions, been
coerced to come by friend, relative….*
Continue
Hysterical: easily excited, highly
apprehensive, unrealistic expectations*
Skeptical: bad results from previous
treatment, doubtful, often have severely
resorbed ridges and poor health, might
have psychological disturbances from
recent personal trajedy #
Chief Complaint & Patient Expectations

Patient’s own words

Why he is seeking prosthodontic
treatment
You should assess if patient expectations
are realistic or not
If not realistic, you should educate pt
and scale them down
Medical History*
Diabetes Mellitus
Cardiovascular diseases
Diseases of joints: osteoarthritis
Diseases of skin: pemphigus ?
Neurological disorders (Bells balsy and
Parkinson)
Sjogren’s syndrome
Transmissible diseases
Radiation Therapy Vs. Dentures

Consequences of Radiation therapy

Preprosthetic surgery
Wearing of previous denture *
Denture Fabrication #
Denture Fabrication in Radiation
Therapy Patient

Avoid impression material that dry tissue (impression

plaster) or heavily flavored materials (ZOE)
Consider non-anatomic teeth
Teeth set in neutral zone
Slight reduction in vertical dimension
Soft liners are controversial due to porosity and
possibility of candida
Current Medication
Insulin *
Anticoagulants
Antihypertensive: dryness & postural
hypotension
Corticosteroids: dryness, confusion & behavioral
changes
Antiparkinson agents like Norflex and Akineton:
dryness, confusion & behavioral changes
Dental History

History of tooth loss: cause, time*

Edentulous period
Beware of Patients Who Have A “Bag of
Dentures” *
Extraoral Examination

General appearance (healthy, signs of

proper nourishment?)
Facial symmetry
Skin: color, deep wrinkles
Palpation of the head & neck (lymph nodes
& muscles)
Extraoral Examination

Muscle tonus
Neuromuscular
coordination*
TMJ examination
Classification of Frontal Face Forms
(House, Frush & Fisher) *
Classification of Lateral Face Forms

Normal

Retrognathic

prognathic
Lips
Length*
Thickness
Mobility
Smile line
 Lip (smile) line *

High smile Normal smile

line line
Intraoral Examination

Cheeks, tongue, floor of the

mouth (FOM), maxillary
tuberosity, hard palate, soft
palate, arch relationship,
residual ridge form, saliva,
undercuts
Cheeks

Draping of the cheeks over the buccal flanges

essential for peripheral seal
Opening of Stenson’s duct
Location for many lesions (lichen planus,
submucosal fibrosis, leukoplakai, malignancies as
sqauamous cell carcinoma (SCC))
Leukoplakia
The Tongue

Favorable tongue is average sized, moves

freely, covered by healthy mucosa
Normally, it should rest in a relaxed position
on lingual flanges, this will retain denture &
contributes to denture stability by
controlling it during speech, mastication &
swallowing.
Tongue Size

Normal
Large *
How to Manage Large Tongue?
1. Lower the occlusal plane
2. Use narrower teeth
3. Increase the intermolar distance
4. Grind off the lingual cusps
5. Avoid setting a second molar
Tongue Position

Normal: normal size and function.

Lateral borders rest at level of
mandibular occlusal plane while
dorsum is raised above it. Apex
rests at or slightly below the incisal
edges of mandibular anteriors
Tongue Position

Retruded tongue position

deprives pt of border seal of
lingual flange in sublingual
crescent and also may produce
dislodging forces on distal regions
of lingual flange
Tongue Mucosa
The specialized mucosa covering
the tongue is said to be a
“window” on systemic diseases. *
Frenal Attachments

Fold of mucosa found at

different locations in the
sulcus region of upper
& lower ridge
Classification
Class I: sulcal or low
attachment
Class II: midway betw.
sulcus & crest of ridge
Class III: crestal
attachment (frenectomy)
Floor of the Mouth
If FOM is near the level of the ridge crest,
retention & stability of denture is less.
Hyperactive FOM reduces retention & stability
If great ridge resorption, FOM in sublingual
and mylohyoid regions spills on the ridge
Patency of submandibular ducts *
Maxillary Tuberosity*

If enlarged:
the posterior
occlusal plane may
be placed too low
no enough space to
set all molars
Maxillary Tuberosity

Palpate for
undercuts - if
extreme, denture
might not seat
The Hard Palate
Class I: U shaped, most favorable for
retention & stability
Class II : V shaped: Not very favorable*
Class III: Flat or shallow vault: Not very
favorable, accompanied by resorbed
ridges, poor resistance to lateral forces
V-shaped hard palate
Tori *

Palatal torus
Mandibular tori
Bony Prominences

Midpalatal raphe
Sharp ridge crest
Sharp mylohyoid ridge
Prominent genial tubercles
Bony fragments & fractured root pieces
Tori
The Soft Palate (Palatal Throat Form)

House’s classification
*
Class I: the soft palate is
almost horizontal curving
gently downwards
Class II: the soft palate turns
downward at about 45 angle
from the hard palte
Class III: the palate turns
downward sharply at about
70 angle to the hard palate.
Palatal Throat Form
Maxill
a
I
I
II I
I
Undercuts

The contour of a
cross section of a
residual ridge that
would prevent the
placement of a
denture or other
prosthesis
 Undercuts
Unilateral or bilateral; labial or lingual;
mild, moderate or severe
Common locations:
a) Labial portion of maxillary anterior ridge
b) Buccal to maxillary tuberosity
c) Retromylohyoid area of residual ridge
d) Labial or lingual slopes of mandibular anterior ridge
Undercuts Management

1. Isolated anterior undercut- not

present any problem
2. Unilateral posterior undercut- may
not present much of a problem as path
of insertion is varied
3. Bilateral undercut-surgical removal of
the more severe one is indicated
 Residual Alveolar Ridge
Arch form (House’s classification)
Class I: square
Class II: tapered (V-
shaped), associated with
high arched palate, less
retention & stability
Class III: ovoid (less
common)
Residual Alveolar Ridge (Cross Sectional Contour) *

a. U shaped
b. V shaped
c. Knife edged
d. Flat
e. Inverted
f. Undercut
Soft Tissue Support of the Ridge

Firm & resilient

Flappy and hypermobile: poor support
because denture base shifts during
masticatory function
Management of flappy ridge ranges
from modified impression techniques to
surgery
Anterior Arch Relationships *
Intraoral Examination

Posterior arch
relationships
Interridge space
Residual ridge size
Saliva *
.
Consistency:
Thin serous: provides an insufficient film for denture
retention.
Thick mucus: thick ropy saliva tends to displace
denture.
Mixed
.
Amount:
Normal: ideal for denture retention
Excessive: make denture const. messy
Reduced: reduced retention and increased soreness;
salivary substitutes may be prescribed
Drugs Causing Xerostomia *
Diuretics
Antihistamines
Atropine
Anticholinergic
Antihypertensive
Antiparkinson (Norflex)
Corticosteroids
Examination of an Old Denture Wearer
Esthetics, lip fullness, symmetry, amount
of display during smiling, phonetics, teeth
position, size, excessive wear
Fracture, cracks, porosity, denture
hygiene
Occlusal vertical dimension (due to
excessive occlusal wear, OVD may have
reduced)
Reduced vertical dimension
Examination of an Old Denture Wearer
.
Epulis fissuratum
.
Angular cheilitis
. Papillary hyperplasia
. Flappy hyperplastic ridge*
. Combination syndrome
Epulis Fissuratum
Inflammatory Papillary Hyperplasia
Angular Cheilitis (Perleche)
Combination (Kelly’s) Syndrome *
Radiographic Examination

A routine radiographic exam.

must be ordered to rule out any
bony conditions that could affect
the treatment
Panomaric radiograph is usually
ordered for denture cases
Radiographic Examination
Fractured roots or roots lying close to the surface
should be removed if pt is fit for surgery; deep
seated retained teeth or root fragments may be
left if they are asymptomatic

Supplemental radiographs may be prescribed if

required such as periapical, occlusal, and
lateral cephalometric
Panoramic Radiograph
Additional Tests & Medical
Consultation
Routine blood test, blood & urine sugar
levels
Medical consultation
Dental consultation
Diagnosis
A specific evaluation of existing
conditions
Involves thorough examination of all
factors which are bound to affect the
success of treatment
This includes both systemic & local
factors & the mental condition of the
patient
Treatment Plan
The sequence of procedures
planned for the treatment of a
patient following diagnosis
Explained to the patient in a
simple and straightforward
manner including all of the
factors that might complicate
the treatment
Alternate Treatment Plan

May be less than ideal but is often

necessary for various reasons
Refusal of Treatment

The patient’s demand may be

unreasonable or against
professional judgment or ethics;
so may refuse treatment or refer
him (“bag of dentures”)
Prognosis
A forecast to the probable result
of a disease or a course of therapy
After considering all the factors,
you should be able to predict the
degree of success that can be
expected & the patient should
know of what can and cannot be
achieved.
Fees & Signed Consent

When patient agreed on

treatment including fees , he must
sign a written consent to prevent
later misunderstanding
Prescription, Nutritional Supplements, &
Tissue Conditioning

Assess if nutritional deficiency

Recommend finger massage of oral tissues
If old denture wearer, tissue conditioner placed
to condition abused soft tissue
Instruct patient to discontinue wearing denture
48 hrs prior making final impression
 A good clinician is one who is able to diagnose
potential problems during the initial
examination & suggest the best possible
treatment plan compatible with the age,
physical, mental & financial status of the patient
Any Question
 References
I. Complete Denture Prosthodontics, 1st
Edition, 2006 by John Joy Manappallil,
Chapter 2.
II.

III. Zarb. Prosthodontic Treatment for

Edentulous Patients, 12th edition. Chapter 7.