DIAGNOSIS AND

TREATMENT PLANNING
IN COMPLETE DENTURE

JOEL ANTO VARGHESE

 DIAGNOSIS

• Definition: Determination of the nature of a disease.

• Diagnosis is the examination and evaluation of the physical and
psychological state and understanding the needs of each patient to ensure
a predictable result.
• Diagnosis involves patient evaluation, history and examination.
 PATIENT EVALUATION

• This process commences as the patient walks to the dentist's chair as well as
during the introductory and history taking conversation.
• The following characteristics are observed:
• Gait
• Observations regarding the patient's walk, steadiness and the level of coordination
can help in gaining an insight into the patients' motor skills and any systemic
disease.
• Stooped shoulders-spinal changes.
• Tremor of head-Parkinson disease, tranquillizers.
• Dragging of one leg-stroke.
• Staggering-excessive alcohol and medication, hyper-ventilation, damage to brain
and spinal cord.
• Age
• This refers to the physiologic age and provides information about the patient's
expectations and care for the dentures. A young patient who appears old may
indicate disinterest, while an old patient who appears young indi-cates willingness
to adapt and look good.

• Facial Expression
• This provides information about the mental attitude and presence of any disorders
• Complexion
• It is used to select the colour of the teeth.
• It may also be indicative of the following conditions:
• Pale-anaemia, lack of nourishment.
• Ruddy-polycythaemia, chronic alcoholic.
• Bronze-radiation therapy, Addison disease.
• Bluish-purple-vitamin deficiency, cyanosis.
• Lemon-yellow-jaundice.
• Mental Attitude
• Dr M.M. House (1950) classified patients as philosophi cal, exacting, indifferent and
hysterical.
• This is the most widely used classification.
• Class I Philosophical patients
• They are rational and composed in difficult situations
• .They desire treatment for maintenance of health and appearance and accept the
complete denture treatment as a normal procedure.
• They learn to adjust rapidly.
• These patients have the best mental attitude for accep tance of the treatment.
• Class II: Exacting patients
• They are very methodical, precise and accurate, making severe demands.
• They are comfortable when each procedure is explained and discussed with them
in detail.
• They require extreme care, effort and patience on part of the dentist.
• The intelligent and understanding category in this class can be the best type of
patient, but for those lacking the same, extra time should be spent in education
and treatment started only after an understanding is reached.
• Class III: Indifferent patients
• These patients are identified by their lack of concern and motivation and
apathetic attitudes.
• They may not pay any attention to instructions, will not cooperate and are prone
to blame others including the dentist for their poor health.
• In many cases, the lack of interest on part of the patient is the reason for their
edentulousness.
• A patient education programme is recommended before treatment.
• If their interest cannot be stimulated, it may be best to refuse such patients. They
present a questionable or unfavorable prognosis
• .Class IV: Hysterical patients
• They are emotionally unstable, excitable and apprehensive.
• They may not be aware that their symptoms may be more related to their
systemic health.
• They often present an unfavorable prognosis and additional psychiatric
counselling is required prior to the treatment
 HISTORY

• A record of all the information obtained from the pa-tient must be made and
kept for further study and later use.
• The health history is an extremely important part the patient's overall
diagnosis and treatment planing.
• It is best obtained by a combination of question-saire and direct
interrogation.
• It should include the Following:General Information
• Name
• This is important for documentation and record maintenance.
• Patients are more comfortable and confident when addressed by their names.
• Also helps to build a rapport with the patient
 HABITS

• Pan chewing, smoking, chronic alcoholism may modify the systemic status and evoke
concerns regarding the hygiene, maintenance and wear of the denture
• .Habits like pencil biting and nail biting may cause denture instability.
• Parafunctional habits like clenching and bruxism should also be verified as they affect
teeth selection and prognosis.
• Nutritional history
• It is important to obtain a record of food intake of the patient over a 3-5 days period. This
helps in evaluating the nutritional status of the patient. The ability of the oral tissues to
withstand the stress of dentures is greater in a well-nourished patient. Dietary counselling
is necessary in malnourished patients.
 MEDICAL HISTORY

• No prosthodontic procedure should be commenced with-out evaluating the systemic status

of the individual.
• The following need to be assessed:
• Debilitating diseases
• The most common is diabetes mellitus
• . Patients are at a higher risk of opportunistic infections such as candidiasis and show delayed
wound healing
• . Salivary flow may also be impaired.
• Their medication and mealtime should be given due importance while scheduling appointments.
• Special emphasis on denture hygiene, re-call and maintenance is also necessary for such
patients
• .Tuberculosis is contagious and necessary precautions are required.
• The therapy is also long term and the drugs can cause nausea.
• Patient with blood dyscrasia require specific precautions if preprosthetic surgery is contemplated.
• Mucosa is also more sensitive to denture pressure.
• All patients with debilitating disease should be under medical control before commencing any dental
treat-ment.
• Diseases of the jointsRheumatoid arthritis and osteoarthritis are common dis-eases affecting the
joints. If fingers are affected, patient will find it difficult to insert and clean dentures. When the
temporomandibular joint (TMJ) is affected, special impression trays are required due to poor mouth
open-ing and frequent occlusal correction may be necessary as jaw relations are difficult to record
due to painful man-dibular movements.
• Cardiovascular disease Patients with stable cardiac problems under the regular
care of a cardiologist are not contraindicated for proce-dures.
• Short appointments may help the patients to manage stress better.
• A consultation with the physician is required if any invasive preprosthetic
procedure is co templated, along with premedication and stoppage anticoagulants.
• Neurological conditionsConditions like Bell palsy and Parkinson disease will present
problems related to denture retention, maxillomadibular records and support for
the musculature.
• Patient needs to be educated regarding these anticipated problem
• Oral malignancies
• Construction of CD may be commenced depending on the tumour prognosis, the
healing of tissues following the treatment and the amount of radiation.
• After CD construction, the tissues should be evaluated constantly for any evidence of
radiation necrosis. Patient should be ad vised to use the dentures on a limited basis.

• Epilepsy
• Patient may aspirate or break the denture during the seizure.
• It will influence the selection of denture base material and teeth.
• Patient and close relatives may also need to be educated on quick removal of the
dentures prior to or during seizures.
• Diseases of the skin
• Dermatological diseases like pemphigus have painful oral manifestations like ulcers and bullae.
• Medical treatment may or may not provide relief to these patients.
• The constant use of dentures in such patients must be discouraged

• Menopause
• This is an important consideration in women as they could undergo CD construction during this
period.
• The period is characterized by bone changes like osteoporosis, burning mouth syndrome, mental
disturbance ranging from mild irritability to complete nervous breakdown
• They may require psychiatric counselling and medica tion.
• Patient must be made aware of this condition before treatment and the possible effect on denture
adjustment
 DENTAL HISTORY

• This should include the following.

• Chief complaint
• The chief complaint is recorded in patient's own words. It should be determined if the complaint is justified and
realistic.
• It is important to find out what the patient expects from the treatment.
• Unrealistic expectations will be detrimental to success of treatment.
• Patient education regarding what is possible is very important in such cases.

• Past dental history

• The following information should be elicited:
• 1. Reason for tooth loss: If periodontal disease was the reason, more bone loss is anticipated. It also helps in prognosis.
• 2. Period and sequence of edentulousness: Longer the period, more will be the bone loss. By understanding the sequence,
bone resorption pattern can be identi fied
• 3. Previous dental and denture experience: Traumatic experiences will affect the attitude of the patient to wards dental
treatment and they will require more counselling and education.
• Patient's experience with previous dentures will give an insight into their attitude, desire
and expectations.
• Current denture
• The examination and evaluation of the present prosthesis gives an insight into the patient's
previous experience, patient tolerance and aesthetic values.
• It is evaluated for the following:
• Extension of denture is evaluated using vestibule, hamular notch and vibrating line as guides for maxil-
lary denture, and vestibule, retromolar pad, retromylohyoid area and buccal shelf as guide for mandibular
denture.
• The jaw relation-vertical and horizontal, is checked using appropriate methods.
• Occlusion is verified for balance and premature contacts.
• Artificial teeth are examined for type and wear or breakage
• Considerable wear in a short time period is indicative of bruxism.
• Retention and stability.Aesthetics.
• Maintenance of the denture is checked which will provide information about patient's hygiene, interest
and methods.
• Any previous prosthesis and the reasons for its change should also be evaluated
• Pre-Extraction records
• This will include old diagnostic casts, radiographs and photographs.
• Old diagnostic casts aid in determining tooth size. position and arrangement
• .Old radiographs aid in determining tooth size and bony changes.
• Photographs give information about tooth size, position and tooth display.
• Diagnostic casts They confirm and sometimes reveal new information obtained from intraoral
examination. It may be of immense benefit to keep the cast ready during intraoral examination.
• Diagnostic casts should be mounted on an articulator following a facebow transfer.
• This allows for dynamic evaluation of interarch relations, most importantly the interarch space
(interridge distance), which is very essential in determining if space exists to place artificial teeth.
• Undercuts and their significance can be evaluated with a dental surveyor.
• Preprosthetic surgeries can be planned and surgical templates can be made
on the diagnostic cast.
• Extraoral Examination
• The patient's head and neck should be examined for the presence of any
pathologic condition.
• Any nodules and ulcerations on the face are noted.
• Facial colour and tone, hair texture, eye clarity, symmetry and neuromuscular
activity should be noted.
• Face and neck are palpated to check for enlarged nodes or masses
• Facial examination Face form
• Leon William has classified the facial form based on the approximate shape of the
face as square, tapering, square-tapering and ovoid .This helps in selecting the
shape of the artificial tooth for the patient.
• Facial profile
• The facial profile is classified as:
• Class 1: Straight profile
• Class II: Retrognathic or convex profile
• Class III: Prognathic or concave profile. This helps in selection and arrangement of
artificial teeth
• Colour of face, hair and eye
• This helps in determining the tooth shade.
• Though there is no scientific evidence to associate this colour with a particular tooth
shade, a harmonious relationship of all of these should exist.

• Lip examination
• Lip health Fissures, cracking or ulcers at the corner of the mouth indicate vitamin B
deficiency, candidiasis and loss of ver-tical dimension or neoplasm.
• The cause should be determined before denture construction.
• Lip support:Lack of proper support can lead to wrinkling.
• If the same is caused due to age and health of the patient, it cannot be corrected with
dentures.
• Correct placement of upper anterior teeth will provide adequate lip support to
eliminate wrinkles around the modiolus.
• Lip thickness
• In patient with thin lips, even a slight change in the labio-lingual tooth position makes an impact
on lip fullness and support.
• Thick lips can tolerate more alterations in tooth position without visible changes.

• Lip Length
• Length of the lips affects the amount of anterior tooth exposure and the anterior tooth size.
• They are classified as long, medium and short.
• Patients with short upper lip will expose all the upper anterior teeth and much of the labial
flange of the denture base with any expression.
• Long lip will hide most of the tooth and denture base.
• Short lips will influence the selection of anterior tooth size and characterization of denture base
• Residual alveolar dual alveolar ridge should be evaluated for the following.
• Arch size
• Greater the arch size larger is the contact and support, hence greater is the retention.
• Discrepancy in the size of the maxillary and mandibular ridges can create problems with
denture stability in the smaller arch due to poor relationship of the teeth.
• This discrepancy may be due to developmental causes, trauma and early loss of teeth in
one of the arches, or from a severe class II or class III malocclusion.
• Size can be classified as-small, medium and large
• Arch form
• Influences support and tooth selection.
• If opposing arches do not have the same form, difficulty in tooth arrangement can
be anticipated.
• Arch forms can be classified as-square, tapering or ovoid
• Ridge contour
• Influences support and stability of the dentures.
• Atwood has classified residual ridges as:
• Order I: Pre-extraction
• Order II: Postextraction
• Order III: High well rounded
• Order IV: Knife-edge
• Order V: Low well rounded
• Order VI: Depressed
• The ideal is a high ridge with a flat crest and nearly parallel sides.
• This offers maximum support and stability
• A flat ridge lacking vertical height affords little resistance to horizontal movement
leading to reduced stability.
• A knife-edged ridge offers the poorest prognosis because it cannot withstand
much occlusal force and can easily become sore.
• Relief is necessary while making impressions.
• Ridge relation
• Ridge relation is evaluated for the following:
• Interidge distance
• The interarch space is noted at normal occlusal vertical distance.
• Excessive space due to resorption will lead to poor denture stability and retention due to excessive
lever-age.
• Less space will make teeth setting difficult.
• Can be classified as normal, excessive and reduced (Fig. 2.5)
• Parallelism
• This affects denture stability as nonparallel ridges will cause movement of the bases when teeth
occlude due to unfavourable direction of forces.
• Classified as parallel, nonparallel.
• Positional relation
• This affects tooth arrangement and denture stability.
• As maxilla resorbs, the crest appears to move upwards and inwards.
• As mandible resorbs, the crest appears to move downwards, forwards and
laterally.
• The positional relation can be normal (class I), retrognathic (class II) and
prognathic (class III)
• Flabby tissue Both the arches should be examined for loose flabby tis-sue which
can cause the denture bases as the founda-tions themselves are moving leading
to poor stability and support
• . This may need surgical correction before impressions or special impression procedures are ad-opted to record the
same.Hyperplastic tissueHyperplastic tissues such as epulis fissuratum and papil-lary hyperplasia may result from an ill-
fitting denture and need to be treated. The patient is advised to rest the tissues by not wearing the existing dentures,
through proper oral hygiene and tissue massage, tissue condition-ing and lastly, if necessary, by surgical
correction.Bony undercutsThese do not aid in retention but cause loss of border seal and retention; may be present in
both maxillary and mandibular ridges.Maxilla-present in anterior ridge and lateral to maxil-lary tuberosity. These may be
selectively relieved without any surgery. Only if the undercuts are severe and previous denture attempts have failed,
surgery should be considered.Mandible-prominent sharp mylohyoid ridge pro-duces undercut. Surgical reduction and
reattachment may be beneficial.Muscle and frenal attachmentsThe location of these attachments in relation to the crest
of the ridge must be verified. In resorbed ridges, they can be near the crest of the ridge. This interferes with the border
seal compromising retention of the dentures. In such cases, a surgical correction may be required. The at-tachments
most often corrected surgically are the maxil-lary labial frenum and the mandibular lingual frenum; buccal frena rarely
require surgical repositioning.Relation with floor of the mouthRelationship of the floor of mouth to crest of the ridge is
important for prognosis of lower denture.If the floor of the mouth is at the crest of ridge at rest, especially in the
sublingual gland and mylohyoid areas, retention and stability of denture will be poor.PalateThe following are evaluated
• Hard palate. (A) U-shaped, (B) V-shaped and (C) FlatHard palateIt is classified
according to the shape as:* U-shaped: Provides good retention and stabilityV-shaped:
Provides least retentionFlat: Provides poor retention and stability (Fig. 2.7)Soft
palateBased on the degree of flexure that the soft palate makes with the hard palate
and the width of the palatal seal area, the soft palate configurations may be
classified as:Class I: Almost horizontal with little movement making angle of less than
10° with hard palate; most favourable, as it allows best tissue coverage (more than 5
mm) and development of a wide posterior palatal seal.Class II: Makes a 45° angle
with the hard palate. Tissue coverage is less than class I (3-5 mm).Class III: Makes a
70° angle with the hard palate; least favourable, as it allows least tissue coverage
(less than 3 mm); usually associated with V-shaped palate
• Palatal sensitivity or gag reflexGagging is a normal defence mechanism to prevent foreign objects from entering the trachea.An
exaggerated gag reflex can compromise prosth-odontic procedures like impression making.The cause of this can be systemic,
psychological, physi-ologic and iatrogenic. The management of such patients may be clinical, psychological or pharmacological.House
classified palatal sensitivity as:o Class I: NormalClass II: Hyposensitive* Class III: HypersensitiveLateral throat formThe retromolar
space can be partially or totally obliter-ated by tongue movement. This area is critical for lingual seal and lateral stability.Neil
classified lateral throat form (Fig. 2.9) according to the extent of anterior movement of retromylohyoid curtain as tongue is extended
anteriorly. Checked by placing a finger in the area.Class 1-Deep-Change in configuration, places heavy pressure on fingerClass II -
Moderate - Any position in between I & IIIClass III-Shallow - Minimal pressureTongueSizeThe size of the tongue may be normal,
enlarged or small. If the patient has been without teeth for a long time,the tongue can become enlarged, which causes tongue biting,
compromises impression making and also leads to denture instability. Small tongue compro mises a lingual seal.PositionTongue
movement, muscular coordination and position control the dentures during speech, mastication and deglutition. Wright has classified
tongue positions as:* Class I: Tongue lies on the floor of the mouth with the tip forwards and slightly below the incisaledges of the
mandibular anterior teeth. • Class II: Tongue is flattened and broadened but the tip is in normal position.* Class III: Tongue is
retracted and depressed into the floor of the mouth with the tip curled upwards downwards or assimilated into the body of the tongue
(Fig. 2.10A-C).Class I position has the best prognosis because the floor of the mouth will be high enough to cover the lingual flange of
the denture producing border seal Class II and class III are unfavourable, as the level of the floor of the mouth drops and does not
provide Adequate seal
• ToriThese are bony prominences which may be present in the palate or lingual alveolar ridge.Torus has an extremely thin mucous
covering which can be traumatized during impression making and by the denture. Adequate relief must be planned. Tori can also
act as a fulcrum to rock the denture and compromise denture stability.Surgical removal is not indicated unless the tori are
large.SalivaMajor salivary glands orifices should be examined to ensure they are open.The amount and consistency of saliva
affects denture retention and construction.Amount of saliva can be classified as:Class 1: NormalClass II: ExcessiveClass III:
XerostomiaIn xerostomia, denture will have poor retention and there is increased potential for soreness as lubricating action of
saliva is lost. Excessive saliva will complicate impression making.ConsistencyIt ranges from thin and serous to thick and ropy.
Thick ropy saliva prevents intimate contact between the denture and the tissues and results in dentures.Radiographic
ExaminationIf some teeth are remaining, periapical and panoramic radiographs are essential to plan the treatment for im-
mediate dentures, single complete dentures and over-dentures.Panoramic radiographs are necessary for the com-pletely
edentulous patients. The aim is to screen the edentulous jaws for any pathology and determine the amount of ridge
resorption.The screening gives information about the defects in jaw structure, root fragments, unerupted teeth or re-tained roots,
foreign bodies, sclerosis, tumours and cysts and TMJ disorders.Amount of bone resorption can be assessed using the method
described by Wical and Swoope. Ac-cording to this, the original alveolar ridge crest height is three times the distance from the
inferior border of the mandible to the inferior margin of the mental foramen. The amount of bone resorption is classified as:Class
I: Mild resorption-loss of one-third of verti-cal ridge height.Class II: Moderate resorption-loss of one-third to two-third of vertical
height.Class III: Severe resorption-greater than two-third loss
• TREATMENT PLANNINGTreatment planning is the process of matching possible treatment options
with patient needs and systematically arranging the treatment in order of priority but in keep-
ing with a logical or technically necessary sequence (Zarb and Bolender Prosthodontic Treatment
for Edentulous Pa-tients, 12th edn).It requires a wide knowledge of treatment possi-bilities, an
idea of patient needs as determined by a thorough diagnosis, while taking into account
prognosis, patient health, attitude and financialcapability. It will involve two processes:Mouth
preparationMouth preparation involves:1. Elimination of infection2. Elimination of pathology3.
Conditioning of tissues4. Nutritional counselling5. Preprosthetic surgery.It is discussed in detail
in Chapter 3.Prosthodontic treatmentPatients with some teeth remaining:1. Interim removable
partial dentures (Chapter 30, RPD Section)2. Immediate dentures (discussed in Chapter 17)3.
Single complete denture (discussed in Chapter 16)4. Overdenture (discussed in Chapter
48).Completely edentulous patient:1. Conventional CD2. Implant supported CD-fixed, removable
• Prosthodontic Diagnostic Index for Complete EdentulismIt was developed by American College of
Prosthodontics. This system classifies edentulous patient's treatment complexity using four diagnostic
criteria:Mandibular bone heightMaxillomandibular relationshipMaxillary residual ridge morphologyMuscle
attachmentsThese four criteria identify patients as:Class I (ideal or minimally compromised)Class II
(moderately compromised)Class III (substantially compromised)* Class IV (severely compromised)PDI for
Edentulous Class I PatientA patient who presents ideal or minimally compromised complete edentulism and
who can be treated by conven-tional prosthodontic techniques.The class I patient exhibits:A residual
mandibular bone height of at least 21 mm measured at the area of least vertical bone height.A
maxillomandibular relationship permitting normal tooth articulation and an ideal ridge relationship.A
maxillary ridge morphology that resists horizontal and vertical movements of denture base.Muscle
attachment locations conducive to the stability and retention.PDI for Edentulous Class II PatientA patient
who presents moderately compromised eden-tulism and continued physical degradation of the den-ture
supporting anatomy. The class II Il patient exhibits:A residual mandibular bone height of 16-20 mm mea-
sured at the area of least vertical bone height
• * A maxillomandibular relationship permitting normal tooth articulation and an appropriate ridge
relationship. A maxillary residual ridge morphology that resists horizontal and vertical movements of the
denturebase. Muscle attachment that exerts limited compromise on denture base stability and retention.PDI
for Edentulous Class III PatientA patient who presents substantially compromised com-plete edentulism and
exhibits:Limited interarch space.A residual mandibular bone height of 11-15 mm mea-sured at the area of
least vertical bone height.An Angle class I, II or III maxillomandibular rela-tionship.Muscle attachment that
results in compromised den-ture base stability and retention.Maxillary residual ridge morphology providing
minimal resistance to movement of the denture base.PDI for Edentulous Class IV PatientA patient who
presents the most debilitated form of complete edentulism where surgical reconstruction is usually
indicated, and specialized prosthodontic techniques are required to achieve an acceptable out-come.The
class IV patient exhibits:Residual mandibular bone height of 10 mm or less.An Angle class I, II or III
maxillomandibular relation-ship.A maxillary residual ridge morphology providing no resistance to movement
of denture base.* Muscle attachment that significantly compromises denture base stability and retention