diagnosis and treatment planning in edentolous pateints

1. DIAGNOSIS & TREATMENTDIAGNOSIS & TREATMENT
PLANNING OFPLANNING OF
EDENTULOUS PATIENTSEDENTULOUS PATIENTS
Dr Saransh Malot
Dept of Prosthodontics

2. CONTENTS:CONTENTS:
• IntroductionIntroduction
• DefinitionDefinition
• General introduction to the patientGeneral introduction to the patient
• Principles of perception & Diagnostic procedurePrinciples of perception & Diagnostic procedure
• House classificationHouse classification
• Observation of the patientObservation of the patient
• Health historyHealth history
• Clinical & radiographic examinationClinical & radiographic examination
• Pretreatment recordsPretreatment records
• Treatment planningTreatment planning
• ConclusionConclusion
• BibliographyBibliography

3. INTRODUCTION:INTRODUCTION:
• Successful complete denture therapy:
Thorough assessment of patients physical and psychological
condition.
Determining a treatment plan that will satisfy patient’s
expectations.
Above all, treating the patient instead of just constructing
complete dentures for them.

4. DEFINITIONS:DEFINITIONS:
• According to HEART WELL
Diagnosis is
The act or process of deciding the nature of the diseased
condition by examination
A careful investigation of facts to determine the nature of
a thing
The determination of the nature, location and causes of a
disease.

5. • According to BOUCHER
Diagnosis consists of planned observations to determine
and evaluate the existing conditions, which lead to
decision making based on the conditions observed.

6. • In short, DIAGNOSIS can be summarized as:
Recognizing the problem
Formulating the plan
Carrying out the necessary examination
Finally, interpreting the result.

7. GENERAL INTRODUCTIONGENERAL INTRODUCTION
TO THE PATIENT:TO THE PATIENT:
• First appointment  most important
time
Fact finding
Development of mutual trust &
understanding
• Familiar with the overall condition of
the patient.

8. • New patients + patients with previous experience 
complete history taking & thorough examinations in which
perceptive abilities of the dentist play an important role.

9. PRINCIPLES OFPRINCIPLES OF
PERCEPTION:PERCEPTION:
• Detection: noticing something
• Discrimination: Distinguish that which we have noticed
from something else.
• Recognition
• Identification
• Judgement

10. DIAGNOSTICDIAGNOSTIC
PROCEDURESPROCEDURES
 Preferably carried out in two
appointments:
THE FIRST APPOINTMENT:
Acquainted with the patient
Beginning of evaluation of the
process involved in diagnosis &
treatment plan

11. Obtain essential information from the patient:
•Radiographic survey •Diagnostic casts
•Thorough history

12. A thorough history should include:A thorough history should include:
• Personal Data:Personal Data:
 Name
 SSN
 Age
 Sex
 Race
 Occupation
 Cosmetic index: Class I- High cosmetic index
Class II- Low cosmetic index
 Personality

13. • Medical HistoryMedical History
 General health
 Pathology
 Denture HistoryDenture History
 Chief complaint
 Expectation
 Edentulism
 Existing or current dentures
 Pre extraction records

14. • Clinical EvaluationClinical Evaluation
Square Square
tapering
Tapering Ovoid
 Facial form according to House & Loop

15.  Facial profile according to Angle
Class I
Normal
Class III
Prognathic
Class II
Retrognathic

16.  Muscle tone according toMuscle tone according to HouseHouse
Class I : Normal muscle tone
Class II: Slightly impaired muscle tone
Class III: Greatly impaired muscle tone
 Muscle Development according toMuscle Development according to HouseHouse
Class I: Heavy
Class II: Medium
Class III: Light
 ComplexionComplexion
Hair
Eye
Skin

17.  Lip ExaminationLip Examination
Cracking, fissuring at corner & ulceration: indicative of
vitamin B-complex deficiency, candida infection,
overclosure of existing denture or neoplasm.
Lip support
Lip thickness
Lip length

18.  Temporomandibular JointTemporomandibular Joint
Clicking, crepitations
Pain & tenderness on palpation
Temporomandibular arthralgia
Impaired mandibular mobility
Irregularity or deviation on opening & closing of
mandible
Locking of mandible.

19.  Neuromuscular EvaluationNeuromuscular Evaluation
Class I: Excellent
Class II: fair
Class III: poor
 Arch SizeArch Size
Class I: Large
Class II: Medium
Class III: Small

20. Determines the amount of basal seat available for
denture foundation.
Greater the size, more the support
Greater the contact surface, greater the retention.
Discrepancy in size of the maxilla and mandible can
present a problem of stability in the smaller arch.

21.  Arch FormArch Form
Class I
Square
Class II
Tapering
Class III
Ovoid

22.  Ridge Form:Ridge Form:
Class I
Class II
ClassIII
Square
V-shaped
Flat
Short
Inverted
Flat
Inverted U-shaped
Inverted
W
Tall
Inverted
Maxillary Mandibular

23. 
Inter ridge spaceInter ridge space
Excessive inter ridge space: poor stability and retention
because of increased leverage.
Small inter ridge distance: difficulty in setting teeth and
maintaining proper freeway space.
Ideal
Insufficient
Excessive

24.  Ridge relationship according toRidge relationship according to AngleAngle
Parallel Divergent Mandibular
Divergent Maxillary & Mandibular

25.  Ridge Contour:Ridge Contour:
Type I:Type I: High, well rounded bone profileHigh, well rounded bone profile
+ve resistance+ve resistance
Type II:Type II: Narrow, knife edge ridgeNarrow, knife edge ridge
-ve resistance-ve resistance
Type III:Type III: Rounded but lowered residual ridgeRounded but lowered residual ridge
-ve resistance-ve resistance
Type IV:Type IV: Terminal stageTerminal stage
-ve resistance-ve resistance

26. Most ideal is a high ridge with a flat crest and parallel or
nearly parallel sides  maximum support & stability.
Knife edge ridges or ridges with multiple bony spicules
offer the poorest prognosis  incapable of with
standing much occlusal force.
Best determined by careful palpation.

27. Class IClass I
Class IIClass II
Class IIIClass III
 Lateral Throat Form [mandibular]:Lateral Throat Form [mandibular]: NeilNeil

28.  Palatal sensitivity according toPalatal sensitivity according to HouseHouse
Class I: NormalClass I: Normal
Class II: HyposensitiveClass II: Hyposensitive
Class III: HypersensitiveClass III: Hypersensitive
 Mucosal Thickness according toMucosal Thickness according to HouseHouse
Class I: Normal uniform densityClass I: Normal uniform density (1 mm)(1 mm)
Class II: Thin investing membraneClass II: Thin investing membrane
Class III: Thick investing membraneClass III: Thick investing membrane

29.  Mucosa condition according toMucosa condition according to HouseHouse
Class I: Healthy
Class II: Irritated
Class III: Pathologic
 SalivaSaliva
Class I: Normal
Class II: Excessive
Class III: Xerostomia

30. Deficient saliva: retention of denture will
be affected.
Excess of saliva: complicates impression
making.
Thin serous saliva is the best to work with.
Thick saliva makes dentures more difficult
to wear.

31.  Colour of Mucosa:Colour of Mucosa:
Ranges healthy pink to angry red.
Redness indicative of inflammation:
related to ill fitting denture,
underlying infection, systemic
disease or chronic smoking.
Pigmented spots or lesions.
White patches  keratotic areas
caused by denture irritation.

32.  Tongue:Tongue:
If patient has been without teeth for a long time: tongue
becomes enlarged & powerful. This will create a problem
in impression making & may contribute to denture
instability.
A small tongue: may jeopardize lingual seal.
Tongue position is very important to the prognosis of the
mandibular denture.

33. Wright classified tongue positions as follows:Wright classified tongue positions as follows:
Class I: Tongue lies in the floor of the mouth with the tip
forward & slightly below the incisal edges of mandibular
anterior teeth. Most favourable prognosis.
Class II: Tongue is flattened and broadened but the tip is
in the normal position.
Class III: Tongue is retracted & depressed into the floor
of the mouth with the tip curled upward, downward or
assimilated into the body of the tongue. Least favourable
prognosis.

34.  Hard palate:Hard palate:
U-shaped palatal vault; most
favourable for retention & lateral
stability.
V-shaped vault: less favourable for
retention.
Flat palatal vault: also unfavourable.

35.  Soft Palate:Soft Palate:
Classified according to configurations based on the degree
of flexure the soft palate makes with the hard palate and
the width of the seal area.
Class I: Horizontal & demonstrating little muscular
movement. Most favourable condition as it allows for
more tissue coverage for posterior palatal seal.
Class II: Turns downward forming a 45o
angle to hard
palate. Potential tissue coverage is less than for class I.
Class III: Turns downward sharply at 70o
angle just
posterior to hard palate. Least favourable soft tissue form.

36. V- shaped vault: associated with Class III soft palate
Flat palatal vault: usually associated with Class I or Class
II soft palate.

37.  Gag Reflex:Gag Reflex:
Normal defense mechanism developed by the
body to prevent foreign bodies from enetering the
trachea.
Can be caused by:
Systemic disorders,
Psychological factors,
Extraoral & intraoral physiological factors
Iatrogenic factors.
Controlled by glossopharyngeal nerve.

38. Management of gag reflex:Management of gag reflex:
Clinical techniques, pharmacological measures,
psychological intervention.
Identify the existence of gag reflex with a thorough
conversation with the patient.
Careful handling of impression procedure and constant
reassurance of the patient will suffice.
In severe cases, a specialist maybe needed to treat the
problem at a psychological level.

39.  Redundant tissue:Redundant tissue:
Excess amount of flabby tissue: cause denture base to
shift & move as force is applied, due to instability of
denture foundation.
Surgical excision may improve the condition before
impression making.

40.  Hyperplastic tissue:Hyperplastic tissue:
When present under ill fitting dentures it may present as
an epulis fissuratum, papillary hyperplasia or
hyperplastic folds.
Patient should be instructed to rest the tissues by not
wearing the existing denture.
Proper oral hygiene and tissue massage.
Existing denture should be refitted with a tissue
conditioning or temporary relining material. Occlusion
should be improved if possible.
Last resort is surgical correction.

41.  Bony undercut:Bony undercut:
Frequently found on both maxillary &
mandibular ridges.
Usually pose no problem in denture
insertion.
Rule should be selective relief of denture
rather than surgical reduction.
On mandibular ridge, the only undercut
that can pose a real problem is a
prominent sharp mylohyoid ridge.

42.  Tori:Tori:
Torus palatinus & lingual tori frequently present.
Torus palatinus: range from a small prominence in the
midline to one that covers the entire hard palate.
Adequate relief must be planned.
Lingual tori: interfere with denture construction & unless
very small should be surgically removed.

43.  Muscle & frenum attachments:Muscle & frenum attachments:
Should be examined for favourable & unfavourable
positions in relation to the crest of the ridge.
Attachments most often corrected are maxillary labial
and mandibular lingual frena.
Unfavourable frenal attachments may necessitate
surgical correction to ensure border seal.

44.  Floor of the Mouth:Floor of the Mouth:
Near the ridge crest or when magnitude of movement is
great, retention and stability of the denture
Sublingual gland & mylohyoid areas are concern where
floor of the mouth is high  cannot be selectively
displaced by the denture flange, the prognosis of the
mandibular denture will be poor.
Retromylohyoid space maybe partially or totally
obliterated by tongue movement.

45. Since success & failure of treatment depends greatly on
mutual confidence & rapport between the dentist &
patient, the first appointment is extremely important.
THE SECOND APPOINTMENT
The dentist discusses the
- Proposed treatment plan
- The sequence in which the treatment will be carried out

46. PATIENT MADE RECENTLYPATIENT MADE RECENTLY
EDENTULOUS:EDENTULOUS:
• Completely unaware of difficulties
• Assume to continue same eating habits
as with their natural teeth
Patient education is of paramount
importance and must begin with the
second examination appointment and
continue throughout the entire treatment
sequence.

47. • Expect their new teeth to last for a life time  not
possible as changes occur in the basal seat causing
position of dentures to change i.r.t their foundation & to
each other.
• “Green Ridge”:
- Tooth sockets do not completely fill with new bone
- Socket edges not rounded off as desired
- Bony spicules remain from extraction site
- Bony undercuts with a thin mucosal covering.

48. • Alveolar ridges recently made edentulous  subject to
large, rapid changes during the first year.
The dentist must inform the patient of these potential
changes before beginning, to avoid problems later on.

49. PATIENT EDENTULOUS FOR A LONGPATIENT EDENTULOUS FOR A LONG
TIME:TIME:
• The problems they present are more difficult to treat
especially if they have been previous denture wearers.
• These problems must be recognized before adequate
treatment procedures are planned
• Most important among this group are the difficult
denture wearers  Personality characteristics should be
assessed.

50. THE HOUSE CLASSIFICATIONTHE HOUSE CLASSIFICATION
• Proposed by Dr. Milus M. House
• General classification of patient’s mental attitude
They can be classified as:
Philosophic
Exacting
Indifferent
Critical
Skeptical
Hysterical

51. PHILOSOPHIC:PHILOSOPHIC:
• Willing to accept the dentist’s judgement without
question.
• Best mental attitude for denture acceptance.
• Motivation is generalized.
• Ideal attitude for successful treatment, provided the
biomechanical factors are favourable.
Dr Saransh Malot
Dept of Prosthodontics

53. EXACTING:EXACTING:
• All good attributes of philosophic patient.
• Require extreme care, effort and patience on the part of
the dentist.
• Methodical, precise and accurate and at times make
severe demands.
• Like each step of the procedure to be explained.
• If intelligent and understanding  they are the best
or else extra hours must be spent, prior to treatment,
in patient education until an understanding is reached.

55. HYSTERICAL:HYSTERICAL:
• Emotionally unstable, excitable, apprehensive and
hypertensive.
• Prognosis is often unfavorable.
• Additional professional help (psychiatric) is required
prior to and during treatment.

56. Hysterical
DEPT.Of Prosthodontics 56

57. INDIFFERENT:INDIFFERENT:
• Questionable or unfavorable prognosis.
• Little concern for their teeth or oral health.
• Seek treatment because of the insistence of family.
• Pay no attention to instructions, are uncooperative &
give up easily if problems are encountered with their
new teeth.
• Require more time for instruction on value and use of
their dentures.

58. Indifferent
58

59. OBSERVATION OF THE PATIENT:OBSERVATION OF THE PATIENT:
• Begins when the patient enters the dental clinic.
• Aspects to be observed
Motor skills
Facial features
Attitude and adaptive response.

60. (i) Motor Skills:(i) Motor Skills:
• CVA, Bell’s Palsy, nerve blocks for
trigeminal neuralgia  hemiplagia and
dyskinesia.
• Facial tremors/spasms indicate
Parkinson’s disease, nervous habits or
possibly drug induced tardive dyskinesia.
• Psychotropic drug therapy may show
Uncontrollable chewing movements
Licking and smacking of lips
Uncoordinated tongue movements

61. Twitching of the nose
Puffing of cheek
These complications often result in
prosthetic failure.
DIAGNOSIS:
• Check fluency and quality of patient’s
speech
• Best judged during casual conversation

62. (ii) Facial features:(ii) Facial features:
• Dentist must note
Length of face
Labial fullness
Apparent support of lips

63.  Observe for hollowness/puffiness in
Philtrum
Nasolabial fold
Labiomental groove

64. • Texture of skin  determines the
tone for anterior teeth setup
Rough textured skin deserves a
more rugged tooth arrangement
than smooth, light coloured skin.

65. • Size of oral cavity, activity of
lips and width of vermilion
border  directly related to
degree of tooth display.
• Profile view indicates position
of maxilla to mandible  first
indication of patient’s occlusal
classification.

66. (iii) Attitude & Level of Expectation:(iii) Attitude & Level of Expectation:
• Factors producing adaptive response to complete
dentures:
Acceptance of & confidence in dentist
Previous favourable experience & capacity to cope
favourably with change
Favourable physical conditions
Realistic expectation of the patient
Good learning capacity
Desire to please the doctor

67. • Factors that produce a maladaptive response to
complete dentures
Lack of trust in the dentist
Poor dentist-patient communication
Negative previous experience
Unrealistic expectations on the part of the patient
Resistance to change
Inadequate tissue tolerance

68. Muscle in coordination
Chronic dissatisfaction
The wish to fail, since the patient craves
for attention from the doctor
Disapproval of the dentures or of the
individual with the dentures by people
important to them.

69. HEALTH HISTORY:HEALTH HISTORY:
• Patients today have a more complex health history than
ever before.
• More likely to involve the dentist in medicolegal
challenge.
• Therefore a complete health history is an extremely
important part of the patient’s overall diagnosis and
treatment planning.

70. (i) Systemic Status of the Patient:(i) Systemic Status of the Patient:
• DEBILITATING DISEASES
They must be kept under medical control
Eg. Diabetes, Blood Dyscrasias and TB
Require
 Extra instruction in oral hygiene, eating
habits & tissue rest
 Physician consultation
 Frequent recall appointments to check the
status of underlying bone and thus
occlusion

71. • DISEASES OF THE JOINTS
Primary osteoarthritis:
 Familial disease
 More common in females
 “Heberdens nodes” involving
terminal joints of fingers  difficult
for patient to insert & clean dentures

72. Osteoarthritis of TMJ:
 Painful mandibular movements  difficulty in
construction of dentures
 Special impression trays  accommodate reduced
mouth opening
 Difficulty in recording jaw relations
 Occlusal corrections have to be made often

73. • CARDIOVASCULAR
DISEASES
 Consultation with patients
cardiologist is indicated
 Surgical procedure of any nature
maybe contraindicated
 Short appointments with pre-
medication

74. • DISEASES OF SKIN
 May have oral
manifestations Eg.
Pemphigus & lichen planus
 Oral mucosa is very painful
 Medical treatment may or
may not give comfort
 Constant use of dentures is
contraindicated  their use
is primarily for mental
comfort

75.  NEUROLOGICAL
DISORDERS:
Eg. Bells palsy
Parkinson’s disease
Added Problems:
 Denture retention
 Maxillo-mandibular relation
records
 Supporting musculature

76. • ORAL MALIGNANCIES:
 Most often detected by the dentist
 Treatment of choice = eradication of
lesion by surgery or radiotherapy.
 Prosthodontic treatment therein is
best handled by a maxillofacial
prosthodontist.

77.  Radiation therapist must be consulted  if tissues lack
tonus & have a bronze colour denture construction should
be delayed.
 Observe for signs of radiation necrosis
 Dentures should be used on a limited basis

78. • MENOPAUSE:
 Bone changes: generalized osteoporosis
 Mental disturbances: mild irritability to complete nervous
breakdown
 Oral symptoms: hot flushes, burning tongue, burning
palate and vague area pains.
 Tranquilizers and psychotherapy may help.
 Patient should be made aware of these conditions and
their possible effect during the period of denture
adjustment.

79. RADIOGRAPHIC EXAMINATIONRADIOGRAPHIC EXAMINATION
• The interpretation of the panoramic radiograph should
follow a five step analysis:
 Screen jaws for defect in structure and bony enlargement,
displacement of jaw parts, unerupted teeth or retained
root fragments, foreign bodies, radiolucencies as well as
radio opacities. TMJ can be screened and findings
correlated with history and clinical examination.

80.  Describe the appearance of the lesion as well as any
bony changes adjoining the lesion
 Correlate the radiographic findings with the clinical,
historical and laboratory findings.
 Perform a differential diagnosis which includes all the
diseases that could explain the findings.
 Estimate the growth of the lesion by the appearance of
the jaw structures adjoining the lesion.

81. • Panoramic radiographs also aid in determining the
amount of ridge resorption.
• Wical & Swoope advocated measuring the distance from
the inferior border of the mandible to the inferior margin
of the mental foramen and then multiplying it by 3, the
resultant product is a reliable estimate of the original
alveolar ridge crest height.

82. • Class I: Mild resorption, is a loss of upto one third of the
orignal vertical height.
• Class II: Moderate resorption, is a loss from one third to
two thirds of vertical height.
• Class III: Severe resorption, is a loss of two thirds or
more of vertical height.

83. PRETREATMENTPRETREATMENT
RECORDS:RECORDS:
• Diagnostic casts:
 Helps dentists avoid a potential problem
 Time consuming
 Aid in determining the inter ridge space, ridge
relationships, ridge shape and form that cannot be
adequately determined by clinical examination alone.

84. • Pre extraction records:
 Old diagnostic casts: determining both size, position &
arrangement of teeth.
 Old radiographs: determining tooth size & bony
change.
 Photographs: relay information regarding tooth size,
position & display during facial expressions. Forms an
effective tool in achieving proper esthetics & patient
satisfaction.

85. TREATMENTTREATMENT
PLANNING:PLANNING:
• 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.
• Must have a parallel process of developing a prognosis.
• Driven by the diagnosis but must take other factors such
as prognosis, patient health and attitudes into account.

86. WHY TREATMENTWHY TREATMENT
PLAN?PLAN?
Treatment Plans
Addresses patient
needs
Lists specific
treatment
Specific logical
sequence
Informed
consent
Treatment
Time
Fees
Enables patient to
give

87. Enables dentist to
Estimate
Operating time
Laboratory time
Calender time
Fees
Dentist delivers &
patient recieves
Patient specific
care

88. • Treatment planning determines the patients problems
by way of a thorough case history as previously
described
Thus making selection of the treatment option that is
most ideally indicated for the particular case at hand.
 By placing a primer on determining patient problems, it
also places a primer on the various treatment options
that are best suited for those particular conditions.

89. PROSTHODONTIC CAREPROSTHODONTIC CARE
 Edentulous PatientEdentulous Patient
 Complete denture
Immediate or conventional
Definite or interim
Tooth, implant or tissue supported.

90. ADJUNCTIVE CAREADJUNCTIVE CARE
 Elimination of infection
 Elimination of pathoses
 Surgical improvement of denture support & space
 Tissue conditioning
 Nutritional counselling

91. • Thus it is seen that diagnosis and treatment planning helpThus it is seen that diagnosis and treatment planning help
both the dentist as well as the patient understand the:both the dentist as well as the patient understand the:
 Diagnostic procedures
 Diagnostic results
 Treatment plan
 Use of prosthesis
 Continuing care
 Fees

92. BIBLIOGRAPHYBIBLIOGRAPHY
• Boucher’s: Prosthodontic treatment for edentulous patients, 11th
edn.
• Winkler: Essentials of complete denture prosthdontics, 2nd
edn.
• J.J. Sharry: Complete denture prosthodontics, 2nd
edn.
• Bouchers: Prosthodontic Treatment for edentulous patients, 10th
edn.
• Rahn & Heartwell: Textbook of complete denture, 5th
edn.
• The dental clinics of North America, Jan 1996;40(1)
• The Dental Clinics of North America, Apr 1977;21(2)
• Radiographic examination of edentulous mouths, JPD 1990;64:180-182.
• Psychological aspects of prosthodontics, JPD 1973;30:736-744
• Wical K.E. & Swoope C.C., Studies pf residual ridge resorption. Part I Use
of panoramic radiographs for evaluation and classification of
mandibular resorption, JPD 1974;32:7-12
• Also courtesy to some unknown authors from whome I copied some of
slides….!!

93. THANK YOU
Dr Saransh Malot
Dept of Prosthodontics