DIAGNOSIS AND TREATMENT PLANNING FOR EDENTULOUS OR POTENTIALLY EDENTULOUS PATIENTS

DIAGNOSIS AND TREATMENT PLANNING FOR EDENTULOUS OR POTENTIALLY EDENTULOUS PATIENTSPresented by: RajsandeepGuided by: Dr. Nidhi DuggalContentsIntroductionPatient rapportDiagnosisVisual observationsRadiographsPanoramic radiographyIntraoral radiographyPalpationMeasurementsDiagnostic castsStepwise diagnosisChief complaintSocial informationDiabetesNutritional disordersDiseases of jointsSclerodermaCardiac and pulmonary disordersCVABone disordersDiseases of skinNeurological dosordersMalignancies and radiotherapyDrug historyMental healthDental healthPatient expectations and attitudesExtra oral examinationIntra oral examinaionTreatment planningPatient educationTreatment options for patients already wearing denturesPrognosisconclusions

INTRODUCTIONThe complete denture more than any other dental treatment depends for its success not only on the oral cavity of the patient but also on his /her general health and attitude. Complete denture rehabilitation involves treating the patient and not just the oral cavity. Hence, the physical and psychological status of the patient along with oral health should be thoroughly assessed.A successful complete denture therapy begins with a thorough assessment of the patients physical and psychological condition and determining a treatment that will deliver a functional complete denture that will satisfy the expectations of the patient which might need to be modified in certain cases.PATIENT RAPPORTThe initial contact with the patient is most important and sets the tone for the future interaction of the patient with the dentist.If the patient has a treatment history in the present practice, both dentist and patient have advantage of prior knowledge. DIAGNOSISIt is the use of scientific or clinical methods to establish the cause and nature of a persons illness.According to GPT it is the determination of the nature of disease.This is done by evaluating the history of the disease process, the signs and symptoms, the laboratory data, and specific tests such as radiography.The value of establishing a diagnosis is to provide a logical basis for treatment and prognosis.Various means of establishing a diagnosisAn experienced clinician uses a variety of tools for coming to a diagnosis.The final diagnosis and prognosis is reached only after careful examination of the patient visually, written and verbal interaction with the patient, palpation, studying of diagnostic casts and making radiographic evaluation.Visual observationsThe gradient between task and ambient lighting should not be too great.The task light should not produce glare to avoid high contrast shadows.The visual acuity decreases with age and higher levels of lighting are required.Color balance is important for not only shade selection but also for evaluation of soft tissue.Through visual perception, typical tasks to be identified are detection, discrimination, recognition, identification and judgmentUse of visual aidsMouth mirror: gives comfortable viewing angles and also helps focus light on the desired areas.Magnification: hand lenses and loupes are used. Loupes also have the advantage of giving a comfortable viewing distance and some also give a comfortable viewing angle using fiberoptics.Still photography.Intraoral videography gives well illuminated and magnified images for immediate viewing and storage.Still digital photography help in treatment planning as the images are easily stored and retrieved for viewing and when taken at the initial subsequent visits help in evaluating treatment progression.Radiography These are important aids in detecting submucosal conditions.These may be foreign bodies, retained roots, unerupted teeth, various pathoses of developmental, inflammatory or neoplastic in origin.They aid in evaluating the quantity and quality of bone around teeth and in edentulous areas.They also provide information regarding bone surrounding the apices of pulpless teeth.The location of the mental foramen and the mandibular canal can also be judged.Sharp spicules of bone, spiny ridges and the thickness of the submucosa affect decisions about the types of impressions and the denture base design to be used. Panoramic radiographyThese incorporate inaccuracies as a result of their tomographic principle and the magnification is of the order of 25%.Therefore the clinician has to have a knowledge of the normal structures as they appear on the panoramic projection.These allow the clinician to have a broad view of the supporting structures.Suspicious areas are then examined using intraoral radiography.Intraoral radiographySince the film used is small it can be placed close to the tooth and therefore has less magnification and since the film is placed flat the distortion is also less.They give more accurate details of a smaller area. They are used to study suspicious areas seen in larger projections.Digital radiography has the advantage of easy storage and retrieval and less radiation exposure to the patient. Palpation It is referred to as the third eye of the clinician.For submucosal structures it complements radiographic examination. It will reveal textural differences and unusual contours.Displaceable structures, discontinuities and enlargements are detected.Sharp residual ridges, mylohyoid ridges are typically tender.Tenderness in apparently normal areas should be investigated radiographically.Both primary and secondary bone support areas should be palpated. The sides of the residual ridge should be palpated along with the crest.Irregularities and patient reactions are noted.The floor of the mouth is examined using bimanual palpation.The patency of the wharton duct and production of saliva is detected by the expression of saliva as the duct and gland are gently squeezed. For examining the tongue the patient is asked to protrude the tongue onto a gauze which helps the dentist to hold the tongue while using a mirror to examine it. The tongue is palpated from the left to the right and the target areas are the lateral borders and the vallate papillae.The intraoral findings are corroborated with extraoral palpation and are used to explore other structures such as the TMJ and associated musclesMeasurements The most commonly used extraoral measurents are the VDO and the VDR which are often made using arbitrary marks on the nose and chin however for future references the menton and the columella of the nose are used.Other extraoral mearurements usually relate to the selection of teeth. Eg. the ratio of the interpupillary line on a photograph and that measured on the patient can be used to calculate the size of the natural teeth by dividing their size on the photograph by the ratio.Intraoral measurements are made using probes, dividers and boley gauges. these are helpful in monitoring various mucosal lesion and in fabrication of custom trays.Diagnostic castsThey allow for an evaluation of anatomy and relations in the absence of the patient.The mounting of casts on an articulator allows for a dynamic evaluation of interarch relations.A facebow can be used to relate the casts to an approximate hinge axis.We will look for arch size, symmetry, interarch space, arch concentricity, anteroposterior jaw relationships and lateral relations especially if a posterior crossbite occlusion is indicated.Undercuts might be seen with the naked eye or surveyed..Displacement of tissues from a previous denture might be more obvious on a dry cast than in the mouth.Stepwise diagnosisHistorySocial informationMedical historyMental healthDental healthDental historyClinical examinationIntra oralExtra oralAny other investigations and diagnostic aidsChief complaintAccording to DeVan, the dentist should meet the mind of the patient before he meets the mouth of the patient.The chief complaint should be written in patients own words, patient should be questioned regarding his chief complaintHistory of the present complaint It is important to ascertain full details of any complaint. If, for example, the complaint is of pain in relation to a denture, the location, character and timing of the pain should be determined; relieving and aggravating factors should also be recorded. It is important to ascertain the relationship of the time of onset of the symptoms with the time that the present set of dentures were fi tted. If a denture is loose, it is important to enquire when the looseness was first noticed. If the denture has been worn satisfactorily for several years before trouble developed, this indicates that the dentures were initially satisfactory and that subsequent changes such as resorption of the residual ridges or wear of the occlusal surfaces are responsible for the problem. In this situation it is essential in addition to identifying the cause of the complaint to note the good features of the denture, as it is usually sensible to replicate these in the replacement dentures.On the other hand, if the looseness was present from the time the denture was fitted, the cause may be attributed to a basic design fault in the denture, to unfavourable anatomical factors or perhaps to the inability of the patient to adapt to dentures. Until an examination is made, it is not possible to distinguish between these causes.Social informationAddressing by name gains patients confidence. Age : Age influences denture success. Tissues of the older patients are less resilient and the oralmucosa and Submucosa are thinner. Repair potential of tissues are altered. Frush and Fisher suggested guidelines for selection and arrangement of anterior teeth based on age, sex and personality.Some age related diseases of interest are Congenital cleft lip and palate, Acute rheumatic fever, Scleroderma, Rheumatoid arthritis,Hypertension, Diabetes ,Climacteric etc. Sex : Generally appearance is of high priority for women and men are more concerned with comfort and function. Women during menopause can be difficult to treat due to psychological problems, dry mouth, burning sensation in the mouth and general vague pain. For female patients the teeth must have softer anatomic features and incisal edges must follow a curve which suggests softness. A more masculine appearance is achieved by a more square or cuboidal tooth form.Some of the sex related disorder which have significant role in complete denture therapy are Heamophilia, Osteomalacia, Iron deficiency anemia. Occupation : A patients job and social standings often determine the value he or she places on oral health, as well as the esthetics and other qualities desired in denture. Tooth position is very important for a musician who plays a wind instrument. Some occupational habits like nail biting of tailors and cobblers may cause attrition of anterior teeth. Occupations like public speakers, teachers and singers are more particular about the phonetics with their new dentures. Address : Helps in future communication, knowledge of patients social status and setting up of appointments. Out Patient Number : Helps to maintain the statistical analysis and hospital data.Medical History :Provides important insights regarding patients dental prognosis.A patient in good general health is generally able to accept and adjust to a complete denture better than one who is in poor health.Systemic factors that may affect complete denture treatment include; anemia, arthritis, Bell's palsy carcinomas, diabetes, nicotinic stomatitis, Paget's disease, Parkinson's disease, and therapies that cause xerostomia and infectious diseases.Diabetes mellitusThe following diagnostic features are in evidence in diabetes: a dry feeling in the mouth; a coated tongue, with swollen edges and tooth impressions along the borders; fissures on the tongue; small abscesses throughout the mouth, poor tissue tone; and a burning and metallic taste in the mouth. It is associated with poor wound healing, increased bone resorption, muscle atrophy and decreased salivation.Appointments should be short and not interfere with meals time. Minimal pressure impression techniques should be used ,care should be taken in teeth selection and type of occlusion. The tissues need functional rest so patients should be advised of less denture wear. Frequent relining and rebasing of dentures may be requiredNutritional DisordersAvitaminosis lowers the defense mechanism of the body and mucosal structures, Various type of anemia present the following generalized symptoms: changes in the mucous membrane; pallor of the tongue and lips; burning, smooth, glossy tongue; and usually pain in the tongue and supporting areas.such painful conditions make the denture use impossible without medical treatment.patients have fragile mucosa so the dentures should be as smooth as possible. Constant use of prosthesis should be discouraged for these patients

Diseases of the jointsThe oral aspects of arthritis are usually seen in the temporomandibular joint. These are limited movement and opening, generalized pain throughout the side of the face, abnormal chewing procedures, and changing occlusal relations. Osteoarthritis : When terminal joints of fingers are arthritic it is difficult for the patient to insert and clean the dentures. When it affects TMJ the mouth opening will be restricted and painful movements of the jaw necessitates the use of special impression trays.it becomes increasingly difficult for the patient to clean dentures adequately. The patient can be helped by increasing the thickness of the brush handle so that it can be gripped without discomfort, by providing brushes which can be attached to a washbasin and by recommending an effective cleansing solution which reduces the reliance on mechanical means of plaque removal.SclerodermaLips become rigid and the aperture narrows, and presents mask like facial expression. Restricted mandibular movements are seen. Management includes improving the mouth opening by stretching exercises and sectional trays for impression making. Dentures can be designed with midline hinge, so that they are collapsible and can be easily inserted and removed.Cardiovascular and pulmonary diseasesCardiovascular conditions include hypertension, angina pectoris, myocardial infarction, previous cardiac bypass surgery, Congestive heart failure, presence of cardiac pacemaker and infective endocarditis. Proper care and treatment planning are necessary for such patients. Hypertension: Morning dental appointments were once suggested for hypertensive patients, however recent evidences indicate that blood pressure levels generally increases around awakening and peaks at mid morning, therefore afternoon dental appointments maybe preferred.Bronchial asthma : The asthmatic patients should be questioned about concerned precipitating factors, frequency and severity of attack, medications used and response to medications Congestive heart failure, chronic bronchitis and emphysema Elderly patients with these conditions are likely to become breathless if the dental chair is tipped back into the supine position.Cerebro-vascular accidentThe occurrence of a stroke may result in unilateral paralysis of the facial muscles, making it more difficult for the patient to control dentures, especially the lower denture.patient may also have difficulty clearing food which has lodged in the buccal sulcus.Speech may be affected, making it difficult for the patient to communicate with the dentist.Bone disordersthe disorders of interest include osteosclerosis, osteomalacia and Osteoporosis.osteoporosis can lead to a hunched posture, or kyphosis, which requires the dentist to ensure that work is undertaken with the patient in the sitting position with the head and neck adequately supported.Diseases of the skinSkin diseases like pemphigus have oral manifestations which may vary from ulcers to bullae, Pemhigus is the most often fatal of the dermatologic diseases. Orally it presents vesicles and bullae on the mucous membrane as well as on the skin. When the vesicles rupture, they leave eroded areas and ulcerations, and the resulting condition causes discomfort and pain.Other dermatological diseases include lichen planus, pemphigoid, DLE. Neurological disordersDiseases like epilepsy, Bells palsy, Parkinsons disease can influence the denture retention, jaw relation records and impression making procedures. Use of anxiety reduction protocol and stress levels should be minimized.Bell's palsy is a toxic, infective, thermal, or mechanical over stimulation of the facial nerve, which results in facial asymmetry, lack of muscular control on the affected side, failure of the eyelid to close normally on the affected side, excessive tearing on the paralyzed side, drooping of the corner of the mouth, and emission of saliva.Parkinsons disease, as well as other tremors that are likely to occur in the elderly, can adversely affect the precise control of the mandible, making it more difficult to obtain an accurate recording of the jaw relationship. Parkinsonism can also cause difficulty in swallowing, leading to pronounced dribbling, which can be very distressing for the patient.Oral malignancies and radiation therapyHigh dose radiation therapy results in hypovascularity, reduction in wound healing capacity and stress bearing capacity of the tissues. Saliva may become extremely viscous or non existent depending on the dose of radiation. Xerostomia may cause a decrease in the normal salivary cleansing mechanisms. Sialogogues and use of denture adhesives may have to be considered. Here posterior occlusion should be such that there is reduced stress. A waiting period should elapse between the end of radiation therapy and beginning of complete denture construction.

Drug historyThe dentist should know the medications a patien is taking. Some drugs have a direct effect on the oral environment. side effects that occur due to various medications are - Xerostomia, changes in the oral microflora, Sialorrhea, dysphagia, postural or orthostatic hypotension, behavioural changes or confusion etc. should be taken care during prosthesis fabrication. The commonest drugs prescribed for elderly people, in descending order of frequency, are diuretics, analgesics, hypnotics, sedatives, anxiolytics, antirheumatics and betablockers. Many of these drugs have side effects that are relevant to the dentist about to undertake prosthetic treatment. Xerostomia is produced by certain antidepressants, diuretics, antihypertensives and antipsychotics, some drugs having a more profound effect on secretion than others. Lack of saliva adversely affects the retention of dentures, increases the possibility of oral infection and, through the absence of lubrication, can result in generalised soreness or even a burning sensation. Certain drugs, such as steroid inhalers used in the treatment of asthma, immunosuppressive drugs and broad-spectrum antibiotics used over a long period, can alter the oral flora thus predisposing to candida infection. Tardive dyskinesia is a condition characterised by spasmodic movements of the oral, lingual and facial muscles. These uncontrollable movements can make it extremely difficult, or even impossible, to provide stable dentures. The condition is brought on by extensive use of drugs such as antipsychotics and tricyclic antidepressants. It will occur in 2040% of patients who have been taking the drugs for longer than 6 months. In approximately 40% of sufferers the condition is not reversible, even if the drug therapy is stopped. Endocrine injections and thyroid, estrogenic, and androgenic compounds often cause an extremely sore mouth for the edentulous patient.Mental healthPsychiatric disorders Depression is the most common mental disorder in later life.This condition can result in poor appetite and weight loss, and can adversely affect motivation and self-care. It is not a normal consequence of ageing and is treatable. With regard to prosthetic treatment, the condition may reduce the patients ability to make an effort to accommodate to new dentures. Dementia is found in 56% of people over the age of 65 and in 20% of those over 80 years old and can result in conditions such as intellectual impairment, a poor memory (particularly for recent events), poor concentration and a reduced level of self-care. The situation can deteriorate to such a level that dentures, particularly the lower, cannot be worn.Psychological changes Advancing age leads to certain inevitable changes that must be taken into account when treating the elderly patient. For example, the patient finds it more difficult to perform tasks that depend upon rapid movements. Such tasks may well include the need to suddenly control a denture that has become destabilized during normal function. It should also be realized that elderly people take rather longer to learn to perform new tasks or to remember new information which is not put over clearly or which may not appear to be immediately relevant Elderly people are less able to accept new situations, be they a change in denture shape, a new dentist or even the appointment time for treatment. It will be appreciated that the clinician must take many aspects of the life of the patient into account when investigating a complaint.House classified patients depending on their mental attitude as philosophical, exacting, indifferent and hysterical.1.Philosophical patient: The best mental attitude for denture acceptance is the philosophical type. This patient is rational, sensible, calm and composed in different situations. His motivation is generalized as he desires dentures for the maintenance of health and appearance and feels that having teeth replaced is a normal, acceptable procedure.2.Exacting patient:The exacting type may have all of the good attributed to the philosophical patient; however, he may require extreme care, effort and patience on the part of the dentist. This patient is methodical, precise, accurate and at times makes severe demands. He likes each step in the procedure explained in detail.

Indifferent patient The indifferent type of patient presents a questionable or unfavorable prognosis. This patient evidences little if any concern; he is apathetic, uninterested and lacks motivation. The indifferent patient pays no attention to instructions, will not cooperate and is prone to blame the dentist for poor dental health. Hysterical patient The hysterical type is emotionally unstable, excitable, excessively apprehensive. The prognosis is often unfavorable and additional professional help (psychiatric) is required prior to and during treatment. This patient is primarily systemic and many of his symptoms are not the result of denturesDental healthUnderstanding of the etiology of the loss of teeth helps estimate the patients appreciation of dentistry. When obtaining a patients dental history, it is necessary to ascertain: When the natural teeth were extracted The reasons for the extractions The occurrence of any surgical complications How many dentures have been worn subsequently the degree of success or failure with the dentures. This history can provide important information on: The rate of bone resorption. The history of tooth loss provides a basis on which to make an assessment of the current rate of bone resorption. If extractions were carried out in the previous few months, resorption will still be continuing at a rapid rate, so that if dentures are provided at this time they will soon become loose and require rebasing. The patient should therefore be warned of this likelihood. If, however, the teeth were extracted several years ago, the alveolar bone will have reached a relatively stable state and the life of a replacement denture will be considerably extended. Retained roots. If there is a history of difficult extractions, it is advisable to obtain radiographs in order to check for the presence and location of retained roots. The adaptive capability of the patient. Clues can be obtained to the adaptive capability of the patient. For example, if three sets of dentures have been worn successfully over a period of 15 years, it may be assumed that adaptation has been satisfactory, whereas if the same number have been provided over the last 2 or 3 years and each has been troublesome, adaptation will be suspect. However, it is vitally important not to jump to conclusions and to put the blame on the patient until one is satisfied that the complaint cannot be related to defects in the design of previous dentures It is thus wise practice to ask the patient to bring all available sets of dentures when attending for the initial assessment, as inspection of them can yield valuable clues and increase the accuracy of the diagnosis.

Patients who have lost teeth in an accident are usually more unhappy about their edentulous state than those who lost their teeth due to neglect. The amount of bone loss would be more for the patient with a long history of progressive periodontal disease than for the patient with a history of caries. Questioning should also include the general order of teeth loss. If all the posterior teeth were extracted prior to the anterior teeth a habit of eating with front teeth may lead to unstabilized effect on full dentures. Past dental experiences good or bad might influence the patients attitude towards and his expectations from the dentist.Patients Expectations And AttitudesThe reason the patient seeks prosthetic treatment is of critical importance. His or her expectations must be evaluated to determine if they are realistic and attainable. The practitioner must be cognizant of patients personality classification and should not make unrealistic promises regarding treatment outcomes.The importance of older denturesMost edentulous people over the age of 65 are wearing dentures that are more than 10 years old and, as a result, mucosal changes are present in between 44% and 63% of cases.The need for treatment, based on clinical judgement, suggests that 40% of 5-year-old dentures and 80% of 10-year-old dentures should be replaced. Need can be measured in a variety of ways: Normative need is the need defined by expert or professional opinion. Felt need is the patients subjective desire. Expressed need is recorded when the felt need is activated through the patient seeking treatment.Elderly people are likely to consider that treatment is required as a result of experiencing pain, difficulty in chewing, a deteriorating appearance, or because the existing dentures are broken or have been lost.Extra-oral examination of the denturesThe dentures are removed from the mouth and a detailed and systematic extra-oral examination is made of their impression, polished and occlusal surfaces. Any relevant findings are recorded.Impression surface The presence or absence of a post-dam and palatal relief. Width of borders. The amount and distribution of plaque, an important cause of denture stomatitis. Painting disclosing solution on the impression surface will help to visualise the plaque. Evidence of adjustments, relines or repairs. Surface roughness.Polished surface Shape and inclination. In essence, is the shape such that it will allow the muscles to help rather than hinder the control of the denture Condition and general cleanliness of the denture material.Occlusal surface Amount of wear; presence of shiny facets. Teeth acrylic or porcelain; size, shape and colour.

Intra-oral examination of the dentures Each denture is placed in the mouth separately and examined for: stability retention border extension. The dentures are then examined together to assess the: occlusion occlusal vertical dimension appearanceAssessing stability and retention An assessment of stability and retention can be made by carrying out the following simple tests. Assessing stability of the upper denture. The upper denture is seated in the mouth and an attempt made to rotate it in the horizontal plane. Any resulting lateral movement of the midline is noted. Some movement is inevitable because of the compressibility of the mucosa, but a movement of 3 mm or more either side of the midline is an indication of loss of fi t or the presence of a fl abby ridge. A similar conclusion can be drawn if an attempt to rock the denture across the midline results in clearly detectable movement of the prosthesis with the centre of the hard palate acting as a fulcrum. (2) Assessing stability of the lower denture. The stability of a lower denture can be investigated by seeing if it stays seated on the ridge when the mouth is slightly open and the tongue is brought forwards so that its tip lightly contacts the lingual surfaces of the anterior teeth. An unstable denture will usually be displaced away from the ridge by the lower lip or by the tongue The patient is asked to move the tip of the tongue from the corner of one side of the mouth to the other. Lack of tongue space within the arch of teeth will readily result in movement of the denture. A lower denture can be unstable if the occlusal table is extended too far posteriorly. Finger pressure applied to the lower second molars to check this should meet with noticeable resistance. An unstable denture will readily slide anteriorly. The lower denture is held against the ridge by a fi nger and thumb in the incisor region and an attempt is made to move it in an antero-posterior direction. The absence of any resistance to movement posteriorly is highly suggestive of lack of extension of the denture base over the pear-shaped pads. The clinical examination should proceed in a logical and orderly sequence so that nothing is overlooked.Extra Oral ExaminationSimply by talking to the patient and making careful observations at the same time, the dentist may obtain important information that will help in treatment planning:(1) Discrepancy between actual and biological ages. Any discrepancy between the actual age and biological age should be noted as this can be important in assessing the likely adaptive capability.(2) Skeletal relationship. The skeletal relationship of the patient should be assessed because this will indicate the appropriate incisal relationship of the planned dentures.(3) Occlusal vertical dimension. The facial appearance provides valuable information about the occlusal vertical dimension of existing dentures. If loss of occlusal vertical dimension is noted, correction may be required before new dentures are started

Facial symmetry : Should observe for the symmetry of the face, whether its bilaterally symmetrical or notFacial form : Leon Williams claimed classified the form of the human face in to 3 types Square/Tapering/ OvoidFacial Profile : Angle classified facial profile into Normognathic/Prognathic/Retrognathic. The lateral surface of the tooth viewed from the mesial aspect should show a contour similar to that when viewed in profile.Complexion : Complexion helps in shade selection of the teeth.

LipsRestoration of the lip support and vermillion border width must be considered during placement of the anterior teeth.Lip thickness: Can be thick /medium/ thin .In patients with thin lips any slight change in the labio lingual position of teeth makes an immediate change in the lip contourThick lips give little more room for alteration in the teeth position before obvious changes occur in lip contour.Lip length : Lip length plays an important role in esthetics. Can be classified as- Long / normal or medium/ shortA long lip reveals very little of the anterior teeth, where as a very short upper lip leads to display of the denture base. Mold selection and denture characterization can be critical factors in these cases.Health of the lips : Angular cheilitis may occur in cases of decreases vertical dimension. Should observe for fissures, cracks or ulcers at the corners of the mouth.Modiolus The muscles of the lips and cheek converge into a thick, mobile hob region called the modiolus, which is slightly inferior and distal to the corner of the mouth. This region is supported primarily by the maxillary teethTemporo mandibular joint examinationTemporomandibular joints should be thoroughly examined. The range of movements and the amount of deviation must be noted. Any pain on palpation or during mandibular movements must be observed. Muscles of mastication must be examined for any tenderness. Joint sounds like crepitus, clicking or popping sounds must be investigated. These could be encountered due to severe discrepancy of vertical dimension of occlusion or due to loss of posterior teeth which causes the load to shift anteriorly. A digital examination of the area over the temporomandibular joint should be made. Place the fingers over each joint/ place in the external auditory meatus behind the tragus and have the patient slowly open and close his mouth. Any pain or tenderness in this area may be indicative of an excessive increase or decrease in the vertical dimension of occlusion. Crepitus, clicking, or abnormal movements should be noted.Influence of musclesMuscle tone : The tone of the facial tissues may indicate the limitations to improve the patients facial contours. The muscle tone of the patient can be classified asClass 1: the patient exhibits normal tension, tone and placement of the muscles of mastication and facial expression. No degenerative changes are apparent , usually only immediate denture patients have normal muscle tone.Class 2 : the patient displays approximately normal function but slightly impaired muscle tone.Class 3 : the patient exhibits greatly impaired muscle tone and function.Muscle development : Classification according to M.M.House-Class 1 : heavy/Class 2: medium/Class 3: lightIntra-oral examination of the patientThe broad objectives of this part of the examination are to determine: Whether there is any pathology in the mouth; What the prospects are for the new dentures providing a satisfactory level of comfort and function.

Detecting systemic diseaseThe mouth has been aptly described as a mirror which reflects the state of health of the individual. When systemic disease develops, the powerful combination of microorganisms, normal wear and tear, and moisture and warmth present in the mouth frequently result in visible changes in the oral tissues before signs of disease are evident elsewhere in the body. Investigation of these changes may allow an early diagnosis of the systemic condition to be made. For example, there may be a change in the population of papillae on the tongue; this change occurs first on the tip and sides, the areas of maximum trauma. The filiform papillae are progressively lost so that the fungiform papillae become more noticeable and produce the appearance of a pebbly tongue; eventually, the fungiform papillae also disappear and the tongue becomes smooth . These changes should lead the dentist to suspect deficiencies such as iron, vitamin B12 and folic acid. Diagnosis may be confi rmed by the appropriate haematological investigations.Mucosa Normal color of the mucous membrane is coral pink , any variation must be investigated. Common prosthetic causes of irritation are - Over extension of the periphery of the denture, ill fitting dentures, continuous wearing of the denture,. faulty articulation of the teeth, rubber suction discs, traumatic injury, allergy, small spicules of alveolar bone etc.Mucosal Condition: Classification according to M.M.House - Class 1: healthy/Class 2: irritated/Class 3: pathologicA mucosa of medium thickness and uniform resiliency offer the most favorable prognosis. If the oral mucosa is excessively thick stability becomes more of a problem than retention. If the mucosa is inflamed it should be treated before impression procedures are started. Thickness of mucosa is classified according to M.M.House as Class1: normal or uniform/Class 2: twice the normal/Class 3 : excessively thickArch Size :Class 1(large) : The alveolar ridge of adequate height gives support and to resist lateral movement of the denture.Class 2 (medium) : The alveolar ridge would have undergone some resorptionClass 3 (small ) : the alveolar ridge is almost or completely resorbed. There is no resistance to lateral movement of the dentureArch Form : Arch form is generally classified as square, tapering, or ovoid.Class 1 : Square arch form is the best form to prevent rotational movementsClass 2 : The tapering form offers some resistance to movement but to a lesser degree than the square archClass 3 : The ovoid form offers little or no resistance to rotational movements.The vault form should be classified as followsClass 1- Square or gently roundedClass 2 - Tapered or V shapedClass 3- FlatMandibular ridge formClass 1- parallel walls & broad crestClass 2- Inverted U shaped , short with flat crestClass 3- Unfavourable-inverted W or short inverted V or with undercutsHigh ridge with a flat crest and parallel walls is ideal which give maximum support and stability. The knife edge ridge with multiple bony spicules offer the poorest prognosis because they are incapable of withstanding much occlusal force. Relief has to be provided for this ridge type in the impression procedures. The flat ridge also has a poor prognosis because of the lack of vertical height affords little resistance to horizontal movement.Inter arch space : Classified asClass 1- Ideal interarch space to accommodate the artificial teethClass 2- Excessive interarch space leading to poor stability and retention of dentures because of increased leverage action.Class 3- Insufficient interarch space to accommodate artificial teeth, enchances the stability of the dentures since the occlusal surface of the teeth are close to the ridge minimizing tilting leverage but decreases retention.Ridge Parallelism : When teeth are gradually lost the residual ridges will diverge from each other. If the ridges are not parallel to the occlusal plane, dentures will slide over the basilar tissues when occlusal forces are applied to them.Classified as :Class 1 - Both ridges are parallel to the occlusal planeClass 2 - Either the mandibular or maxillary ridge diverging anteriorlyClass 3 - Both ridges diverge anteriorlyRidge Relationship : Jaw relationship can be Normal (Angle class1): Anterior segment of the mandibular ridge is directly below or slightly posterior to the maxillary ridgesRetrognathic mandible (Angle class2) : Anterior segment of the mandibular ridge is retruded beyond the normal position as related to the maxillary anterior ridge segment.Prognathic (Angle class 3): Anterior segment of the mandibular ridge is protruded beyond the normal position as related to the maxillary anterior ridge segment.Lateral ThroatformNeils Classification : Class1 : Indicates that the anatomical structures will accommodate a fairly long and wide flange; minimal or no pressure is exerted on the finger , can be classified as deep. Class 2 : It is about half as long and narrow as the class1 and twice as long as class3. it can be classified as moderate. Class 3 : This form has minimum length and thickness Heavy pressure is placed on the finger. This is important for ascertaining the border extension in this area. This form can be classified as shallowThe patient with the class 1 will be more comfortable with a fairly thin posterior border of 1 to2 mm. The patient with class 2 throat form can tolerate a posterior border of moderate thickness. The patient with the class 3 has little or no area for a posterior seal, so the posterior border can be made thicker.

Maxillary TuberositiesClassified as-normal/Pendulous or bulbous Large pendulous or bulbous tuberosities may present a number of problems like encroachment on the interridge distance. Sometimes maxillary tuberosities may be fibrous that hangs pendulously. They should be surgically reduced as they contribute to excessive vertical and horizontal movement seriously jeopardizing the stability of the denture.PalateShape of The Hard Palate : Classified as flat/rounded/ U shaped / V shaped.A flat palate resists vertical displacement but easily displaced by lateral or torquing forces. The rounded and U shaped palate has the best resistance to vertical and horizontal forces. The V shaped palate is the most difficult one because any vertical or torquing movement tends to break off the seal easily.Relationship of the Soft Palate to the Hard Palate is classified as:Class 1 : It is horizontal, makes 10 degree angle to the hard palate and demonstrates little muscular movement. In this case more tissue coverage is possible for posterior palatal sealClass 2 : Soft palate makes 45 degree angle to the hard palateClass 3 : Soft palate makes 70 degree angle to the hard palate.Shape of the Soft Palate: MM House classified it asClass 1 : More than 5mm of movable tissue available for post damming. Ideal for retentionClass 2 : One to five mm of movable tissue available for post damming. Good retention is usually possibleClass 3 : Less than one mm movable tissue available for post damming. Retention is usually poorBony Undercuts:Class1 : bony undercuts are absentClass2 : small undercuts, the denture can be placed by altering the path of insertionClass 3 : prominent bilateral undercuts, must be corrected surgically.Tori : A torus palatinus or lingual tori are occasionally present. Extremely large tori must be removed surgically. Small or moderate tori can be managed by altering the impression procedures, since the thin mucosal covering of these tori cannot tolerate pressure. Adequate relief must be planned for tori in the impression and the denture.FreniFrenal Attachments: Classification according to M.M.HouseClass 1: high in the maxilla as low in the mandible with respect to the crest of the ridgeClass 2 : mediumClass 3 : freni encroach on the crest of the ridge and may interfere with the denture seal , surgical correction may be required.Inadequate clearance may result in pain and ulceration of mucosa or displacement of the denture. Over clearance may result in a loss of seal and a loose denture.TongueClassification according to M.M.House:Class 1 : normal in size, development and function.Class 2 : teeth have been absent long enough to permit a change in the form and function of the tongue.Class 3 : excessively large tongue. All teeth have been absent for an extended period of time allowing for abnormal development of the size of the tongue. A small narrow tongue contributes to the ease of impression making , but jeopardizes the lingual seal for the mandibular denture. A broad thick tongue always is in the way during impression making, provides an excellent seal for the denture. An extremely large tongue poses additional problems during impression making and impairs denture stability.Tongue Position : Classification according to WrightNormal or Class1: the tongue fills the floor of the mouth and is confined by the mandibular teeth.Retracted or Class2 : the tongue is retraced. The floor of the mouth is pulled downward is exposed back to the molar area.Class 3 : the tongue is very tense and pulled back ward and curled upward.SalivaSaliva is classified as follows:Class1 : normal quality and quantity of saliva, cohesive and adhesive properties of saliva are ideal.Class 2 : excessive saliva, contains much mucousClass 3 : xerostomia, remaining saliva is mucinous

Copious thick ropy saliva interferes with impression procedures and often provokes nausea and increased hydrostatic pressure leads to loss of retention of maxillary denture. Scanty thin saliva interferes with the seal of the dentures and provides poor protection against scuffing and chafing.Mylohyoid Ridge : Should be examined by palpation, can be sharp or normal. The mucous membrane over a sharp or irregular mylohyoid ridge will be easily traumatized by the denture base, unless relief is provided in the denture base.Genial Tubercles : May be sharp or normal. The genial tubercles become prominent with resorption of the ridges.(3) Assessing retention. Tests of retention are usually only of value in assessing the upper denture as the physical retention of lower dentures is normally minimal: Seat the upper denture and attempt to dislodge it by pulling vertically downwards with the thumb and first finger on the buccal aspects of the right and left premolar teeth. Lack of resistance indicates poor retention. Seat the upper denture and ask the patient to open the mouth until the incisal separation is 23 cm. If this causes the denture to drop, an error in either the impression or the polished surface should be suspected. (4) Border extension. The denture base is assessed for over- and under-extension. Underextension of the upper and lower denture buccally, labially and at the post-dam can be determined by direct vision. Overextension is present if the denture moves occlusally when the muscles are gently pulled. Lingual extension is less easy to assess. Anteriorly a mouth mirror can help, and overextension can be inferred if the lower denture lifts when the tongue is raised. A fully border moulded alginate wash impression within the denture can be very informative, indicating either over- or underextension.(5) Occlusion. Both dentures are examined together in the mouth and a check is made on occlusal balance. (6) Appearance. A further assessment of the appearance of the dentures should be made. The lips can be retracted and features such as orientation of the occlusal plane, and the colour, shape and arrangement of the anterior teeth can be noted.InvestigationsRadiographic Examination : A complete radiographic study furnishes information as to the presence of retained roots, foreign bodies, pathologic areas and generalized osteoporosis in the bony support.A panoramic radiograph is useful in assessing the amount of ridge resorption.Wical and Swoope found that in panoramic radiographs if the distance from the inferior border of mandible to the lower border of the mental foramen was measured and multiplied by three, it gives the actual height of the alveolar ridge crest.

Other Investigations : Blood investigations Blood glucose levels for diabetics, Hb % of blood for anemic patients is important for any preprosthetic surgery desired.Treatment planningIt is the process of matching possible treatment options with patient needs and systematically arranging the treatment in order of priority but in keeping with logical or technically necessary sequence.The adjunctive care in treatment planning includes:Elimination of infectionElimination of pathosesSurgical improvement of denture support and spaceTissue conditioning Nutritional counsellingProsthodontic careFor the patient destined to become edentulous:Removable partial dentureConventionalInterimHybrid complete dentureTransitionalComplete dentureImmediate or conventionalDefinitive or interimTooth or implant supportedFor the edentulous patient soft tissue supported or implant supported dentures may be given. The implant supported dentures may be removable or fixed.WHY TREATMENT PLANPATIENT EDUCATIONManagement of completely edentulous patients already wearing complete denturesPossible treatment options include: No treatment. Preparatory treatment such as denture adjustment or a short-term reline Defi nitive denture modifi cations such as reline, rebase , repair or cleaning. Replacement dentures.If replacement dentures are to be made, it is of great value to make a note of the features in the existing dentures that must be modified in order to overcome the patients complaint. It is just as important to make a note of those aspects of the existing design which have proved to be successful and therefore need to be incorporated into the design of the new dentures. There are several approaches to designing and constructing complete dentures. The dentist should make a positive decision at the treatment plan stage as to which is appropriate for the patient.(1) Carving record rims. The shape, or design, of the dentures may be determined by the dentist carving the record rims, so that the upper rim provides adequate lip support and the lower rim lies in the neutral zone.(2) Copy dentures. Where dentures have provided satisfactory service for the patient in the past, it may be advisable to base the design of replacement dentures on the well-accepted features of the old ones. Such an approach is particularly appropriate for the treatment of elderly patients who have a reduced ability to adapt.(3) Biometric guides. measurements from certain anatomical landmarks which allow the denture teeth and base to be placed in positions similar to those formerly occupied by the natural teeth and alveolar bone.(4) Functional neutral zone impression. When there are particular problems in achieving stability of a lower denture for example, if there is abnormal muscular activity or intra-oral anatomy the dentist can record the neutral zone by getting the patient to mould a soft record rim into a position of stability between the tongue and cheeks and lips by means of swallowing and speaking. A lower denture is then produced whose shape is derived from the neutral zone impression. This clinical technique has been shown to enhance the tongues retentive ability over a conventional design

PrognosisThe findings of the history and examination will enable the dentist to assess the degree of success the proposed line of treatment is likely to achieve. If problems are anticipated,they should be explained to the patient before treatment proceeds. The patient is thenmore likely to accept and to cope with the unavoidable limitations of the new dentures.Conclusions Dentists must have a sense of real concern for the health comfort and welfare of the patients to establish necessary mutual confidence. A tender loving care approach towards dental patients should be taken before treatment is started and continued throughout the treatment planning and the treatment itself. Dentists must have a sense of real concern for the health comfort and welfare of the patients to establish necessary mutual confidence. A tender loving care approach towards dental patients should be taken before treatment is started and continued throughout the treatment planning and the treatment itself.