EXAMINATION, DIAGNOSIS AND

TREATMENT PLANNING FOR

EDENTULOUS PATIENTS
Diagnosis and treatment plan are most important
parameters in the successful management of a
patient
LECTURE OUTLINE

• Procedures Carried Before starting Treatment

• The First Meeting
• Recording General Information
• Psychological Evaluation
• Clinical history taking
 PROCEDURES CARRIED
BEFORE STARTING
TREATMENT
 General information
 Chief complaint & patient expectations
 Medical history & current medication
 Dental history
 Visual & manual examination of the mouth ,head and
neck
 Radiographic examination
 CONTINUE

 Referring for additional tests or medical consultation

 Referring for second opinion
 Making alginate impressions & preparing mounted
study models
 Discussion of diagnosis, treatment planning &
prognosis with patient
 Finalizing the fees & obtaining a signed consent
 THE FIRST MEETING
 Most important
 Prior to meeting, you should review general
information
 Your confidence is as important as the treatment
itself
 You should be a good listener
 Your communication should be in a simple &
truthful manner
THE GAIT OF THE PATIENT
 RECORDING GENERAL
INFORMATION
�. Name

�. Gender

�. Age

�. Occupation

�. Address and telephone no.

�. Previous dentist
 AGE AND GENDER
With advancing age*:
�. Decrease capacity of tissue to tolerate stress
�. Tissue takes longer time to heal
�. Many diseases are prevalent in older age
�. Women at postmenopause may have psychological
disturbances (exacting or hysterical)
�. Men at this age may be concerned with only comfort &
function (indifferent)
 PSYCHOLOGICAL EVALUATION

“meet the mind of the patient before meeting the mouth of the patient”
De Van
 (HOUSE CLASSIFICATION OF
DENTURE PATIENTS)

Philosophical patient: well motivated, cooperative, calm

&composed even in difficult cases (easy going) .

Exacting (critical): likes each step in detail, makes

alternative treatment for dentist, makes severe demands.
 CONTINUE

Indifferent: not very interested in treatment, blames

the dentist for any mishap, not follow instructions,
been coerced to come by friend, relative….*(don’t
appreciate the effort of the dentist)
Hysterical: easily excited, highly apprehensive,
unrealistic expectations.
 CLINICAL HISTORY TAKING

Is a systematic procedure for collecting the details of the patient to do a

proper treatment planning
 CHIEF COMPLAINT & PATIENT
EXPECTATIONS
 Patient’s own words
 Why he is seeking prosthodontic treatment
 You should assess if patient expectations are realistic or not
 If not realistic, you should educate pt and scale them down
 MEDICAL HISTORY
 Diabetes Mellitus
 Cardiovascular diseases
 Diseases of joints: osteoarthritis
 Diseases of skin: pemphigus ?
 Neurological disorders (Bells balsy and Parkinson)
 Sjogren’s syndrome
 Transmissible diseases
 Radiation therapy
 CURRENT MEDICATION

 Insulin *
 Anticoagulants
 Antihypertensive: dryness & postural hypotension
 Corticosteroids: dryness, confusion & behavioral
changes
 Antiparkinson agents like Norflex and Akineton:
dryness, confusion & behavioral changes
 DENTAL HISTORY

History of tooth loss: cause, time*

Edentulous period
BEWARE OF PATIENTS WHO HAVE A
“BAG OF DENTURES” *
 EXTRAORAL EXAMINATION

General appearance (healthy, signs of proper

nourishment?)
Facial symmetry
Skin: color, deep wrinkles
Palpation of the head & neck (lymph nodes &
muscles)
 EXTRAORAL EXAMINATION

•Muscle tonus
•Neuromuscular coordination*
•TMJ examination
CLASSIFICATION OF FRONTAL
FACE FORMS (HOUSE, FRUSH &
FISHER) *
CLASSIFICATION OF LATERAL FACE
FORMS

• Normal

• Retrognathic

• prognathic
 LIPS

• Length*
• Thickness
• Mobility
• Smile line
 LIP (SMILE) LINE *

High smile line Normal smile line

INTRAORAL EXAMINATION
Cheeks,
tongue,
floor of the mouth (FOM),
maxillary tuberosity,
hard palate,
soft palate,
arch relationship,
residual ridge form,
saliva,
undercuts
 CHEEKS

 Draping of the cheeks over the buccal flanges essential

for peripheral seal

 Opening of Stenson’s duct

 Location for many lesions (lichen planus, submucosal

fibrosis, leukoplakai, malignancies as sqauamous cell
carcinoma (SCC))
LEUKOPLAKIA
 THE TONGUE

 Favorable tongue is average sized, moves freely,

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

• Normal
• Large *
HOW TO MANAGE LARGE TONGUE?

�. Lower the occlusal plane

�. Use narrower teeth
�. Increase the intermolar distance
�. Grind off the lingual cusps
�. Avoid setting a second molar
 TONGUE POSITION

• Normal: normal size and function. Lateral borders rest at level of

mandibular occlusal plane while dorsum is raised above it. Apex rests
at or slightly below the incisal edges of mandibular anteriors
 TONGUE POSITION

• Retruded tongue position deprives pt of border seal of lingual flange in

sublingual crescent and also may produce dislodging forces on distal
regions of lingual flange
 TONGUE MUCOSA

The specialized mucosa covering the

tongue is said to be a “window” on
systemic diseases. *
 FRENAL ATTACHMENTS

Fold of mucosa found at

different locations in the
sulcus region of upper &
lower ridge
Classification
Class I: sulcal or low
attachment
Class II: midway betw.
sulcus & crest of ridge
Class III: crestal
attachment (frenectomy)
 FLOOR OF THE MOUTH

 If FOM is near the level of the ridge crest, retention

& stability of denture is less.
 Hyperactive FOM reduces retention & stability
 If great ridge resorption, FOM in sublingual and
mylohyoid regions spills on the ridge
 Patency of submandibular ducts *
 MAXILLARY TUBEROSITY*

If enlarged:
the posterior occlusal
plane may be placed
too low
no enough space to
set all molars
 MAXILLARY TUBEROSITY

Palpate for undercuts - if

extreme, denture might not
seat
 THE HARD PALATE

 Class I: U shaped, most favorable for retention & stability

 Class II : V shaped: Not very favorable*
 Class III: Flat or shallow vault: Not very favorable, accompanied by
resorbed ridges, poor resistance to lateral forces
V-SHAPED HARD PALATE
 BONY PROMINENCES

 Midpalatal raphe
 Sharp ridge crest
 Sharp mylohyoid ridge
 Prominent genial tubercles
 Bony fragments & fractured root pieces
 Tori
 TORI *

Palatal torus

Mandibular tori
 THE SOFT PALATE (PALATAL
THROAT FORM)

House’s classification
*
 Class I: the soft palate is almost
horizontal curving gently
downwards
 Class II: the soft palate turns
downward at about 45 angle from
the hard palate
 Class III: the palate turns downward
sharply at about 70 angle to the
hard palate.
PALATAL THROAT FORM
Maxilla

II
III
 UNDERCUTS

 The contour of a cross

section of a residual ridge
that would prevent the
placement of a denture or
other prosthesis
 UNDERCUTS
 Unilateral or bilateral; labial or lingual; mild, moderate or severe
 Common locations:

a) Labial portion of maxillary anterior ridge

b) Buccal to maxillary tuberosity
c) Retromylohyoid area of residual ridge
d) Labial or lingual slopes of mandibular anterior
ridge
 UNDERCUTS MANAGEMENT

�. Isolated anterior undercut- not present

any problem

�. Unilateral posterior undercut- may

not present much of a problem as path of insertion is varied

�. Bilateral undercut-surgical removal of the more

severe one is indicated
 RESIDUAL ALVEOLAR RIDGE

Arch form (House’s classification)

Class I: square
Class II: tapered (V-shaped),
associated with high arched
palate, less retention &
stability
Class III: ovoid (less common)
RESIDUAL ALVEOLAR RIDGE (CROSS
SECTIONAL CONTOUR) *

a. U shaped
b. V shaped
c. Knife edged
d. Flat
e. Inverted
f. Undercut
 SOFT TISSUE SUPPORT OF
THE RIDGE
 Firm & resilient
 Flappy and hypermobile: poor support because
denture base shifts during masticatory function
 Management of flappy ridge ranges from
modified impression techniques to surgery
ANTERIOR ARCH RELATIONSHIPS *
 INTRAORAL EXAMINATION

•Posterior arch relationships

•Inter-ridge space
•Residual ridge size
 SALIVA *

Consistency:
Thin serous: provides an insufficient film for denture retention.
Thick mucus: thick ropy saliva tends to displace denture.
Mixed

Amount:
Normal: ideal for denture retention
Excessive: make denture const. messy
Reduced: reduced retention and increased soreness; salivary substitutes
may be prescribed
DRUGS CAUSING XEROSTOMIA *

• Diuretics
• Antihistamines
• Atropine
• Anticholinergic
• Antihypertensive
• Antiparkinson (Norflex)
• Corticosteroids
 EXAMINATION OF AN OLD
DENTURE WEARER
o Esthetics, lip fullness, symmetry, amount
of display during smiling, phonetics,
teeth position, size, excessive wear

o Fracture, cracks, porosity, denture

hygiene

o Occlusal vertical dimension (due to

excessive occlusal wear, OVD may have
reduced)
REDUCED VERTICAL DIMENSION
EXAMINATION OF AN OLD
DENTURE WEARER
Epulis fissuratum

Angular cheilitis

Papillary hyperplasia

Flappy hyperplastic ridge*

Combination syndrome
EPULIS FISSURATUM
 INFLAMMATORY
PAPILLARY HYPERPLASIA
ANGULAR CHEILITIS (PERLECHE)
COMBINATION (KELLY’S) SYNDROME *
• This occurs when a maxillary denture is worn opposing natural
mandibular anterior teeth and a distal extension partial denture.
The mandibular anterior teeth exerts a lot of force on the
maxillary anterior ridge and causes it to resorb.
�. The maxillary anterior ridge becomes hyperplastic and flappy
�. Epulis fissuratum may form in maxillary labial sulcus
�. Resorption under mandibular partial denture
�. Supraeruption of mandibualr anterior teeth
�. Enlargement of maxillary tuberosities
�. The maxillary occlusal plane drops posteriorly and rises
anteriorly
�. Papillary hyperplasia may develop in palate
RADIOGRAPHIC EXAMINATION

• A routine radiographic exam. must be

ordered to rule out any bony conditions
that could affect the treatment
• Panomaric radiograph is usually ordered
for denture cases
 RADIOGRAPHIC EXAMINATION

Fractured roots or roots lying close to the surface should be removed

if pt is fit for surgery; deep seated retained teeth or root fragments
may be left if they are asymptomatic

Supplemental radiographs may be prescribed if required

such as periapical, occlusal, and lateral cephalometric
PANORAMIC RADIOGRAPH
 ADDITIONAL TESTS & MEDICAL
CONSULTATION
 Routine blood test, blood & urine sugar levels
 Medical consultation
 Dental consultation
 DIAGNOSIS
 A specific evaluation of existing conditions
 Involves thorough examination of all factors which are bound to affect
the success of treatment
 This includes both systemic & local factors & the mental condition of
the patient
 TREATMENT PLAN
 The sequence of procedures planned for the
treatment of a patient following diagnosis
 Explained to the patient in a simple and
straightforward manner including all of the factors
that might complicate the treatment
ALTERNATE TREATMENT PLAN

May be less than ideal but is often

necessary for various reasons
 REFUSAL OF TREATMENT

 The patient’s demand may be unreasonable or against

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

 When patient agreed on treatment including fees , he

must sign a written consent to prevent later
misunderstanding
 PRESCRIPTION, NUTRITIONAL
SUPPLEMENTS, & TISSUE
CONDITIONING
 Assess if nutritional deficiency
 Recommend finger massage of oral tissues
 If old denture wearer, tissue conditioner
placed to condition abused soft tissue
 Instruct patient to discontinue wearing
denture 48 hrs prior making final impression
 A good clinician is one who is able to diagnose potential
problems during the initial examination & suggest the best
possible treatment plan compatible with the age, physical,
mental & financial status of the patient
References

I. Zarb. Prosthodontic Treatment for

Edentulous Patients, 13th edition. Chapter 5.
II. Complete Denture Prosthodontics, 1st
Edition, 2006 by John Joy Manappallil,
Chapter 2.