J Orofac Sci, 2(3)2010

Journal of

OROFACIAL SCIENCES
Review Article

Examination, Diagnosis and Treatment Planning for Complete Denture Therapy A Review
Sandeep Chiramanaa*, Ashok .Ka
a

Department of Prosthodontics, SIBAR Institute of Dental Sciences Guntur, Andhra Pradesh, India.

ARTICLE INFO
Article History : Received : 18 Oct, 2010 Received in revised form : 5 Nov, 2010 Accepted : 26 Nov, 2010 Key Words : Personal data Medical history Dental history General history Extraoral and Intraoral examination Radiographic examination Diagnosis and Treatment planning

ABSTRACT
Each patient is an individual, different in his own way from other individual and each edentulous oral environment presents conditions peculiar to it alone. Inorder to arrive at a proper diagnosis and plan the treatment a thorough extraoral and intraoral examination combined with physical and psychological evaluation of the patient is of utmost importance. This article is aimed towards a proper diagnosis and treatment plan for a successful complete denture therapy.

2010 SIDS.All Rights Reserved

INTR ODUCTION : INTRODUCTION 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. This article will be helpful to undergraduate students in general and post graduate students in particular to arrive at a proper diagnosis and treatment plan for complete edentulous patients. Name : It is useful for establishment of patients identity. Addressing 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 * Corresponding author :
Dr. Sandeep Chiramana,
Professor, Department of Prosthodontics, SIBAR Institute of Dental Sciences Guntur, (A.P) e-mail : chiramanasandeep@gmail.com

altered. Frush and Fisher suggested guidelines for selection and arrangement of anterior teeth based on age, sex and personality5.Some age related diseases like - 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 disorders 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
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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. Chief Complaint : According to DeV an eVan an, the dentist should meet the mind of the patient before he meets the mouth of the patient.3The chief complaint should be written in patients own words, patient should be questioned regarding his chief complaint. Out P atient N umber : Helps to maintain the statistical Patient Number analysis and hospital data. Medical History : Provides important insights regarding patients dental prognosis. Systemic factors that may affect complete denture therapy include Diabetes Mellitus : 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 required Nutritional D isor ders : Avitaminosis lowers the defence Disor isorders mechanism of the body and mucosal structures, Anaemias : Iron deficiency causes anaemia, atrophic mucosa, purpura and burning sensation of mucosa Pernicious anaemia and Iron deficiency anaemia patients have fragile mucosa so the dentures should be as smooth as possible. Diseases of the joints : 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. Scleroderma: Lips 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. vascular disor ders : These conditions include Car dio Cardio diov disorders 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 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 preferred2. Pulmonary diseases : Bronchial asthma : The asthmatic patients should be questioned about concerned precipitating factors, frequency and severity of attack, medications used and response to medications Diseases of the skin : Skin diseases like pemphigus have oral manifestations which may vary from ulcers to bullae, such painful conditions make the denture use impossible without medical treatment. Constant use of prosthesis should be discouraged for these patients. Neur ological disor ders : Diseases like epilepsy, Bells eurological disorders 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. Oral malignancies and radiation therapy : High 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.
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Medication : Side effects that occur due to various medications are - Xerostomia, changes in the oral microflora, mucosal changes, Sialorrhea, dysphagia, postural or orthostatic hypotension, behavioural changes or confusion etc. Should be taken care during prosthesis fabrication. Climacteric : Climacteric condition like menopause can cause glandular changes, osteoporosis and psychiatric changes in the patient. These can influence treatment planning and the efficiency of the complete denture. Personal H istor y : It includes oral hygiene maintenance Histor istory by the patient, habits like smoking, alcohol etc., type of diet and nutritional status of the patient which may help in posterior teeth selection DENT AL HIST OR Y: DENTAL HISTOR ORY Reasons for loss of teeth : 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. Pre extraction records : Includes pre extraction radiographs, photographs, diagnostic casts. They can be helpful to reproduce anterior esthetics in complete denture fabrication. Previous denture experience : Questions should be directed towards the length of time she or he has worn the current dentures, the number and types of previous dentures, reasons for replacement . The existing dentures should be examined for tooth shade, mold, and material, esthetics, phonetics, retention, stability, extensions and contours, vestibule, Centric relation and vertical dimension of occlusion and orientation of occlusal plane. Characterization or staining , comfort of existing dentures should be examined. The patients ability and motivation to clean the dentures should be assessed during clinical evaluation. Mental Attitude : M.M.House classified patients as Philosophical/ Exacting/ Indifferent / Hysterical patients4

Patient s E xpectations And A ttitudes : The reason the atient Expectations Attitudes 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. Examination : It includes extra oral examination and intra oral examination. Extra Oral Examination : Facial symmetr y : Should observe for the symmetry of symmetry the face, whether its bilaterally symmetrical or not Facial form : Leon Williams claimed classified the form of the human face in to 3 types Square/Tapering/ Ovoid6 Facial P r ofile : Angle classified facial profile into Pr 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. Lips : Restoration of the lip support and vermillion border width must be considered during placement of the anterior teeth. Lips can be- Supported/unsupported 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 contour Thick 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 / short A 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.
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Tempor o mandibular joint examination : emporo Temporomandibular joint 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. Muscle 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 as Class 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 dev elopment : Classification according to development Class 2: medium/Class Class 3: light4 M.M.House- Class 1 : heavy/Class Neuromuscular evaluation : Classification Normal/ Affected Coor dinatio n : Patients with good neuromuscular Coordinatio dination coordination can be expected to learn to manipulate dentures relatively quickly and likewise adapt readily to new dentures. Classification Excellent/Fair/Poor Intra Oral Examination : 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: pathologic4

Thickness of mucosa and tissue resiliency : A 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 thick4 Arch Size : Classification 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 resorption Class 3 (small ) : the alveolar ridge is almost or completely resorbed. There is no resistance to lateral movement of the denture Ar ch F orm : Arch form is generally classified as square, Arch Form tapering, or ovoid. Class 1 : Square arch form is the best form to prevent rotational movements Class 2 : The tapering form offers some resistance to movement but to a lesser degree than the square arch Class 3 : The ovoid form offers little or no resistance to rotational movements Ridge Contour : System of six orders of ridge form The maxillary residual alveolar ridge and vault form should be classified as follows Class 1- Square or gently rounded/ Class 2 - Tapered or V shaped/ Class 3- Flat Mandibular ridge form Class 1- Inverted ridge form, with parallel walls & broad crest Class 2- Inverted U shaped , short with flat crest Class 3- Unfavourable-inverted W or short inverted V or with undercuts High 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
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also has a poor prognosis because of the lack of vertical height affords little resistance to horizontal movement. Inter arch space : Classified as Class 1- Ideal interarch space to accommodate the artificial teeth Class 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 P arallelism : When teeth are gradually lost the Parallelism 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 plane Class 2 - Either the mandibular or maxillary ridge diverging anteriorly Class 3 - Both ridges diverge anteriorly Ridge Relationship : Jaw relationship can be Normal (Angle class1): Anterior segment of the mandibular ridge is directly below or slightly posterior to the maxillary ridges Retrognathic 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 Thr oatform : N eil s Classification : Throatform Neil eil 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 shallow Maxillar y Tuber osities : Classified as-normal/Pendulous axillary uberosities 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. Shape of The H ar dP alate : Classified as flat/rounded/ Har ard Palate 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 S oft P alate to the H ar dP alate: Soft Palate Har ard Palate: Classified as: Class 1 : It is horizontal, makes 100 angle to the hard palate and demonstrates little muscular movement. In this case more tissue coverage is possible for posterior palatal seal Class 2 : Soft palate makes 450 angle to the hard palate Class 3 : Soft palate makes 700 angle to the hard palate. Shape of the S oft P alate: MM House classified it as Soft Palate: Class 1 : More than 5mm of movable tissue available for post damming. Ideal for retention Class 2 : One to five mm of movable tissue available for post damming. Good retention is usually possible Class 3 : Less than one mm movable tissue available for post damming. Retention is usually poor The patient with the class 1 will be more comfortable with a fairly thin posterior border of 1 to 2 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.
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P alatal S ensitivity : Classification according to Sensitivity M.M.House-4 Class 1 : normal/ Class2: subnormal (hyposensitive)/ Class3 : supernormal (hypersensitive) Bony U nder cuts: Under ndercuts: Class1 : bony undercuts are absent Class2 : small undercuts, the denture can be placed by altering the path of insertion Class 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. Fr enal A ttachments: Classification according to Attachments: M.M.House4 Class 1: high in the maxilla as low in the mandible with respect to the crest of the ridge Class 2 : medium Class 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. Tongue : Classification according to M.M.House4: 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 P osition : Classification according to Wright Position Normal 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. Saliva: Saliva 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 mucous Class 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 examine by palpation, it 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. cles : May be sharp or normal. The genial Genial Tuber ubercles tubercles become prominent with resorption of the ridges. Investigations : Radiographic 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 crest11. Classification : Class 1: mild resorption with loss of ridge upto one third of the vertical height. Class 2: which is moderate resorption with loss of ridge from 1/3 to 2/3 of original vertical height.
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Class 3: severe resorption with loss of ridge more than 2/3 of the original vertical height. Other Investigations : Blood investigations - Blood glucose levels for diabetics, Hb % of blood for anemic patients is important for any preprosthetic surgery desired. lanning : Evaluation of the patient includes Planning Treatment P assessment of mental as well as physical conditions. Treatment planning should include: Tissue conditioning, Preprosthetic surgery, Articulator type, Tooth selection, Denture base material, characterization of the denture etc. The treatment and expected level of achievement, fees, manner of payment, duration of treatment, any necessary tissue preparation in conditioning should be discussed. Prognosis : Prognosis in denture service is an opinion of the prospects for success of a restoration A number of factors affect the prognosis are - gross appraisal of the patient, patients needs and expectations, medical, psychological and behavioral considerations, anatomic factors, physiological factors etc. It can be rated as - most favourable prognosis/ integral / least favourable prognosis 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.

REFERENCES :
1. Bandookar, Kranti Ashoknath, Aras Meena. Psychological considerations for complete denture patients; Journal of Indian prosthodontic society 2007; 7[2]:71-76. 2. Robert L.Engelimeier, Rodney D.Phoenix. Complete dentures. The Dental clinics of North America1996;40: 1-19 3. DeVan MM. Methods and procedures in a diagnostic service to the edentulous patients. Journal of American Dental Association 1989; 29:29-38 4. House MM: The relationship of oral examination to dental diagnosis, Journal of Prosthetic Dentistry 1958; 8:208. 5. Frush JP,Fisher RD: Introduction to dentogenic restorations, Journal of Prosthetic Dentistry 1955; l 5: 586: 6. Williams JL: A new classification of human tooth forms with special reference to a new system of artificial teeth, Cosmos 1914; 56: 627 7. Charles M Heartwell, Arthur O. Rahn. Syllabus of complete dentures: 4th edition 1984;573 8. Essentials of complete denture prosthodontics by Sheldon Winkler 2nd edition 2009;464 9. Alexander Halperin. Mastering the art of complete dentures Quintessence Publications. 988; 3-30 10. Bernard Levin. Impressions for complete dentures Quintessence Publications.1984:223 - 28 11. George Albert Zarb, Charles L Bolender, Steven E. Eckert . Prosthodontic treatment for edentulous patients, 12th edition Mosby Publications, 2004:73-93 12. Harold Robert Blackwell Fenn, Liddelow KP, Gimson AP. Clinical dental prosthetics. 3rd edition. Staples Press.1961-838. 13. John J. Sharry. Complete denture prosthodontics. McGraw-Hill Publications. 3rdedition.1974:161-174. Source of Support : Nil, Conflict of Interest : None declared.

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