1 Diagnosis

Examination, Diagnosis Examination, Diagnosis and Treatment Planning and Treatment Planning

for Edentulous or for Edentulous or Partially Edentulous Partially Edentulous

PatientsPatients

Rola M. Shadid, BDS, MScRola M. Shadid, BDS, MSc

Procedures Carried Before Denture Procedures Carried Before Denture TreatmentTreatment

General informationGeneral information Chief complaint & patient Chief complaint & patient

expectationsexpectations Medical history & current medicationMedical history & current medication Dental historyDental history Visual & manual examination of the Visual & manual examination of the

mouth and head and neckmouth and head and neck Radiographic examinationRadiographic examination

ContinueContinue

Referring for additional tests or Referring for additional tests or medical consultationmedical consultation

Referring for second opinion Referring for second opinion Making alginate impressions & Making alginate impressions &

preparing mounted study modelspreparing mounted study models Discussion of diagnosis, treatment Discussion of diagnosis, treatment

planning & prognosis with patientplanning & prognosis with patient Finalizing the fees & obtaining a Finalizing the fees & obtaining a

signed consentsigned consent

The First MeetingThe First Meeting Most importantMost important Prior to meeting, you should Prior to meeting, you should

review general informationreview general information Your confidence is as important Your confidence is as important

as the treatment itselfas the treatment itself You should be a good listenerYou should be a good listener Your communication should be Your communication should be

in a simple & truthful mannerin a simple & truthful manner

Recording General InformationRecording General Information

1.1. NameName

2.2. RaceRace

3.3. OccupationOccupation

4.4. Address and telephone no.Address and telephone no.

5.5. Previous dentistPrevious dentist

AgeAge With advancing age*:With advancing age*:1.1.Decrease capacity of tissue to tolerate Decrease capacity of tissue to tolerate

stressstress2.2.Tissue takes longer time to healTissue takes longer time to heal3.3.Many diseases are prevalent in older ageMany diseases are prevalent in older age4.4.Women at postmenopause may have Women at postmenopause may have

psychological disturbances (exacting or psychological disturbances (exacting or hysterical)hysterical)

5.5.Men at this age may be concerned with Men at this age may be concerned with only comfort & function (indifferent)only comfort & function (indifferent)

Psychological Evaluation Psychological Evaluation (House (House Classification of Denture Patients)Classification of Denture Patients)

Philosophical patient: well motivated, Philosophical patient: well motivated, cooperative, calm & composed even in cooperative, calm & composed even in difficult cases.difficult cases.

Exacting (critical): likes each step in Exacting (critical): likes each step in detail, makes alternative treatment detail, makes alternative treatment for dentist, makes severe demands.*for dentist, makes severe demands.*

ContinueContinue Indifferent: not very interested Indifferent: not very interested

in treatment, blames the dentist in treatment, blames the dentist for any mishap, not follow for any mishap, not follow instructions, been coerced to instructions, been coerced to come by friend, relative….*come by friend, relative….*

ContinueContinueHysterical: easily excited, highly Hysterical: easily excited, highly

apprehensive, unrealistic expectations*apprehensive, unrealistic expectations*Skeptical: bad results from previous Skeptical: bad results from previous

treatment, doubtful, often have treatment, doubtful, often have severely resorbed ridges and poor severely resorbed ridges and poor health, might have psychological health, might have psychological disturbances from recent personal disturbances from recent personal trajedy #trajedy #

Chief Complaint & Patient Chief Complaint & Patient ExpectationsExpectations

Patient’s own wordsPatient’s own words Why he is seeking prosthodontic Why he is seeking prosthodontic

treatmenttreatment You should assess if patient expectations You should assess if patient expectations

are realistic or notare realistic or not If not realistic, you should educate pt and If not realistic, you should educate pt and

scale them downscale them down

Medical History*Medical History*

Diabetes MellitusDiabetes Mellitus Cardiovascular diseasesCardiovascular diseases Diseases of joints: osteoarthritisDiseases of joints: osteoarthritis Diseases of skin: pemphigus ?Diseases of skin: pemphigus ? Neurological disorders (Bells balsy Neurological disorders (Bells balsy

and Parkinson)and Parkinson) Sjogren’s syndromeSjogren’s syndrome Transmissible diseasesTransmissible diseases

Radiation Therapy Vs. DenturesRadiation Therapy Vs. Dentures

Consequences of Radiation therapyConsequences of Radiation therapy Preprosthetic surgeryPreprosthetic surgery Wearing of previous denture *Wearing of previous denture * Denture Fabrication #Denture Fabrication #

Denture Fabrication in Radiation Denture Fabrication in Radiation Therapy PatientTherapy Patient

Avoid impression material that dry tissue (impression Avoid impression material that dry tissue (impression plaster) or heavily flavored materials (ZOE)plaster) or heavily flavored materials (ZOE)

Consider non-anatomic teethConsider non-anatomic teeth Teeth set in neutral zoneTeeth set in neutral zone Slight reduction in vertical dimensionSlight reduction in vertical dimension Soft liners are controversial due to porosity and Soft liners are controversial due to porosity and

possibility of candida possibility of candida

Current MedicationCurrent Medication Insulin *Insulin * AnticoagulantsAnticoagulants Antihypertensive: dryness & postural hypotensionAntihypertensive: dryness & postural hypotension Corticosteroids: dryness, confusion & behavioral Corticosteroids: dryness, confusion & behavioral

changeschanges Antiparkinson agents like Norflex and Akineton: Antiparkinson agents like Norflex and Akineton:

dryness, confusion & behavioral changesdryness, confusion & behavioral changes

Dental HistoryDental History

History of tooth loss: cause, History of tooth loss: cause, time*time*

Edentulous periodEdentulous period

Beware of Patients Who Have A Beware of Patients Who Have A “Bag of Dentures” *“Bag of Dentures” *

Extraoral ExaminationExtraoral Examination

General appearance (healthy, General appearance (healthy, signs of proper nourishment?)signs of proper nourishment?)

Facial symmetryFacial symmetry Skin: colorSkin: color, deep wrinkles, deep wrinkles Palpation of the head & neck Palpation of the head & neck

(lymph nodes & muscles)(lymph nodes & muscles)

Extraoral ExaminationExtraoral Examination

Muscle tonusMuscle tonus Neuromuscular Neuromuscular

coordination* coordination* TMJ examinationTMJ examination

Classification of Frontal Face Classification of Frontal Face FormsForms (House, Frush & Fisher) *(House, Frush & Fisher) *

Classification of Lateral Face Classification of Lateral Face FormsForms

NormalNormal

RetrognathicRetrognathic

prognathicprognathic

LipsLips

Length*Length* ThicknessThickness MobilityMobility Smile lineSmile line

Lip (smile) line *Lip (smile) line *

High smile line Normal smile line

Intraoral ExaminationIntraoral Examination

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

CheeksCheeks

Draping of the cheeks over the buccal Draping of the cheeks over the buccal flanges essential for peripheral sealflanges essential for peripheral seal

Opening of Stenson’s ductOpening of Stenson’s duct

Location for many lesions (lichen Location for many lesions (lichen planus, submucosal fibrosis, planus, submucosal fibrosis, leukoplakai, malignancies as leukoplakai, malignancies as sqauamous cell carcinoma (SCC))sqauamous cell carcinoma (SCC))

LeukoplakiaLeukoplakia

The TongueThe Tongue

Favorable tongue is average sized, Favorable tongue is average sized, moves freely, covered moves freely, covered by healthy by healthy mucosamucosa

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

Tongue SizeTongue Size

NormalNormal Large *Large *

How to Manage Large How to Manage Large Tongue?Tongue?

1.1.Lower the occlusal planeLower the occlusal plane2.2.Use narrower teethUse narrower teeth3.3. Increase the intermolar Increase the intermolar

distancedistance4.4.Grind off the lingual cuspsGrind off the lingual cusps5.5.Avoid setting a second Avoid setting a second

molarmolar

Tongue PositionTongue Position

Normal: normal size and function. Normal: normal size and function. Lateral borders rest at level of Lateral borders rest at level of mandibular occlusal plane while mandibular occlusal plane while dorsum is raised above it. Apex rests dorsum is raised above it. Apex rests at or slightly below the incisal edges at or slightly below the incisal edges of mandibular anteriorsof mandibular anteriors

Tongue PositionTongue Position

Retruded tongue position Retruded tongue position deprives pt of border seal of deprives pt of border seal of lingual flange in sublingual lingual flange in sublingual crescent and also may produce crescent and also may produce dislodging forces on distal regions dislodging forces on distal regions of lingual flangeof lingual flange

Tongue MucosaTongue Mucosa

The specialized mucosa covering The specialized mucosa covering the tongue is said to be a the tongue is said to be a “window” “window” on systemic diseases. * on systemic diseases. *

Frenal AttachmentsFrenal Attachments

Fold of mucosaFold of mucosa found at different found at different locations in the locations in the sulcus region of sulcus region of upper & lower ridgeupper & lower ridge ClassificationClassification Class I: sulcal or Class I: sulcal or low attachmentlow attachment Class II: midway Class II: midway betw. sulcus & crest betw. sulcus & crest of ridgeof ridge Class III: crestal Class III: crestal attachment attachment (frenectomy)(frenectomy)

Floor of the MouthFloor of the Mouth

If FOM is near the level of the ridge crest, If FOM is near the level of the ridge crest, retention & stability retention & stability of denture is less.of denture is less.

Hyperactive FOM reduces retention & Hyperactive FOM reduces retention & stabilitystability

If great ridge resorption, FOM in If great ridge resorption, FOM in sublingual and mylohyoid regions spills on sublingual and mylohyoid regions spills on the ridgethe ridge

Patency of submandibular ducts *Patency of submandibular ducts *

Maxillary Tuberosity*Maxillary Tuberosity*

If enlarged: If enlarged: the posterior the posterior

occlusal plane occlusal plane may be placed may be placed too lowtoo low

no enough no enough space to set all space to set all molarsmolars

Maxillary TuberosityMaxillary Tuberosity

Palpate for undercuts - Palpate for undercuts - if extremeif extreme, denture , denture might not seatmight not seat

The Hard PalateThe Hard Palate

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

Class II Class II : V shaped: Not very favorable*: V shaped: Not very favorable* Class IIIClass III: Flat or shallow vault: Not very : Flat or shallow vault: Not very

favorable, accompanied by resorbed favorable, accompanied by resorbed ridges, poor resistance to lateral forcesridges, poor resistance to lateral forces

V-shaped hard palateV-shaped hard palate

Tori *Tori *

Palatal torusPalatal torus

Mandibular toriMandibular tori

Bony ProminencesBony Prominences

Midpalatal rapheMidpalatal raphe Sharp ridge crestSharp ridge crest Sharp mylohyoid ridgeSharp mylohyoid ridge Prominent genial tuberclesProminent genial tubercles Bony fragments & fractured root piecesBony fragments & fractured root pieces ToriTori

The Soft Palate (The Soft Palate (Palatal Throat Form)Palatal Throat Form)

House’s classification *House’s classification * Class IClass I: the soft palate is : the soft palate is

almost horizontal curving almost horizontal curving gently downwardsgently downwards

Class IIClass II: the soft palate : the soft palate turns downward at about turns downward at about 4545 angle from the hard angle from the hard paltepalte

Class IIIClass III: the palate turns : the palate turns downward sharply at about downward sharply at about 7070 angle to the hard palate. angle to the hard palate.

Palatal Throat FormPalatal Throat Form

II

IIIIIIIIII

MaxillaMaxilla

UndercutsUndercuts

The contour of a The contour of a cross section of a cross section of a residual ridge that residual ridge that would prevent the would prevent the placement of a placement of a denture or other denture or other prosthesisprosthesis

UndercutsUndercuts Unilateral or bilateral; labial or lingual; Unilateral or bilateral; labial or lingual;

mild, moderate or severemild, moderate or severe Common locations:Common locations:a)a) Labial portion of maxillary anterior ridgeLabial portion of maxillary anterior ridgeb)b) Buccal to maxillary tuberosityBuccal to maxillary tuberosityc)c) Retromylohyoid area of residual ridgeRetromylohyoid area of residual ridged)d) Labial or lingual slopes of mandibular anterior ridgeLabial or lingual slopes of mandibular anterior ridge

Undercuts ManagementUndercuts Management

1.1. Isolated anterior undercut- Isolated anterior undercut- not not present any problempresent any problem

2.2. Unilateral posterior undercut- Unilateral posterior undercut- may may not present much of a problem as path not present much of a problem as path of insertion is variedof insertion is varied

3.3. Bilateral undercut-Bilateral undercut-surgical removal of surgical removal of the more severe one is indicatedthe more severe one is indicated

Residual Alveolar RidgeResidual Alveolar Ridge

Arch form (House’s classificationArch form (House’s classification))

Class I: squareClass I: squareClass II: tapered (V-shaped), Class II: tapered (V-shaped),

associated with high arched associated with high arched palate, less retention & palate, less retention & stabilitystability

Class III: ovoid (less common) Class III: ovoid (less common)

Residual Alveolar Ridge (Cross Sectional Residual Alveolar Ridge (Cross Sectional Contour) *Contour) *

a.a. U shapedU shapedb.b. V shapedV shapedc.c. Knife edgedKnife edgedd.d. FlatFlate.e. InvertedInvertedf.f. UndercutUndercut

Soft Tissue Support of the RidgeSoft Tissue Support of the Ridge

Firm & resilientFirm & resilient Flappy and hypermobile: poor support Flappy and hypermobile: poor support

because denture base shifts during because denture base shifts during masticatory functionmasticatory function

Management of flappy ridge ranges Management of flappy ridge ranges from modified impression techniques to from modified impression techniques to surgerysurgery

Anterior Arch Relationships *Anterior Arch Relationships *

Intraoral ExaminationIntraoral Examination

Posterior arch Posterior arch relationshipsrelationships

Interridge spaceInterridge space Residual ridge sizeResidual ridge size

Saliva *Saliva *

Consistency: Consistency: Thin serous: provides an insufficient film for denture Thin serous: provides an insufficient film for denture

retention.retention. Thick mucus: thick ropy saliva tends to displace denture.Thick mucus: thick ropy saliva tends to displace denture. MixedMixed

Amount: Amount: Normal: ideal for denture retentionNormal: ideal for denture retention Excessive: make denture const. messy Excessive: make denture const. messy Reduced: reduced retention and increased soreness; Reduced: reduced retention and increased soreness;

salivary substitutes may be prescribedsalivary substitutes may be prescribed

Drugs Causing Xerostomia *Drugs Causing Xerostomia * DiureticsDiuretics AntihistaminesAntihistamines AtropineAtropine AnticholinergicAnticholinergic AntihypertensiveAntihypertensive Antiparkinson (Norflex)Antiparkinson (Norflex) CorticosteroidsCorticosteroids

Examination of an Old Denture WearerExamination of an Old Denture Wearer

o Esthetics, lip fullness, symmetry, amount of Esthetics, lip fullness, symmetry, amount of display during smiling, phonetics, teeth display during smiling, phonetics, teeth position, size, excessive wearposition, size, excessive wear

o Fracture, cracks, porosity, denture hygieneFracture, cracks, porosity, denture hygiene

o Occlusal vertical dimension (due to Occlusal vertical dimension (due to excessive occlusal wear, OVD may have excessive occlusal wear, OVD may have reduced)reduced)

Reduced vertical dimensionReduced vertical dimension

Examination of an Old Denture WearerExamination of an Old Denture WearerEpulis fissuratumEpulis fissuratum

Angular cheilitisAngular cheilitis

Papillary hyperplasiaPapillary hyperplasia

Flappy hyperplastic ridge*Flappy hyperplastic ridge*

Combination syndromeCombination syndrome

Epulis FissuratumEpulis Fissuratum

Inflammatory Papillary Inflammatory Papillary HyperplasiaHyperplasia

Angular Cheilitis Angular Cheilitis (Perleche)(Perleche)

Combination (Kelly’s) Syndrome *Combination (Kelly’s) Syndrome *

Radiographic ExaminationRadiographic Examination

A routine radiographic exam. A routine radiographic exam. must be ordered to rule out any must be ordered to rule out any bony conditions that could affect bony conditions that could affect the treatmentthe treatment

Panomaric radiograph is usually Panomaric radiograph is usually ordered for denture casesordered for denture cases

Radiographic ExaminationRadiographic Examination

Fractured roots or roots lying close to the Fractured roots or roots lying close to the surface should be removed if pt is fit for surface should be removed if pt is fit for surgery; deep seated retained teeth or root surgery; deep seated retained teeth or root fragments may be left if they are fragments may be left if they are asymptomaticasymptomatic

Supplemental radiographs may be Supplemental radiographs may be

prescribed if required such as periapical, prescribed if required such as periapical, occlusal, and lateral cephalometricocclusal, and lateral cephalometric

Panoramic RadiographPanoramic Radiograph

Additional Tests & Medical Additional Tests & Medical ConsultationConsultation Routine blood test, blood & urine sugar levelsRoutine blood test, blood & urine sugar levels Medical consultationMedical consultation Dental consultationDental consultation

DiagnosisDiagnosis A specific evaluation of existing conditionsA specific evaluation of existing conditions Involves thorough examination of all Involves thorough examination of all

factors which are bound to affect the factors which are bound to affect the success of treatmentsuccess of treatment

This includes both systemic & local factors This includes both systemic & local factors & the mental condition of the patient& the mental condition of the patient

Treatment PlanTreatment Plan The sequence of procedures The sequence of procedures

planned for the treatment of a planned for the treatment of a patient following diagnosispatient following diagnosis

Explained to the patient in a Explained to the patient in a simple and straightforward simple and straightforward manner including all of the factors manner including all of the factors that might complicate the that might complicate the treatment treatment

Alternate Treatment Plan Alternate Treatment Plan

May be less than ideal but is often May be less than ideal but is often necessary for various reasonsnecessary for various reasons

Refusal of TreatmentRefusal of Treatment

The patient’s demand may be The patient’s demand may be unreasonable or against unreasonable or against professional judgment or ethics; professional judgment or ethics; so may refuse treatment or refer so may refuse treatment or refer him him (“bag of dentures”)(“bag of dentures”)

PrognosisPrognosis A forecast to the probable result of A forecast to the probable result of

a disease or a course of therapya disease or a course of therapy After considering all the factors, you After considering all the factors, you

should be able to predict the degree should be able to predict the degree of success that can be expected & of success that can be expected & the patient should know of what can the patient should know of what can and cannot be achieved.and cannot be achieved.

Fees & Signed ConsentFees & Signed Consent

When patient agreed on When patient agreed on treatment including fees , treatment including fees , he must he must sign a written consent to prevent sign a written consent to prevent later misunderstandinglater misunderstanding

Prescription, Nutritional Supplements, Prescription, Nutritional Supplements, & Tissue Conditioning& Tissue Conditioning

Assess if nutritional deficiencyAssess if nutritional deficiency Recommend finger massage of oral tissuesRecommend finger massage of oral tissues If old denture wearer, tissue conditioner placed If old denture wearer, tissue conditioner placed

to condition abused soft tissueto condition abused soft tissue Instruct patient to discontinue wearing denture Instruct patient to discontinue wearing denture

48 hrs prior making final impression48 hrs prior making final impression

A good clinician is one who is able A good clinician is one who is able to diagnose potential problems to diagnose potential problems during the initial examination & during the initial examination &

suggest the best possible treatment suggest the best possible treatment plan compatible with the age, plan compatible with the age,

physical, mental & financial status physical, mental & financial status of the patientof the patient

ReferencesReferences

I.I. Complete Denture Prosthodontics, 1Complete Denture Prosthodontics, 1stst Edition, 2006 by John Joy Manappallil, Edition, 2006 by John Joy Manappallil, Chapter 2.Chapter 2.

II.II.Zarb. Prosthodontic Treatment for Zarb. Prosthodontic Treatment for Edentulous Patients, 12Edentulous Patients, 12thth edition. Chapter 7. edition. Chapter 7.