Diagnosis and treatment planning

Prosthodontic Diagnosis for Complete Denture and Partial Denture.

1. DIAGNOSIS AND Treatment planning Seminar By E.SHREEPRADA III BDS 1

2. Diagnosis and Treatment Planning are the most important p arameters in the successful management of a patient. Inadequate diagnosis and treatment planning are the major reasons behind the failure of a complete denture. 2

3. 3 Diagnosis It is defined as “The Determination of the Nature of the Disease.” -GPT Essential Diagnostic data obtained from Patient Interview, Definitive Oral Examination, Consultation with Medical And Dental Specialists, Radiographs, Mounted and Surveyed Diagnostic casts s hould be carefully evaluated during Treatment Planning.

4. 4 DIAGNOSIS Clinical Diagnosis Post Clinical or Derived Diagnosis

5. 5 What to do for a proper clinical diagnosis? Patient evaluation Clinical history taking Clinical examination of the patient Radiographic examination Examination of existing prosthesis

6. 6 PATIENT EVALUATION Gait Age of the patient Sex Complexion Cosmetic index Mental attitude

7. 7 Gait (How the patient walks?) People with neuromuscular disorders have different gait and difficulty to adapt to the dentures. Age The age of the patient determines the outcome of the t reatment. For example, Patient belonging to fourth decade has g ood healing abilities compared to patient belonging t o sixth decade. Sex Males are mostly busy and bothered only about comfort but Female patients are more critical about aesthetics.

8. 8 Complexion and Personality Patient’s complexion and personality, for example, p atient’s eye color, hair color, height, weight, etc. help us for teeth selection. Cosmetic Index It basically speaks about aesthetic expectations of the p atient. It can be classified as: Class I: High Cosmetic Index Class II: Moderate Cosmetic Index Class III: Low Cosmetic Index

9. 9 Mental Attitude of the Patient De Van Stated “ meet the mind of the patient before m eeting the mouth of the patient .” Hence, Patient’s attitude and opinion can influence The outcome of the treatment. Based on Mental attitude, Patient’s can be grouped under t wo classifications. MM House proposed the first classification in 1950, which is w idely followed.

10. 10 HOUSE’S CLASSIFICATION Classified Patient’s psychology into 4 types: Class I: Philosophical Easy going, congenial, mentally well adjusted, c ooperative, and confident of the dentist. Excellent prognosis. Class II: Exacting These patient’s are precise, above average in intelligence, c oncerned in their appearance, usually dis-satisfied by previous treatment, do not have confidence in dentist. Once they become satisfied they become the dentist’s g reatest support.

11. 11 Class III: Hysterical They are hysterical, nervous, very exacting temperament a nd will demand efficiency and appearance like natural t eeth. They usually come out of compulsion from family and r elatives. They show poor prognosis. Class IV: Indifferent Those who are unconcerned or feel no necessity for teeth f or mastication. They are uncooperative and will hardly try to accustom to d entures.

12. 12 CLASSIFICATION II Patient’s can also be classified as Cooperative: Open minded and amenable to suggestions. Procedures can be explained very easily and are fully c ooperative. Apprehensive: Even though they realize importance of dentures they have some irrational problem. The approach to such patient’s is by making them speak o ut their thoughts and opinions.

13. 13 Apprehensive Patient’s are of different types, Anxious Frightened Obsessive or Exacting Chronic complainers Self conscious Uncooperative: Their general attitude is negative. They do not feel need for a denture and come due to compulsion by family and friends.

14. 14 CLINICAL HISTORY TAKING Name Age Sex Occupation Race Location Religion M edical History Dental History Collecting details of the patient for proper treatment p lanning. It includes:

15. 15 Name Used for communication and maintaining proper records. Also gives an idea about patient’s family and community. Age Some diseases are pertained to some age groups. Hence, age can be used to rule out systemic conditions a part from determining prognosis. Sex Some diseases are sex related and hence helpful in ruling o ut certain systemic conditions. Also, Mental Attitudes differ with sex.

16. 16 Occupation The appearance of teeth varies with occupation. Sales executives require idealistic teeth whereas people w orking in high physical exertions have rugged teeth. Race Helps in selecting shade of the teeth. Location Some disorders are endemic to an area. Eg: Fluorosis. Religion and Community Gives an idea about dietary habits and helps to design Denture accordingly.

17. 17 Medical History Debilitating Diseases (Diabetes, Tuberculosis, etc.) Diseases of the Joints (Osteoarthritis) Cardiovascular Diseases Diseases of the Skin (Pemphigus) Neurological Disorders (Bell’s palsy, Parkinson’s) Oral Malignancies Climacteric Conditions (Menopause)

18. 18 Dental History Chief complaint Expectations Period of Edentulousness Pre-Treatment Records Previous denture Current denture Pre-Extraction Records Diagnostic casts Denture success

19. 19 Chief Complaint The reason the patient has come to the hospital. Recorded in patient’s own words. Expectations The dentist should evaluate the patient’s expectations and c lassify them as realistic/attainable and unrealistic. Period of Edentulousness The cause for tooth loss must be found out. This period gives the dentist an idea of amount of bone loss. Pre-Treatment Records Includes information of previous denture, current denture, pre-extraction records and diagnostic casts.

20. 20 Previous Denture The reason for the failure of previous denture must be f ound out. Current Denture The current denture must be examined thoroughly. The reason for wanting a replacement should be evaluated. Gives information about denture experience, denture care, d ental knowledge and parafunctional habits of the patient.

21. 21 Factors to be noted in existing prosthesis The period for which the patient is wearing the denture. The amount of ridge resorption. The amount of expected ridge resorption after placement of new prosthesis. Anterior and posterior teeth shade and material used. Centric occlusion ( “ the centered contact position of the occlusal surfaces of the mandibular teeth against the occlusal surfaces of the maxillary teeth” ). Vertical dimension at occlusion. Plane of orientation of occlusion. Improper orientation leads to Reverse smile line. Normal Smile Line

22. 22 The tissue surface of the palate should be examined. Reproduction of rugae should be noted. The patient’s speech pattern should be noted. Posterior extension of maxillary denture. Posterior palatal seal area should be examined. Proper basal seat coverage and adaptation should be noted. The midline of the denture should be noted. Acceptable deviation < 2mm Unacceptable deviation >2mm The amount of space in buccal vestibule. Patient’s comfort should be examined.

23. 23 Cross bite should be checked.

24. 24 Denture maintenance should be evaluated. Denture wear (due to bruxism) should be evaluated. Retention and stability of denture. Attachments and other components. Pre-Extraction Records Pre extraction photographs, diagnostic casts should be e xamined to reproduce anterior aesthetics and guide jaw r elation. Diagnostic Casts Helps us to assess inter-ridge space, ridge form and r idge shape. Denture success The patient should be asked about aesthetics and function of the present denture.

25. 25 CLINICAL EXAMINATION OF THE PATIENT Extra Oral Examination Intra Oral Examination

26. 26 Extra Oral Examination Facial Examination Muscle Tone Muscle Development Complexion Lip Examination TMJ Examination Neuromuscular Examination

27. 27 Facial Examination It includes Facial features, Facial form, Facial profile and Lower facial height. Facial Features The following features must be noted Length of lips Lip fullness Apparent support of lips Philtrum Nasolabial Fold Mentolabial sulcus or Labiomental groove Labial Commissures and Modiolus Width of Vermillion border Size of Oral opening Texture of Skin (Rough or Smooth and Light color.)

28. 28 Facial Form House and Loop, Frush and Fisher, and Williams classified Facial Form based on outline of the face as Square tapering facial form Oval facial form Tapering facial form Square facial form

29. 29 Facial Profile It determines the jaw relation and occlusion. Class I Normal or straight Class II Retrognathic profile Class III Prognathic profile

30. 30 Lower Facial Height Normal Lower facial height Decreased lower facial height Increased lower facial height The face appears wrinkled. The face appears stretched.

31. 31 Muscle Tone Muscle tone can affect the stability of the denture. House classified Muscle Tone as Class I: Normal tension, tone and placement of muscles of mastication and facial expression. Class II: Normal muscle function but slightly decreased m uscle tone . Class III: Decreased muscle tone and function. It is usually a ccompanied with ill fitting dentures, decreased vertical d imension, decreased biting force, wrinkles in the cheeks a nd drooping of commissures.

32. 32 Muscle Development People with excessive muscle development have more b iting force. House classified muscle development as Class I: Heavy Class II: Medium Class III: Light Complexion The color of the eye, hair and the skin guide in selection o f artificial teeth. Pale skin color is indicative of Anemia.

33. 33 Lip Examination Lip Support (Adequately supported or unsupported) Lip Mobility: Normal (Class 1) Reduced Mobility (Class 2) Paralyzed (Class 3) Thickness of Lips (Thick or Thin) Length of Lips (Long, Normal or Medium and Short) Health of Lips TMJ Examination The joint should be examined for movements, pain, Muscles of mastication, joint sounds upon opening and closing. Severe pain in TMJ indicates increased or decreased VD.

34. 34 Neuromuscular Examination It includes Speech and Neuromuscular coordination. Speech Type 1: Normal Type 2: Affected Neuromuscular Coordination Patients with good neuromuscular coordination can easily l earn to manipulate dentures. Neuromuscular Coordination of a patient can be classified as Class I: Excellent Class II: Fair Class III: Poor.

35. 35 Intra Oral Examination Existing Teeth Mucosa Saliva Residual Alveolar Ridge Ridge Defects Redundant Tissue Hyperplastic Tissue Hard Palate Soft Palate and Palatal Throat Form Lateral Throat Form Gag Reflex Bony Undercuts Tori Muscle and Frenal Attachments Tongue Floor of the Mouth

36. 36 Existing Teeth T he condition of existing teeth is important for Single Complete Denture. The state of remaining teeth influence the success of tooth s upported dentures. Mucosa The color, condition and the thickness of mucosa should b e examined. Color of the Mucosa T he mucosa should have healthy Pink color. Inflammatory mucosa appears Red (Ill fitting dentures, Smoking, Infection or Systemic Disease). White Patches might indicate an area of F rictional Keratosis.

37. 37 Healthy Oral Mucosa Inflamed Oral Mucosa Mucosa In Frictional Keratosis

38. 38 Condition of the Mucosa House classified Condition of the Mucosa as Class I: Healthy Mucosa Class II: Irritated Mucosa Class III: Pathologic Mucosa Thickness of the Mucosa House classified Thickness of the Mucosa as Class I: Normal uniform density of 1mm Thickness. Investing tissue forms ideal cushion for basal seat of the Denture.

39. 39 Class II: It is of two types Thin investing membrane and highly susceptible to irritation. Twice n ormal thickness. Class III: Excessively thick investing membranes filled with redundant tissue which requires treatment.

40. 40 Saliva It can be classified as Class I: Normal quality and quantity of saliva. Class II: Excessive saliva. Thick ropy saliva alters the seat o f the denture. Class III: Xerostomia. Poor retention and excessive irritation. Residual Alveolar Ridge Should examine Arch size Arch form Ridge Contour Ridge Relation Inter-Arch Space

41. 41 Arch size It can be classified as follows Class I: Large (Ideal Retention and Stability) Class II: Medium (Good Retention and Stability) Class III: Small (Difficult to achieve Retention and Stability). Class I Class II Class III

42. 42 Arch form House classified Arch Form as Class I: Square Class II: Tapering Class III: Ovoid

43. 43 Ridge Contour Ridges can be classified according to contour as High Ridge with Flat Crest and Parallel sides Flat Ridge Knife-Edged Ridge Classification of Maxillary Ridge Contour Class I: Square to gently Rounded Class II: Tapering or ‘V’ shaped Class III: Flat

44. 44 Classification of Mandibular R idge Contour Class I: Inverted ‘U’ Shaped (Parallel walls, medium to tall r idge with broad ridge crest) Class II: Inverted ‘U’ Shaped (Short with Flat Crest) Class III: Unfavorable Inverted ‘W’ Short Inverted ‘V’ Tall, Thin Inverted ‘V’ Undercut (due to Labioversion or Linguoversion of the teeth)

45. 45 Ridge Relation Ridge Relation is defined as “The positional relation of the Mandibular ridge to the Maxillary ridge.” Ridge Relation refers to the antero-posterior relationship between the ridges . Angle classified Ridge Relation as Class I: Normal Class II: Retrognathic Class III: Prognathic

46. 46 Ridge Parallelism Ridge parallelism refers to “The relative parallelism between the planes of the ridges.” Ridge Parallelism can be classified as Class I: Both ridges are parallel to occlusal plane. Class II: The mandibular ridge diverts the occlusal plane a nteriorly. Class III: Either the maxillary or both the ridges divert the o cclusal plane anteriorly.

47. 47 Inter-Arch Space Increased Inter-Arch space will be due to excessive r esorption. These people will have decreased retention and s tability of dentures. Decreased Inter-Arch space will make teeth arrangement d ifficult. However, stability is increased due to decrease in l everage forces acting on dentures. Inter-Arch Space can be classified as Class I: Ideal Inter-Arch Space. Class II: Excessive Inter-Arch Space. Class III : Insufficient Inter-Arch Space.

48. 48 Ridge Defects They include Exostosis (Benign Bony Growth) Pivots Redundant Tissue Movable Flabby tissues tend to cause movement of the d enture when forces are applied. Leads to loss of Retention. Hyperplastic Tissues Most common hyperplastic lesions are Epulis Fissuratum , Papillary hyperplasia of the mucosa and Hyperplastic folds. Surgery is considered if following lesions exist.

49. 49 Hard Palate Hard Palates can be classified as U-Shaped: Ideal for both retention and stability. V-Shaped: Retention is less, as the peripheral seal is e asily broken. Flat: Reduced resistance to lateral and rotatory forces.

50. 50 Soft Palate Soft Palates can be classified as Class I: Horizontal and Little muscular movements. Class II: Soft palate makes 45° angle to the hard palate. Class III: Soft palate makes 70° angle to the hard palate.

51. 51 Palatal Throat Form “The relationship between the soft palate and hard palate is c alled Palatal Throat Form.” House classified Palatal Throat Form as Class I: Large and normal in form, relatively with an Immovable band of tissue 5 to 12mm distal to the line drawn a cross the distal edge of the tuberosity's.

52. 52 Class II: Medium sized and normal in form, with relatively Immovable resilient band of tissues 3 to 5mm distal to the l ine drawn across the distal edge of the tuberosity’s. Class III: Usually accompanies a small maxilla. The curtain o f soft tissue turns down 3 to 5mm anterior to a line drawn a cross the palate at the distal edge of the tuberosity’s.

53. 53 Lateral Throat Form Neil classified Lateral Throat Form as Class I (Deep lateral throat form) Class II (Moderate lateral throat form) Class III (Shallow lateral throat form )

54. 54 Gag Reflex and Palatal Sensitivity Some patient’s may have an exaggerated gag reflex. It can be due to a Systemic disorder, Psychological, Extra oral, Intra oral or Iatrogenic Factors. House classified Palatal Sensitivity as Class I: Normal Class II: Subnormal (Hyposensitive) Class III: Supernormal (Hypersensitive)

55. 55 Bony Undercuts Bony undercuts do not help in retention. Undercuts are seen in both, Maxilla and mandible. In Maxilla, the undercut is found in anterior region and o nly providing relief is enough. In Mandible, the area under Mylohyoid ridge acts as an u ndercut. Surgical reduction or repositioning of Mylohyoid attachment can be done.

56. 56 Tori Tori are abnormal bony prominences found in middle of Palatal vault and on the lingual side of the Mandible in the Premolar region. Maxillary and Mandibular Tori can be classified as Class I: Tori are absent or minimal. Class II: Clinical examination reveals tori of moderate size. Class III: Large Tori are present. Require surgical contouring or removal.

57. 57 Muscle and Frenal Attachments In case with residual ridge resorption, Maxillary Labial and Lingual frenal attachments approximate to the crest of the Ridge. Such attachments can produce displacement of Denture during muscular action. House classified border and frenal attachments. Classification of Border Attachments Class I: Attachments are placed away from the crest of the r idge. There is at least 0.5 inches distance between the Attachment and the Crest of the Ridge. Class II: Distance between the Crest of the Ridge and the Attachment is around 0.25 to 0.5 inches. Class III: Distance between the Crest of the Ridge and the Attachment is less than 0.25 inches.

58. 58

59. 59 Classification of Frenal Attachments Class I: The Frenum is located away from the Crest. Class II: The Frenum is located nearer to the Crest. Class III: Freni encroach the crest of the ridge and may interfere with the denture seal. Surgical correction may be r equired.

60. 60 Tongue The tongue is examined for the following Size Movement and Coordination House’s classification for T ongue sizes Class I: Normal in size, position and function. Sufficient Teeth are present to maintain this form. Class II: Teeth have been absent long enough to change its f orm and function. Class III: excessively large tongue due to absence of teeth f or a longer period of time.

61. 61 Wright’s classification of Tongue Positions Class I: The Tongue lies on the floor of the mouth with the t ip forward and slightly below the incisal edges of the Mandibular anterior teeth. Class II: The Tongue is flattened and broadened but the tip i s in normal position. Class III: The Tongue is retracted and depressed into the Floor of the mouth, with the tip curled upward, downward o r assimilated into the body of the tongue.

62. 62 Floor of the Mouth In some cases, the floor of the mouth is found near the crest o f the ridge, especially in the sublingual and mylohyoid r egions. This decreases the stability and the retention of the denture. The floor of the mouth can be measured with a William’s probe. The patient should touch his upper lip with the tongue to a ctivate the muscles of the floor of the mouth.

63. 63 Additional Clinical diagnostic procedures for Partially Edentulous Condition Clinical Evaluation of Existing Teeth Periodontal Health Occlusion of the Existing Teeth Conservative and Endodontic status of the Existing teeth.

64. 64 Periodontal Health Clinical Signs of Periodontal Health like Inflammation of the Gingiva Bleeding on Probing Periodontal Breakdown Mobility of the Teeth Oral Hygiene Index should be evaluated. The Periodontal Health can also be determined Radiographically. The amount of horizontal or vertical bone loss is measured Radiographically. After evaluating the Periodontal health, the clinician should d ecide whether to retain or extract a periodontal week tooth.

65. 65 The Periodontal status evaluated Clinically using Periodontal Probe. Bone Loss evaluated Radiographically.

66. 66 Occlusion of Existing Teeth The Teeth should have a good CUSP TO FOSSA relationship. Some Teeth may be tilted which couldn’t support the Prosthesis. Such teeth can either be extracted or orthodontically aligned.

67. 67 One other factor to be examined is Trauma from Occlusion. Trauma due to Excessive Occlusal Force is characterized by the presence of Premature Contacts (High Points) Mobility of Teeth Buttressing Bone Formation Wear Facets, etc.

68. 68 Conservative and Endodontic Status o f Existing Teeth The E xisting Teeth must be examined to rule out Pit and Fissure Caries Deep Caries Gross Tooth Decay, etc. Vitality of the Pulp should be checked. Cracks, Chipped Corners and fractures should be examined. Endodontic therapy must be done to such teeth prior to t he start of the treatment. Retained root stumps must be extracted.

69. 69 Radiographic Examination Considerations for Radiographic Examination T he jaws should be screened for retained root fragments, Un erupted teeth, sclerosis, cysts, tumors and TMJ disorders. The amount of ridge resorption should be assessed. Ridge resorption can be classified as Class I: Mild Resorption (one-third of vertical height) Class II: Moderate Resorption (two-third of vertical height) Class III: Severe Resorption(more than two-third loss of v ertical height) The quantity and quality of the bone should be assessed. Branemark et al classified Radiographically Bone Quantity as Classes A, B, C, D and E. Bone Quality as Classes 1, 2, 3 and 4.

70. 70 Derived Diagnosis or Post-Clinical Diagnosis Derived diagnosis for a Removable Partial Denture include the e valuation of diagnostic data like DIAGNOSTIC CASTS. The Diagnostic Casts must be surveyed prior to teeth setting. The purpose/uses of surveying are To Locate and demark the soft tissue undercuts and severe undercuts located on the surface of existing teeth. To determine the need for pre-prosthetic mouth preparation and also perform mock surgeries. To determine the path of insertion of the denture.

71. 71 Adjunctive Care Prosthodontics Care Treatment Plan Elimination of infection Elimination of pathology Pre-Prosthetic surgery Tissue Conditioning Nutritional Counselling Patient’s destined to be Edentulous Immediate or Conventional Denture Definitive or Interim denture Implant or soft tissue supported denture. Patient’s already Edentulous Soft tissue supported Implant supported Material of choice Selection of teeth Anatomic Palate

72. 72 Prosthodontic treatment for partially edentulous patient’s can be divided into SIX separate phases or stages. PHASE I Collection and evaluation of diagnostic data Treatment of emergency conditions. Determining the type of prosthesis to be fabricated. Patient Motivation. PHASE II Pre-Prosthetic Mouth preparation Making the primary impression Patient Motivation

73. 73 PHASE III Designing the RPD. PHASE IV Prosthetic mouth preparation Making the Final Impression Patient Motivation. PHASE V Fabrication of the Removable partial Denture. PHASE VI Insertion Post-Insertion management Periodic recall and review.

74. 74 Advantages of Treatment Planning Improves the patient’s cooperation and motivation. Helps to communicate between two clinicians. Records from the previous dentist give an idea about the current status of the patient and the outcome of the treatment. Provides the treatment coordination between recall visits. Acts as a reminder to complete all the procedures enlisted for treatment.

75. 75 THANK YOU