Diagnosis and treatment planning in complete denture

Diagnosis and treatment planning in complete denture

#prosthodontics #cd
#complete_denture #case_history #edentulous_patient
#edentulous

1. Diagnosis and treatment planning in complete denture ABHIRAM A B III RD YEAR

2. CONTENTS

3. Diagnosis Diagnosis is the examination and evaluation of the physical and psychological state and understanding the needs of each patient to ensure a predictable result. Diagnosis involves patient evaluation, history and examination. 

4. Patient evaluation This process commences as the patient walks to the dentist’s chair as well as during the introductory and history taking conversation. Gait • Stooped shoulders—spinal changes.  • Tremor of head—Parkinson disease, tranquillizers. • Dragging of one leg—stroke.  • Staggering—excessive alcohol and medication, hyperventilation, damage to brain and spinal cord.

5. Age This refers to the physiologic age and provides information about the patient’s expectations and care for the dentures.  A young patient who appears old may indicate disinterest, while an old patient who appears young indicates willingness to adapt and look good. 

6. Facial expression  This provides information about the mental attitude and presence of any disorders.  Absence of any expression indicates loss of muscle tone, trigeminal neuralgia, plastic surgery or disorders of central nervous system.

7. Complexion It is used to select the colour of the teeth.  It may also be indicative of the following conditions:   Pale— anaemia , lack of nourishment.   Ruddy— polycythaemia , chronic alcoholic.   Bronze—radiation therapy, Addison disease.   Bluish-purple—vitamin deficiency, cyanosis.   Lemon-yellow—jaundice.

8. Speech The fluency and quality of the speech should be noted, as it will help in arranging artificial teeth. Speech can also be altered due to the following pathologies:  Hypernasality—paralysis of palatal musculature.   Hoarseness—paralysis of both vocal cords, excessive smoking.

9. Breathing pattern  Abnormal breathing patterns may indicate the following:   Heavy sighing—emotionally disturbed   Wheezing—asthma   Shortness of breath—lung disease, heart failure   Shallow breathing at rapid rate—pulmonary fibrosis   Erratic breathing—continuous hyperventilation

10. Mental attitude Dr M.M. House (1950) classified patients as Class I: Philosophical patients  • They desire treatment for maintenance of health and appearance and accept the complete denture treatment as a normal procedure.  • They learn to adjust rapidly.  • These patients have the best mental attitude for acceptance of the treatment.  Class II: Exacting patients   • They are very methodical, precise and accurate, making severe demands.  • They are comfortable when each procedure is explained and discussed with them in detail.  • They require extreme care, effort and patience on part of the dentist. Class III: Indifferent patients  • These patients are identified by their lack of concern and motivation and apathetic attitudes.  • They may not pay any attention to instructions, will not cooperate and are prone to blame others including the dentist for their poor health.   • A patient education  programme  is recommended before treatment.  Class IV: Hysterical patients  • They are emotionally unstable, excitable and apprehensive.  • They may not be aware that their symptoms may be more related to their systemic health.  • They often present an  unfavourable  prognosis and additional psychiatric counselling is required prior to the treatment. 

11. History A record of all the information obtained from the patient must be made and kept for further study and later use. The health history is an extremely important part of the patient’s overall diagnosis and treatment planning. It should include the following: General information Medical history Dental history

12. General information Name This is important for documentation and record maintenance. Patients are more comfortable and confident when addressed by their names. This Photo by Unknown author is licensed under CC BY .

13. Age Younger patients usually show better healing ability. They also adapt easily to treatment and a new prosthesis.  Older patients need more care and patience on part of the dentist. Proper nutritional care is very important in geriatric patients. This is an important consideration in the selection and arrangement of artificial teeth.

14. Gender Generally, appearance is a higher priority for women. Males may be more concerned about comfort and function of the dentures. Menopause and its associated hormonal and behavioural changes are a concern with women. This is also an important consideration in the selection and arrangement of artificial teeth. 

15. Occupation/Social information Particulars such as the occupation can help in setting up a convenient appointment for the treatment procedure and in tooth selection and arrangement. Executives in high stress jobs may exhibit bruxism. People who work in places with high physical exertion and factories where abrasive dust abounds require rugged teeth which do not wear easily.  Public speakers and singers may need greater attention to palatal shape and thickness and perfect retention.  Wind instrument players may require special positioning of anterior teeth. Patients in high socioeconomic groups may be more demanding and critical, while those of low economic status may show disinterest and poor hygiene maintenance.

16. Location/Address   Some endemic disorders may be confined to certain localities.  Habits  Pan chewing, smoking, chronic alcoholism may modify the systemic status and evoke concerns regarding the hygiene, maintenance and wear of the denture.  Habits like pencil biting and nail biting may cause denture instability. Parafunctional habits like clenching and bruxism should also be verified as they affect teeth selection and prognosis.

17. Nutritional history It is important to obtain a record of food intake of the patient over a 3– 5 days period. This helps in evaluating the nutritional status of the patient.  The ability of the oral tissues to withstand the stress of dentures is greater in a well-nourished patient.  Dietary counselling is necessary in malnourished patients.

18. Medical history No prosthodontic procedure should be commenced without evaluating the systemic status of the individual.  Debilitating diseases The most common is diabetes mellitus.  Patients are at a higher risk of opportunistic infections such as candidiasis and show delayed wound healing.  Salivary flow may also be impaired.  Special emphasis on denture hygiene, recall and maintenance is also necessary for such patients.  Tuberculosis is contagious and necessary precautions are required. The therapy is also long term and the drugs can cause nausea.  Patient with blood dyscrasia require specific precautions if pre-prosthetic surgery is contemplated. All patients with debilitating disease should be under medical control before commencing any dental treatment.

19.     Diseases of the joints  Rheumatoid arthritis and osteoarthritis are common diseases affecting the joints.  In the jaw, RA and OA can cause pain, swelling, and stiffness, making it difficult to wear dentures comfortably. When the temporomandibular joint (TMJ) is affected, special impression trays are required due to poor mouth opening and frequent occlusal correction may be necessary as jaw relations are difficult to record due to painful mandibular movements.

20.      Cardiovascular disease  Patients with stable cardiac problems under the regular care of a cardiologist are not contraindicated for procedures.  A consultation with the physician is required if any invasive pre-prosthetic procedure is contemplated, along with premedication and stoppage of anticoagulants. Cardiac patients with dentures may need to take special precautions when it comes to their dental health. Poor dental health can lead to infections, which can affect the heart and increase the risk of complications for cardiac patients. 

21.      Neurological conditions  Neurological conditions such as Parkinson's disease, stroke, and multiple sclerosis can affect oral hygiene and the ability to wear dentures comfortably. Patients need to be educated regarding these anticipated problems.

22.      Oral malignancies  Construction of CD may be commenced depending on the tumor prognosis, the healing of tissues following the treatment and the amount of radiation.  After CD construction, the tissues should be evaluated constantly for any evidence of radiation necrosis.  Patient should be advised to use the dentures on a limited basis.

23.     Epilepsy  Patient may aspirate or break the denture during the seizure.  It will influence the selection of denture base material and teeth.  Patient and close relatives may also need to be educated on quick removal of the dentures prior to or during seizures .

24.      Diseases of the skin  Dermatological diseases like pemphigus have painful oral manifestations like ulcers and bullae.  Medical treatment may or may not provide relief to these patients. The constant use of dentures in such patients must be discouraged.

25. This is an important consideration in women as they could undergo CD construction during this period.  The period is characterized by bone changes like osteoporosis, burning mouth syndrome, mental disturbance ranging from mild irritability to complete nervous breakdown.  They may require psychiatric counselling and medication.  Patient must be made aware of this condition before treatment and the possible effect on denture adjustment.

26.        Medications  It can be an indication of a systemic problem or dental treatment may be modified and influenced by the effect of the drug. Xerostomia is a common side effect of antihypertensives and antidepressants.  This can decrease denture retention and cause increased soreness. Diuretics cause changes in tissue fluids which affect retention and stability of dentures.  Psychotropic drugs can cause uncontrollable tongue or facial movements.  Drugs can also act as synergists or antagonists to produce undesirable effects. Hence, the dentist must be aware of all the patient’s medications

27. Dental history Chief complaint  The chief complaint is recorded in patient’s own words. It should be determined if the complaint is justified and realistic.  Patient’s desires and expectations  It is important to find out what the patient expects from the treatment. Unrealistic expectations will be detrimental to success of treatment. Patient education regarding what is possible is very important in such cases.

28. Past dental history   The following information should be elicited:  Reason for tooth loss: If periodontal disease was the reason, more bone loss is anticipated. It also helps in prognosis.  Period and sequence of edentulousness: Longer the period, more will be the bone loss. By understanding the sequence, bone resorption pattern can be identified. Previous dental and denture experience: Traumatic experiences will affect the attitude of the patient towards dental treatment and they will require more counselling and education. Patient’s experience with previous dentures will give an insight into their attitude, desire and expectations.

29. Current denture  The examination and evaluation of the present prosthesis gives an insight into the patient’s previous experience, patient tolerance and aesthetic values. It is evaluated for the following:   Extension of denture is evaluated using vestibule, hamular notch and vibrating line as guides for maxillary denture; and vestibule, retromolar pad, retromylohyoid area and buccal shelf as guide for mandibular denture.  The jaw relation—vertical and horizontal, is checked using appropriate methods.  Occlusion is verified for balance and premature contacts.  Artificial teeth are examined for type and wear or breakage. Considerable wear in a short time period is indicative of bruxism.  Retention and stability.  Aesthetics.  Maintenance of the denture is checked which will provide information about patient’s hygiene, interest and methods.   Any previous prosthesis and the reasons for its change should also be evaluated. 

30. Pre-Extraction records  This will include old diagnostic casts, radiographs and photographs.   Old diagnostic casts aid in determining tooth size, position and arrangement.  Old radiographs aid in determining tooth size and bony changes.   Photographs give information about tooth size, position and tooth display.

31. Diagnostic casts  They confirm and sometimes reveal new information obtained from intraoral examination. It may be of immense benefit to keep the cast ready during intraoral examination.  Diagnostic casts should be mounted on an articulator following a facebow transfer. This allows for dynamic evaluation of interarch relations, most importantly the interarch space (interridge distance), which is very essential in determining if space exists to place artificial teeth.  Undercuts and their significance can be evaluated with a dental surveyor.   Preprosthetic surgeries can be planned and surgical templates can be made on the diagnostic cast.

32. Examination    Extraoral examination  The patient’s head and neck should be examined for the presence of any pathologic condition.   Any nodules and ulcerations on the face are noted.  Facial colour and tone, hair texture, eye clarity, symmetry and neuromuscular activity should be noted.  Face and neck are palpated to check for enlarged nodes or masses

33.   Facial examination  Face form  Leon William has classified the facial form based on the approximate shape of the face as square, tapering, square–tapering and ovoid   Facial profile  The facial profile is classified as: • Class I: Straight profile • Class II: Retrognathic or convex profile • Class III: Prognathic or concave profile. This helps in selection and arrangement of artificial teeth

34. Color of face, hair and eye   This helps in determining the tooth shade. Though there is no scientific evidence to associate this  colour  with a particular tooth shade, a harmonious relationship of all of these should exist.

35. Lip examination  Lip health  Fissures, cracking or ulcers at the corner of the mouth indicate vitamin B deficiency, candidiasis and loss of vertical dimension or neoplasm.  Lip support  Lack of proper support can lead to wrinkling. Correct placement of upper anterior teeth will provide adequate lip support to eliminate wrinkles around the modiolus. Lip thickness In patient with thin lips, even a slight change in the labiolingual tooth position makes an impact on lip fullness and support. Thick lips can tolerate more alterations in tooth position without visible changes.  Lip length  Length of the lips affects the amount of anterior tooth exposure and the anterior tooth size. Patients with short upper lip will expose all the upper anterior teeth and much of the labial flange of the denture base with any expression. Long lip will hide most of the tooth and denture base. Short lips will influence the selection of anterior tooth size and characterization of denture base.

36.   Muscular examination  The musculature surrounding the mouth plays an important part in the stability of the prosthesis. The musculature can be classified according to House as:  Class 1: Normal muscle function and tone or patients showing no degeneration. This is most commonly seen in patients with recent extractions.  Class 2: Normal muscle function with mildly decreased muscle tone.  Class 3: Decreased muscle tone and function, seen as drooping commissures, exaggerated nasolabial fold or loss of vertical dimension.

37.  Temporomandibular joint  The TMJ and associated muscles should be examined for pain by palpation or mandibular movement. Range of opening, deviation, clicking and crepitus should be noted. It must be decided if CD construction will solve some of the problems associated with the TMJ and explained to the patient.

38. Intraoral examination Teeth present  Teeth, if present, are examined for planning the following treatments: 1. Immediate denture  2. Overdenture  3. Single complete denture 

39.     Mucosa  The mucosa of the cheeks, lips, floor of the mouth, residual ridge, hard palate and soft palate is evaluated for colour and thickness and the condition is noted.      Colour    Redness is a sign of inflammation, which could be due to ill-fitting dentures, infections, smoking and systemic diseases such as diabetes. It is important to eliminate the cause and allow the tissues to return to normal before impression making.   White patches and brown/blue pigmented spots should be noted. If the cause is uncertain, a biopsy is indicated.     Thickness  M.M. House has classified mucosa thickness as follows:   Class 1: Normal uniform density of mucosal tissue (approximately 1 mm thick). Investing membrane is firm but not tense and forms an ideal cushion for the basal seat of a denture.  Class 2:  Soft tissues have mucous membranes twice the normal thickness.  Class 3: Soft tissues have excessively thick investing membranes . At the very least, this requires tissue treatment. Such conditions may require surgical correction.      Condition  Classified by House as:   Class I—healthy   Class II—irritated   Class III—pathological

40.   Residual alveolar ridge   Residual alveolar ridge should be evaluated for the following.     Arch size   Greater the arch size larger is the contact and support, hence greater is the retention.   Discrepancy in the size of the maxillary and mandibular ridges can create problems with denture stability in the smaller arch due to poor relationship of the teeth. This discrepancy may be due to developmental causes, trauma and early loss of teeth in one of the arches, or from a severe class II or class III malocclusion. Arch Size can be classified as—small, medium and large

41.      Arch form     Influences support and tooth selection.  If opposing arches do not have the same form, difficulty in tooth arrangement can be anticipated.  Arch forms can be classified as—square, tapering or ovoid    Ridge contour    Influences support and stability of the dentures.  The ideal is a high ridge with a flat crest and nearly parallel sides. This offers maximum support and stability. A flat ridge lacking vertical height affords little resistance to horizontal movement leading to reduced stability.  A knife-edged ridge offers the poorest prognosis because it cannot withstand much occlusal force and can easily become sore.

42.   Ridge relation.  Ridge relation is evaluated for the following: 1.  Interridge distance 2. Parallelism 3. Positional relation    Bony undercuts These do not aid in retention but cause loss of border seal and retention; may be present in both maxillary and mandibular ridges. Maxilla—present in anterior ridge and lateral to maxillary tuberosity. These may be selectively relieved without any surgery. Only if the undercuts are severe and previous denture attempts have failed, surgery should be considered. Mandible—prominent sharp mylohyoid ridge produces undercut. Surgical reduction and reattachment may be beneficial. 

43. Muscle and frenal attachments  The location of these attachments in relation to the crest of the ridge must be verified.  In resorbed ridges, they can be near the crest of the ridge. This interferes with the border seal compromising retention of the dentures. In such cases, a surgical correction may be required.  The attachments most often corrected surgically are the maxillary labial frenum and the mandibular lingual frenum; buccal frena rarely require surgical repositioning. 

44. Palate  The following are evaluated.  Hard palate  It is classified according to the shape as:  • U-shaped: Provides good retention and stability  • V-shaped: Provides least retention  • Flat: Provides poor retention and stability 

45. Soft palate   Based on the degree of flexure that the soft palate makes with the hard palate and the width of the palatal seal area, the soft palate configurations may be classified as:   Class I: Almost horizontal with little movement making angle of less than 10° with hard palate; most favourable .  Class II: Makes a 45° angle with the hard palate. Tissue coverage is less than class I (3–5 mm).  Class III: Makes a 70° angle with the hard palate; least favourable ; usually associated with V-shaped palate

46.  Gag reflex  Gagging is a normal defence mechanism to prevent foreign objects from entering the trachea. An exaggerated gag reflex can compromise prosthodontic procedures like impression making. The cause of this can be systemic, psychological, physiologic and iatrogenic. The management of such patients may be clinical, psychological or pharmacological. House classified palatal sensitivity as:             ○ Class I: Normal             ○ Class II: Hyposensitive             ○ Class III: Hypersensitive

47. Lateral throat form   The retromolar space can be partially or totally obliterated by tongue movement. This area is critical for lingual seal and lateral stability.  Neil classified lateral throat form according to the extent of anterior movement of retromylohyoid curtain as tongue is extended anteriorly. Checked by placing a finger in the area.   Class I - Deep - Change in configuration, places heavy pressure on finger   Class II - Moderate - Any position in between I & III   Class III - Shallow - Minimal pressure 

48. Tongue  Size  The size of the tongue may be normal, enlarged or small. If the patient has been without teeth for a long time, the tongue can become enlarged, which causes tongue biting, compromises impression making and also leads to denture instability. Small tongue compromises a lingual seal.  Position  Tongue movement, muscular coordination and position control the dentures during speech, mastication and deglutition.  • Wright has classified tongue positions as:       ○ Class I: Tongue lies on the floor of the mouth with the tip forwards and slightly below the           incisal edges of the mandibular anterior teeth.       ○ Class II: Tongue is flattened and broadened but the tip is in normal position.       ○ Class III: Tongue is retracted and depressed into the floor of the mouth with the tip curled upwards, downwards or assimilated into the body of the tongue. 

49.    Tori  These are bony prominences which may be present in the palate or lingual alveolar ridge.  Torus has an extremely thin mucous covering which can be traumatized during impression making and by the denture. Adequate relief must be planned. Tori can also act as a fulcrum to rock the denture and compromise denture stability. Surgical removal is not indicated unless the tori are large.

50. Saliva   Major salivary glands orifices should be examined to ensure they are open. The amount and consistency of saliva affects denture retention and construction.  Amount of saliva can be classified as: • Class I: Normal  • Class II: Excessive  • Class III: Xerostomia  In xerostomia, denture will have poor retention and there is increased potential for soreness as lubricating action of saliva is lost. Excessive saliva will complicate impression making.   Consistency  It ranges from thin and serous to thick and ropy. Thick ropy saliva prevents intimate contact between the denture and the tissues and results in dentures.

51. Radiographic examination If some teeth are remaining, periapical and panoramic radiographs are essential to plan the treatment for immediate dentures, single complete dentures and overdentures. Panoramic radiographs are necessary for the completely edentulous patients. The aim is to screen the edentulous jaws for any pathology and determine the amount of ridge resorption. The screening gives information about the defects in jaw structure, root fragments, unerupted teeth or retained roots, foreign bodies, sclerosis, tumours and cysts and TMJ disorders. Amount of bone resorption can be assessed using the method described by Wical and Swoope. According to this, the original alveolar ridge crest height is three times the distance from the inferior border of the mandible to the inferior margin of the mental foramen.  The amount of bone resorption is classified as: ○ Class I: Mild resorption—loss of one-third of vertical ridge height. ○ Class II: Moderate resorption—loss of one-third to two-third of vertical height. ○ Class III: Severe resorption—greater than two-third loss 

52. Treatment planning  Treatment planning is the process of matching possible treatment options with patient needs and systematically arranging the treatment in order of priority but in keeping with a logical or technically necessary sequence.  It requires a wide knowledge of treatment possibilities, an idea of patient needs as determined by a thorough diagnosis, while taking into account prognosis, patient health, attitude and financial capability. It will involve two processes: Mouth prepration Prosthodontic treatment

53. Mouth preparation  Mouth preparation involves: 1. Elimination of infection  2. Elimination of pathology 3. Conditioning of tissues 4. Nutritional counselling 5. Preprosthetic surgery. 

54. Prosthodontic treatment Patients with some teeth remaining: 1. Interim removable partial dentures 2. Immediate dentures  3. Single complete denture 4. Overdenture. Completely edentulous patient: 1. Conventional CD 2. Implant supported CD—fixed, removable

55. PDI for edentulous class I   patient A patient who presents ideal or minimally compromised complete edentulism and who can be treated by conventional prosthodontic techniques.   PDI for edentulous class II patient   A patient who presents moderately compromised edentulism and continued physical degradation of the denture supporting anatomy.  PDI for edentulous class III patient   A patient who presents substantially compromised complete edentulism  PDI for edentulous class IV patient   A patient who presents the most debilitated form of complete edentulism where surgical reconstruction is usually indicated, and specialized prosthodontic techniques are required to achieve an acceptable outcome.  Prosthodontic diagnostic index for complete edentulism

56. conclusion Diagnosis and treatment planning are the most important parameters in the successful management of a patient. A major reason for prosthetic failure is the inadequate and inappropriate diagnosis and treatment planning. Therefore, care must be taken to elicit and record an informative case history to understand the patients’ needs and expectations for a successful outcome

57. Thank you