Diagnosis and treatment planning in complete denture.pptx

Diagnosis and treatment planning in complete dentures involve a thorough clinical evaluation and a systematic approach to ensure optimal fit and function. The process begins with a comprehensive patient history and oral examination to assess the condition of the oral tissues, bone structure, and any existing dental appliances. Diagnostic tools such as radiographs and oral impressions are essential to evaluate the supporting structures and anatomical landmarks. The treatment plan is then formulated, considering factors like ridge resorption, tissue health, and patient-specific needs. It includes selecting appropriate denture materials, designing the prosthesis for maximum stability and comfort, and planning for follow-up adjustments to address any issues that arise post-placement. Effective communication with the patient about expectations and maintenance is crucial for the long-term success of the complete dentures.

1. Diagnosis And Treatment Planning In Complete Denture DR. SATVIKA PRASAD MDS DEPT. OF PROSTHODONTICS SEMINAR PRESENTATION

2. CONTENTS Introduction Definitions Patient Evaluation History Extra Oral Examination Intra Oral Examination Supplemental Diagnostic Aids Treatment Planning Conclusion

3. Introduction Every patient has specific problems and specific needs, which need to ascertained, evaluated and as far as possible, incorporated in the treatment of the patient. The successful complete denture should fulfill the following objectives- MASTICATION for adequate nutrition ESTHETICS by restoring the normal appearance of the patient PHONETICS PRESERVATION of the oral tissues All these objectives can only be attained by careful examination & correct treatment plan

4. Definition DIAGNOSIS- Is the examination of the physical state, evaluation of the mental or psychological makeup, & understanding the needs of each patient to ensure a predictable result -WINKLER TREATMENT PLANNING- Means developing a course of action that encompasses the ramification & sequelae of treatment to severe the patient’s needs -WINKLER

5. BOUCHER stated- “The first 5 min. spent with the patient is the most important period the dentist spends with the patient.”

6. PATIENT EVALUATION

7. Components

8. GENERAL INFORMATION OPD No. – for maintaining records & for medico legal purposes. NAME – patient must be addressed by name which would add a personal touch & build confidence and for records as well . AGE – With advancing age the capacity of the tissues to withstand stress and ability of tissue to heal Many diseases like diabetes and cardiovascular diseases are prevalent in older individuals Women at the age of menopause may present as exacting or hysterical patients Patient’s with older age may present as indifferent patient. Only concerned with comfort or function while younger males have a higher priority on appearance. SEX – women place a higher priority on appearance than men, certain diseases are gender specific.

9. OCCUPATION – tells about the patient’s financial & social status in the society & the importance the patient would have of the dentures, in its esthetic value and implications of oral health. ADDRESS AND TELEPHONE NO. – for the purpose of communication. 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 or nail biting may cause denture instability Para-functional habits like clenching and bruxism should also be verified as they affect teeth selection and prognosis. NUTRITIONAL HISTORY – Obtain a record over a 3-5 days period. This helps in evaluating the ability of oral tissues to withstand the stress of the dentures .

10. Should be recorded in patients’ own words – Lost all teeth and need denture Old dentures are unsatisfactory / ill fitting Old dentures worn out / broken / lost Any others Chief complaint

11. DENTAL HISTORY How long have you been without natural teeth – upper / lower (amount & pattern of bone resorption) Primary reason for tooth loss – gum disease, dental caries, any other Previous denture experience & its duration Reason of seeking denture – aesthetics / mastication / phonetics / on others’ suggestion

12. MEDICAL HISTORY No prosthodontics procedure should be commenced without evaluating the systemic status of the individual. Some systemic diseases have a direct relation to denture success even though no local manifestations are apparent Many systemic diseases have local manifestations with no apparent systemic symptoms & other have both local and systemic reactions EVALUATION OF SYSTEMIC DISEASES

13. Debilitating diseases E.g. :- diabetes, TB & blood dyscrasia Most common is DIABETES MELLITUS Patients are at a high risk of opportunistic infections such as candidiasis and show delayed wound healing. Rapid resorption of residual ridge, hence time to time adjustement is needed. Wound healing capacity is low, if pre-prosthetic surgery is planned Salivary flow is impaired Mucostatic impression technique (because muco -compressive will apply pressure to the mucosa and injure it) TUBERCULOSIS is contagious and necessary precautions should be taken Therapy is long term and can cause nausea BLOOD DYSCRASIA require specific precautions if pre-prosthetic surgery is contemplated Mucosa is more sensitive to denture pressure (Either physical or mental health conditions that weaken our bodies and brain functioning over time)

14. MUCOSTATIC TECHNIQUE should be used because mucocompressive technique causes palatal hemangioma - due to compression of blood vessels. ANAEMIA Soft tissues overlying bone becomes fragile with possibilty of enhanced bone loss. Decrease in stress bearing capacity Decrease in healing capacity Advice patient for haemogram , to improve blood picture Bleeding disorders

15. Pts. with oral malignancies may require radiation therapy before prosthetic t/t. Tissues having bronze color & loss of tonicity are not suitable for denture support. Osteoradionecrosis & necrosis of the soft tissues is that the common occurrence. This would imply the treatment is contraindicated or if required, posterior occlusion would have to be such that there is reduced stress. E.g.- flat occlusal table. Xerostomia can also occur due to radiotherapy. Hence, sialogouges & use of denture adhesives may have to be considered. Radiation treatment

16. RA & osteoarthritis are common, paget’s disease Osteoarthritis of TMJ poses problem in complete denture construction, as mandibular movements are painful. In extreme cases, surgery is indicated. TMD- special trays are required due to poor mouth opening and frequent occlusal correction will be needed If fingers are affected – difficult to insert and clean dentures, so, denture cleansers are given for cleaning the dentures. An enlarged head may relate to paget’s disease. Generalized enlargement of either the maxillary or mandibular alveolar ridges, so inability to wear the old dentures. Sometimes necrosis of the underlying bone can occur where they cause pressure on the gum. Profuse bleeding may be encountered during the alveoloctomy when the large vessels in the marrow spaces are cut. DISEASES OF JOINTS

17. Cardiovascular disease Patient with stable cardiac problems under regular care of cardiologist are not contraindicated for procedures. Short appointments- manage stress better A consultation with the physician is required if any invasive pre-prosthetic procedure is contemplated along with premedication and stoppage of anticoagulants. Adrenaline free LA is administered if indicated.

18. There are large no. of diseases which can be transmitted from pt.( through blood, saliva, sputum etc.) to dentist & laboratory personnel( through impressions & casts) if adequate precautions are not taken. Disease are TB, AIDS, hepatitis, herpes, SARS( severe acute respiratory syndrome). The pt. is asked whether he has had or is currently undergoing t/t for any of these diseases. Proper precautions should be taken by the operator. TRANSMISSIBLE DISEASES

19. E.g.- Bell’s palsy & Parkinson’s disease, Tic douloureux – present problems related to denture retention, maxillomandibular records and support for the musculature Uncontrolled movements will poses difficulty in impression making & jaw relation recording. Neurotropics can be advised to the patient NEUROLOGICAL CONDITIONS EPILEPSY Disorder in which nerve cell activity in the brain is disturbed, causing seizures. Pt. may aspirate or break the denture during seizure. It will influence the selection of denture base materials and teeth Patients & close relatives may also be need to be educated on quick removal of dentures prior or during seizures

20. DRUG HISTORY The value of knowing what medication a pt. is taking is two fold – 1) it can be an indication of systemic problems. 2) the dental t/t can be influenced by the effects of the drug.

21. Medications Xerostomia -- side effect of antihypertensive – dec. denture retention and inc. soreness Diuretics – changes in tissue fluids – affect retention and stability of dentures Psychotropic drugs– can cause uncontrollable tongue and facial movements Drugs which act as synergists / antagonists – produce undesirable effects Dysphagia (gagging could cause difficulty during impression making) – all agents causing xerostomia , belladona derivatives. Behavioral changes or confusion (pt. acceptance of dentures could be affected) – adrenal corticosteroids, antiparkinsonian drugs, cardiac glycosides. Anticoagulants – used for stroke & cardiovascular pts. E.g.- aspirin, heparin, dicumarol . The dentist should not perform any t/t that involves bleeding( e.g.- preprosthetic surgery) without consulting a physician. The drug should not be withdrawn, but dosage can be adjusted, if necessary. Insulin- used to treat DM. pt. can go into hypoglycemic shock when blood sugar level drops below normal. It may be induced by a LA injection. The dentist must enquire whether the pt. has eaten a meal after his insulin injection. Uncontrollable tongue or facial movement – phenothiazines , tricyclic antidepressants .

22. HABITS Oral hygiene habits- a) method b) frequency Other habits- smoking/ pan/ tobacco chewing/ betel nut/ alcohol/ clenching/ bruxism/ any other.

23. A) Family status B) Educational status C) Mental attitude - classified by M.M.HOUSE into 4 categories- Philosophical Exacting Hysterical Indifferent SOCIO- PSYCHOLOGICAL EVALUATION Poor

24. EXTRA ORAL EXAMINATION The general appearance of the face is noted. This includes -

25. Face of the patient should be observed. Note the philtrum , nasolabial fold and labiomental groove for hollowness or puffiness. Loose wrinkled skin that has lost its tone may be difficult to properly support artificial anterior teeth. Thin tense skin is easily supported, but very sensitive to small changes in the anterior tooth position. FACIAL EXAMINATION

26. It includes the evaluation of facial form and facial profile. Classification according to House & Loop, Fisher & Williams . Square Square Tapering Tapering ovoid Examining the facial form helps in teeth selection square ovoid square tapering tapering

27. ACCORDING TO LEON WILLIAMS- The operator imagines two lines , one on either side of the face, running about 2.5 cm in front of the tragus of the ear and through the angle of the jaw. Use of TRUBYTE TOOTH INDICATOR Place the indicator on the patient’s face, allowing the nose to come through the central triangle. Center the pupils of the eye in the eye slots and hold the indicator with its central line coinciding with the median line of the face. HOW TO IDENTIFY THE FACE FORM ?

28. J Indian Prosthodont Soc (Jan-Mar 2011) 11(1):7–13

29. Examination of the facial profile is important because it determines the jaw relation and occlusion. The facial profile is determined by 3 points- The forehead ( nasion ) The base of the nose (sub nasion ) The prominent point of chin ( pogonion ) FACIAL PROFILE

30. Classification of the facial profile (lateral face form) by Angle: Class I – Normal – when all the 3 points are in one line Class II – Prognathic - if sub nasion is ahead of the pogonion or pogonion is behind the sub nasion . Class III – Retrognathic – if sub nasion is behind or the pogonion is ahead of sub nasion .

31. It is most commonly associated with the state of facial equilibrium, in which there is correspondence in size, shape, and arrangement of facial landmarks on the opposite sides of the median sagittal plane HOW TO IDENTIFY FACIAL SYMMETRY? FACIAL SYMMETRY

32. Congenital defects Craniofacial Microsomia SIGNIFICANCE OF FACIAL SYMMETRY Obvious asymmetry may be a red flag for neoplastic growths, muscle atrophy or hypertrophy, and neurological problems. Asymmetry is also associated with temporomandibular joint dysfunction and malocclusion

33. It determines vertical dimension FACIAL HEIGHT

34. Palpated for enlarged lymph nodes or masses. Enlarged tender lymph nodes indicate infections. Hard attached lymph nodes or other masses may indicate secondary tumors or metastasis usually from primary tumors in the head and neck regions. PALPATION OF THE HEAD AND NECK

35. Muscle tone is critical for several steps of denture construction. If the muscles are too tense cheek and lip manipulations are too difficult, if too slack the lips and cheek are easily displaceable by impression material and the patient may take more than usual time to learn to use the dentures. Affect the stability of the denture. EXAMINATION OF MUSCLE TONE

36. HOUSE classified the muscle tone as: Class I: Normal tension, tone and placement of the muscle of mastication & the facial expression. No Degeneration. Common in immediate denture patients Class II: Normal muscle function but slightly decreased muscle tone. Class III: Decreased muscle tone and function. Usually accompanied with ill-fitting dentures, decreased vertical dimension, decreased biting force, wrinkles in the cheeks and drooping of the commissures.

37. The lips may be examined for cracking, fissuring at the corners and ulceration. These changes could be caused by a vitamin B-complex deficiency, infection from organisms such as Candida Albicans , an excessive overclosure of an existing denture. EXAMINATION OF LIPS

38. LIP SUPPORT Classified as Adequately supported Unsupported A) If the tissue around the mouth has wrinkles and rest of the face does not, lack of lip support can be suspected. B) A rolled-in vermillion border is an evidence of inadequate lip support.

39. LIP MOBILITY Can be classified as : Class I : Normal Class II : Reduced mobility Class III : Paralysis Paralysis of the lips will cause drooping of the mouth and facial asymmetry on the affected side. Patients with low lip mobility will have less display of front teeth.

40. LIP THICKNESS Lip thickness should not be confused with lip fullness since thickness involves the intrinsic structure of lips while fullness involves the support it gets from bone or denture base. Lips can be classified as : - Thick - Thin Thin lips -sensitive to small changes in the anterior teeth position. Thick lips - flexibility in positioning anterior teeth.

41. LIP LENGTH Classified as : - Long - Medium - Short Evaluation of anterior tooth position is complicated by short lips. The patient may ask for less-than-natural show of lips. A patient with short upper lip may expose all the upper anterior teeth and much of the labial flange of the denture base as well. Long lips may require teeth to be set too long to make them more visible. Measured from the sub-nasal to the most inferior visible portion of the upper lip at the midline

42. LIP LINE OR SMILE LINE Certain individuals show minimal display of teeth during normal smiling or talking. While others may show excessive display of teeth and gums (gummy smile). Thus denture base esthetics should not be neglected in such individuals. Extent of vertical tooth display in smiling or elevation of the upper lip in relation to the maxillary incisors

43. 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. EYES

44. Skin colour indicates the presence of underlying systemic diseases- Pallor – Anemia , Hyperthyroidism Ruddy complexion – Polycythemia or Neoplasm Bronzed skin – Addison’s disease Lemon yellow - Jaundice The color of the facial skin serves as basic guide to tooth shade. Specifically it is suggested that the value of the teeth must correspond to darkness or lightness of the facial skin tone. COMPLEXION anemia polycythemia Addison’s disease jaundice

45. Examination should be done for any temporo -mandibular joint disorder. The symptoms include- Pain and tenderness in the muscles of mastication and TMJ. Sounds during condylar movement. Limitations of mandibular movement. TMJ EXAMINATION

46. The observation of the patient’s physical abilities and motor skills is an important part of the overall evaluation. The patients gait, coordination of movement, steadiness should be observed. The facial movements should also be evaluated. A cerebrovascular accident, Bell’s palsy, or nerve blocks for trigeminal neuralgia will result in hemiplegia. NEURO MUSCULAR EXAMINATION

47. INTRA ORAL EXAMINATION

48. Formed by the buccal and facial surfaces of the teeth when observed from the occlusal aspect. The dentulous arch form undergoes changes following tooth loss due to surgery or resorption ARCH FORM

49. Arch form dictates arch size Denture bearing area increases with arch size & increases support and retention. Discrepancy between the mandibular and maxillary arch size - difficulties in artificial teeth arrangement and decrease the stability of the denture resting in the smaller one of the two arches. Enable anticipation of the form of the teeth to be used. Indication of the relative development of the lower 1/3 of the face Significance of arch form

50. Resorption after removal of teeth radially changes the cross section form. Residual ridge becomes progressively narrower and sharper and is unable to withstand much force. Knife edge ridges with multiple bony spicules offer the poorest prognosis :- Incapable of withstanding occlusal force Easily become sore Crest and slopes offer poor bearing surfaces, reducing the unstable basal seat RESIDUAL RIDGE FORM

51. Lower edge of mental foramen divides mandible into thirds in normal dentulous panoramic radiographs. Distance from inferior border of the mandible to the inferior edge of the mental foramen x 3 is an accurate indication of the original alveolar crest height. System of classifying the amount of RRR was developed by Wical and Swoope : Class I - Mild resorption Upto 1/3 of original vertical height Class II - Moderate resorption 1/3-2/3 of original vertical height Class III - Severe resorption >2/3 of original vertical height

52. Acc. Dental clinic of North America Class 1- Inverted “U” shaped (parallel walls from medium to tall with broad crest) Class 2- Inverted “U” shaped (short with flat crest) Class 3- Unfavorable – Inverted “W” Short inverted “V” Tall, thin inverted “V” Undercut (results from all teeth in labial or lingual version) Mandibular Ridge Form classification

53. Shape of palatal vault Class I- U shaped / square Class II- V shaped Class III- Flat residual ridge Maxillary Ridge Form

54. Ideal ridge - well developed high ridge with broad crest and parallel sides. Types based on shapes: RESIDUAL RIDGE (CROSS SECTIONAL) CONTOUR

55. It is the diminishing quantity and quality of the residual ridge after teeth are removed. - GPT 8 Maxilla resorbs- upward and inward Mandible resorbs- downward, forward, and laterally RIDGE RESORPTION

56. Order 1- Pre – extraction Order 2- Post exaction Order 3- High, well rounded Order 4- Knife- edge Order 5- Low, well rounded Order 6- Depressed Atwood’s classification (RRR)

57. The positional relation of the mandibular ridge to the maxillary. - GPT. Angle Classified Ridge Relationship: METHOD TO DIAGNOSE: Maxillary and mandibular ridges should be observed at the appropriate vertical dimension. Ask the patient to relax his mandible and carefully retract the lips and view intraorally . Mounting diagnostic casts on an articulator via facebow transfer Class I - Normal Class III – Retrognathic Class II - Prognathic RIDGE RELATION

58. Determine the amount of space available to set teeth May be: Normal Excessive Insufficient INTERARCH DISTANCE (INTER RIDGE SPACE) Occurs due to RRR Results in poor stability and retention due to increased leverage. Recent extraction cases Results in: - Difficulty in teeth arrangement. Establishing proper freeway space. Better stability as occlusal surfaces of teeth are as close to the ridge, thus minimizing leverage, tilt, and tongue forces.

59. CLINICAL SIGNIFICANCE: Non parallel ridges will cause movement of bases when teeth occlude because of unfavourable direction of forces. Classify as: By Sears Class 1: Both ridges parallel to occlusal plane Class 2: Mandibular ridge divergent from occlusal plane anteriorly Class 3: Maxillary ridge divergent from occlusal plane anteriorly/both ridges divergent anteriorly RIDGE PARALLELISM

60. The Prosthodontist has the opportunity to examine oral tissues more closely than any other professional and the responsibility to diagnose any potential pathologic condition should not be overlooked or underestimated. METHOD:- Examine inside surfaces of cheeks, lips, residual ridges, floor of mouth, hard and soft palate, and tongue. Wrap 2x2 gauze around anterior aspect of tongue and forcefully pull it forwards and examine anterior and posterior tonsillar pillars and lateral borders. Prevalence of malignant lesions in this region mandates this examination procedure. Examine oropharynx and nasopharynx for presence of lesions. ORAL MUCOSA

61. Oral mucosa can be classified as – Masticatory mucosa : Residual alveolar ridge &palate It is keratinized, firm and resilient. It is usually attached to the underlying periosteum . If not attached ,denture instability can be a problem. Area of attachment diminishes with ridge resorption . Mandibular ridge more susceptible to this problem. Lining mucosa: Cheeks & lips Lining mucosa of lips, cheeks and floor of the mouth is relatively thin and easily traumatized. Specialized mucosa: Tongue Specialized mucosa over the tongue is sometimes said to be a “window” on systemic disorders. Examined for irregularities , abnormalities and pathosis .

62. House classified the condition of the mucosa as: Class I : Healthy mucosa Class II : Inflamed mucosa Class III : Pathologic mucosa

63. The posterior convexity of the maxillary arch is termed as the maxillary tuberosity. They provide resistance against horizontal movements of the maxillary denture. The tuberosity often hangs low(pendulous) because, when the maxillary posterior teeth are retained after the Mandibular molar are lost and not replaced, the maxillary teeth extrude, bringing the process with them. Excess tissue may be fibrous or bony. Can be unilateral or bilateral. If fibrous- provide poor denture support, and interfere with denture construction by excessive encroachment on or obliteration of the inter-arch space. If mobile: diminish stability of denture. Surgical excision is the treatment of choice MAXILLARY TUBEROSITY pendulous maxillary tuberosity

64. Hyperplasia of the tissue associated with ill fitting dentures is common finding. Hyperplastic tissue is found in relation to edentulous ridge and border tissue, as a reaction to trauma or to the resorption of supporting bone. Border tissues chronically traumatized by overextended flanges produce reactive hyperplasia i.e. EPULIS FISSURATUM Papillary hyperplasia tends to occur on the anterior of palate, of long term denture wearer. Often it is inflamed and prone to candidal infection . HYPERPLASTIC TISSUES

65. Tori are benign bony enlargements found at the midline of the hard palate or on the lingual aspect of mandible in the premolar region . They vary in sizes from small ones to large that interfere with denture construction. Torus has an extremely thin mucosal covering that can be easily pressurized in the impression making and by subsequent denture. Adequate relief should be planned in impression and denture. Ridge resorption can cause denture to settle over torus palatinus causing rocking of prosthesis & soreness. Generally surgical removal of torus palatinus is avoided, but if torus is large that it extends beyond the vibrating line &over part of soft palate, it should be removed or reduced in size. Mandibular tori occur singly or in rows. It is difficult to provide adequate denture relief for them because it would break the border seal of the denture. TORI

66. Presents with variations of form, resiliency and position relative to the crest of the ridge. Floor of the mouth affect the prognosis of the lower denture. Ideally minimal changes in form and elevation are desirable. Anteriorly a well developed and resilient sublingual fold space is advantageous If the floor is at or near the level of the ridge crest, the retention and stability is less. Sometimes ridge resorption is so great that the floor of the mouth in sublingual gland & the mylohyoid regions spill onto the ridge. FLOOR OF THE MOUTH

67. GENIAL TUBERCLES : usually not seen but sometimes may be prominent as a result of advanced ridge reduction in anterior part of the body of the mandible In Class IV ridges , superior spine of the genial tubercle is at a higher level. When sharp or covered with thin mucosa, it presents with problems of retention, patient discomfort, and tissue injury. Management :- Surgical reduction If surgery is not feasible, cover the tubercles with the denture base. Class 1 – RRR height is ≥21mm Class II – RRR height is 16 – 20 mm Class III – RRR is 11 – 15 mm Class IV – RRR is minimal and similar to least vertical height of the mandible

68. MIDDLE/MYLOHYOID VESTIBULE Intraoral appearance is misleading, because the membranous attachments make the muscle appear to be horizontal while contracting. Nagel and Sears have shown that at maximum contraction, the fibers are in a downward and forward direction so the denture can be extended below the muscle attachment along the mylohyoid ridge. Method of Evaluation: Evaluate by palpation. Mylohyoid muscle should be in a functional, but not extreme, contracted or elevated position Elevates tongue

69. Neil defined as the contour of the hard lingual surfaces of the mandibular ridge and the velum like tissue distal to the mylohyoid ridge in the retromylohyoid fossa as it functions under the influence of tongue Examination:- By placing a mouth mirror in the distolingual vestibule Need to be recorded, especially with severely resorbed ridge CLASSIFICATION : By Neil CLASS I CLASS II CLASS III RETROMYLOHYOID FOSSA (LATERAL THROAT FORM) deep shallow moderate

70. Most edentulous mouths have class I and class II lateral throat form class III is rare . Besides border seal, another important reason for extending the lingual flanges into lingual vestibules as far possible within their anatomical and functional limits. These flanges present favourable inclined planes to the tongue resulting in vectors of force that helps maintain the mandibular denture in place.

71. Visual examination - followed by manual palpation. Sulcus areas, ridge crest and slopes & palatal areas are palpated. Midpalatal raphe - Prominent in some individuals Always needs relief, or denture will cause soreness over that area, and denture may rock Bony spicules and sharp ridge crest - Result of resorption Relieve the area or remove surgically Sharp mylohyoid ridge - Resorption of the lower ridge - cause pain if not relieved BONY PROMINENCES

72. Some Retained roots will be partially resorbed and difficult to distinguish from surrounding bone. If such roots are asymptomatic and apparently covered completely in bone, they are usually left undisturbed. Roots covered only by mucosa and roots with defined PDL, associated with cyst, or abscesses should be removed. RETAINED ROOT PIECES

73. The contour of a cross section of a residual ridge that would prevent the placement of a denture or other prosthesis. Undercuts cause- difficulty in denture removal & insertion ;abrasion of mucosa & pain. Do not aid in retention and may cause some loss of border seal. Management :- Isolated anterior undercut - not present any problem Unilateral posterior undercut- may not present much of a problem as path of insertion is varied Bilateral undercut- surgical removal of the more severe one is indicated UNDERCUT

74. If patient without teeth or prostheses for long time or worn maxillary denture against lower anterior teeth only-tongue become enlarged and powerful-problem in impression making & denture instability. Small tongue facilitate impression making but jeopardize a lingual seal. Tongue movement and muscular coordination are important for : Proper tongue movements necessary for border molding impressions. Essential in controlling the dentures in the mouth during normal physiological activity such as speech, mastication, and deglutition. TONGUE

75. Class I – the tongue lies in the floor of the mouth with the tip forward and slightly below the incisal edges of the mandibular anterior teeth. Class II – the tongue is flattened and broadened but the tip is in a normal position. Class III – the tongue is retracted and depressed into the floor of the mouth with the tip curled upward, downward, or assimilated into the body of the tongue. Tongue position is important to the prognosis of the mandibular denture. Wright classified tongue positions as follows: Class I Class III Class II

76. The lingual seal class I position has the most favorable prognosis. The floor of the mouth will be high enough to cover the lingual flange of the denture producing a border seal. The class II and especially the class III are unfavorable tongue positions as they drop the level of the floor of the mouth and do not provide an adequate seal. An attempt to extend the flange to gain border seal will result in an overextension during tongue movements that would dislodge the denture.

77. According to House: Class I: Normal in size, development, and function. Sufficient teeth present to maintain normal form and function. Class II: teeth absent long enough to permit a change in the form and function of the tongue. Class III: excessively large tongue. Teeth absent for extended period of time- abnormal development of the size of the tongue. Insufficient dentures can lead to development of class 3 tongue.   TONGUE SIZE Class I Class II Class III

78. The hard palate should be examined and its shape noted. Hard palates can be classified as: U-shaped: The U-shaped palatal vault is most favorable for retention and lateral stability. V-shaped : The V-shaped vault is less favorable for retention as slightest movement of the denture base will cause the seal to be broken with a resultant loss of retention. A V-shaped palatal vault is usually associated with a Class III soft palate. In such cases placement of seal and its depth is most critical for maximum retention. FLAT : The flat palatal vault is also unfavorable. It is usually accompanied by resorbed ridges and although retention may be satisfactory in a downward direction, any lateral or rotary forces results in poor resistance and loss of retention. A flat palatal vault is usually associated with a Class I or Class II soft palate enabling the dentist to gain an improved posterior seal to compromise for the poor palatal shape. HARD PALATE

79. The anatomy of the soft palate usually will determine the location of the distal border of the maxillary complete denture and its posterior palatal seal. There are three classifications of the soft palate configurations which are based on the degree of flexure the soft palate makes with the hard palate and the width of the palatal seal area - SOFT PALATE

80. CLASS I - Soft palate is rather horizontal and demonstrates little muscular movement. - Most favorable condition as it allows for more tissue coverage for the palatal seal. CLASS II – The soft palate turns downwards at about a 45 degree angle to the hard palate - The potential tissue coverage for palatal seal is less than that for class I. CLASS III - Soft palate turns downwards sharply at about a 70 degree angle just posteriorly to the hard palate. - Since this is the most acute relation the available space for coverage by posterior palatal seal is at a minimum. Class I Class III Class II

81. The relationship between the soft palate and hard palate. HOUSE CLASSIFICATION It can be classified as: CLASS I – Large and normal in form, relatively with an immovable band of tissue 5-12 mm distal to the line drawn across the distal edge of the tuberosities . CLASS II – Medium sized and normal in form with a relatively immovable resilient band of tissue 3-5 mm distal to a line drawn across the distal edge of the tuberosities . CLASS III - Usually accompanies a small maxilla. The curtain of the soft palate turns down abruptly 3-5 mm anterior to a line drawn across the palate at the distal edge of the tuberosities . PALATAL THROAT FORM

82. Present in the anterior part of hard palate Irregularly shaped rolls of dense connective tissue Secondary stress bearing If they are distorted in an impression technique, rebounding tissue tends to unseat the denture. Significance : 1.Said to be concerned with phonetics. 2.Increase the surface area of the foundation and thus supplement the values of retention. 3.It is the denture stabilizing area in the maxillary foundation. RUGAE

83. Covers the incisive foramen through which nasopalatine nerves and vessels make their exit to the palate. Located in the midline of the palate behind and between the central incisors. Denture should be relieved Significance : 1. Stable landmark and gives its relation to incisive foramen through which the neurovascular bundle emerge and lie on the surface of bone. 2. It is a biometric guide giving information on positional relation to central incisors which are about 8-10 mm anterior to incisive papilla. 3. Biometric guide which gives us information about location of maxillary canines (A perpendicular drawn posterior to the centre of incisive papilla to sagittal plane passes through canines). INCISIVE PAPILLA

84. If not relieved – results in

85. LABIAL VESTIBULE The anterior region extends from one buccal frenum to the other on the labial side of the maxillary space. The labial denture border should make intimate contact with the loosely attached alveolar mucosa. The denture flange should be neither overextended nor underextended , because seal depends upon contact between the external surface of denture border and the lining mucosa of the lip. VESTIBULE

86. BUCCAL VESTIBULE It extends from buccal frenum on one side to the hamular notch in maxilla and to outside back corner of the retromolar pad. Size of the buccal vestibule varies with the contraction of buccinator , the position of the mandible and the amount of the bone lost from the maxilla.

87. With the resorption of the alveolar ridge we encounter a decrease in the depth of the vestibule. The anterior part of the body of the mandible is the site most frequently involved: the labial sulcus is virtually obliterated and the mentalis muscle attachments appear to migrate to the crest of the residual ridge. In order to overcome this problem myoplasty accompanied by sulcus deepening has been proposed in an attempt to improve denture retention.

88. SIGNIFICANCE :- During impression procedure the vestibule should be completely filled with impression material for proper border contact between denture and tissues. When the vestibular space that is distal and lateral to the alveolar tubercles is properly filled with denture flange, the stability and retention of the maxillary denture is greatly enhanced.

89. Examined in relation to the crest of the ridge because it can interfere with denture extension and border House classification :- Class 1- at least 0.5” distance between attachment and crest of the ridge Class 2- distance between attachment and crest of the ridge 0.25” – 0.5” Class 3- Below 0.25” CLINICAL SIGNIFICANCE: Freni encroaching on the crest will compromise the peripheral seal and cause a decrease in retention. Surgical correction is warranted. FRENAL ATTACHMENT

90. Folds or folds of mucous membrane extending from mucous membrane reflection area to the slope or crest of residual alveolar ridge. It forms the dividing line between the labial and the buccal vestibule. Significance: LEVATOR ANGULIORIS (CANINUS MUSCLE) lies beneath it and affect position of the frenum ORBICULARIS ORIS muscle pulls frenum forward. BUCCINATOR MUSCLE pulls frenum backward BUCCAL FRENUM

91. CLINICAL SIGNIFICANCE :- During final impression procedure and in final prosthesis sufficient relief should be given for the movement of frenum because over- riding of function of frenum will cause pain and dislodgement of denture. During impression procedure the cheek should be reflected laterally and posteriorly. If frenum is attached close to the crest of alveolar ridge  frenectomy

92. It appears as a fold of mucous membrane extending from the mucous lining of the lip to the crest of residual ridge on the labial surface. It may be single It may be narrow/ broad It contains no muscle fibres of significance It starts superiorly as a fan shape and converges as it descends to its terminal attachment on the labial side of the ridge. LABIAL FRENUM

93. CLINICAL CONSIDERATION :- Sufficient relief should be given during final impression procedure and in completed prosthesis because overriding of function of frenum will cause pain and dislodgement of denture. During impression procedure the lip should be stretched horizontally outwards for the proper recording of frenum . If frenum is attached close to the crest, frenectomy is done, failure of which will lead to the denture border being placed on the bone tissue which will cause decreased border seal

94. It is also called as Post dam, Post palatal seal. Defined as the soft tissue area at or beyond the junction of the hard and soft palates on which pressure, within physiologic limits can be applied by a denture which aid in its retention. - GPT-7 Hardy and Kapur stated that retention and stability that is achieved from adhesion, cohesion and interfacial surface tension are able to resist those dislodging forces that are perpendicular to the denture base. Horizontal and lateral torqueing of the maxillary denture can be resisted only by adequate border seal. POSTERIOR PALATAL SEAL (PPS)

95. Determining PPS on master cast Boucher’s Technique Bernard Levin’s Technique Swenson’s Technique Calomeni , Feldman, Kuebker’s Technique Pound’s Technique Apple Baum Technique Winkler’s Technique Silverman’s Technique Hardy and Kapur Technique Boucher’s technique

96. An imaginary line located at the junction of the attached tissues overlying the hard palate and the movable tissues of the immediately adjacent hard palate. Shape- CUPID’S BOW Located by- Valsava Maneuver - Both the nostrils are held firmly while the patient blows gently through the nose. This positions the soft palate downwards at its junction with the hard palate. Patient is asked to say “ah” with short vigorous bursts. ANTERIOR VIBRATING LINE

97. An imaginary line at the junction of the aponeurosis of the tensor veli palatini and the muscular portion of the soft palate. Located by- it can be visualised when the patient says “ah” in a normal un exaggerated fashion. POSTERIOR VIBRATING LINE

98. CLINICAL SIGNIFICANCE :- It maintains contact of denture with soft tissue during functional movements of stomatognathic system ( mastication, deglutition and phonation) Decreases gag reflex Decreases food accumulation with adequate tissue compressibility Decreases patient discomfort of tongue with posterior part of denture. Compensation of volumetric shrinkage that occurs during the polymerization of PMMA. Permits normal movement of muscles and ligaments Increases retention and stability by creating a partial vaccum Increased strength of maxillary denture base.

99. The palatine glands are of special interest to the prosthodontist because they secrete saliva directly between the maxillary denture base plate and the mucosa. The secretion is purely mucus. Both flow rate and viscosity important to denture success. Lubricates the mucosa and assists retention CONSISTENCY Thin serous : more favorable for denture retention. Thick mucus : difficult to work with and tends to displace the denture. Mixed : Contains equal quantities of both kinds. SALIVA

100. AMOUNT: Decreased salivary flow: - Retention compromised: -Moisture is necessary for the factors of retention to act. Increased potential for soreness: Decreased comfort with which patient can wear dentures. Increased salivary flow: Complicates denture fabrication When new dentures are inserted, it is common for the patient to experience a temporary increase in salivary flow, due to the foreign body sensation. Patients must be educated regarding this CAUSES Medication Radiation therapy in the region of the salivary glands Glands may be diseased or ducts may be blocked. long term wearing of a complete maxillary - destruction of palatal gland due to pressure atrophy resulting from lost residual alveolar ridge support of the denture.

101. CONSISTENCY Ideally there should be a moderate flow of thin serous saliva. Thick, ropy, and mucus saliva is made up of heavy secretions of mucus from the palatal glands under the maxillary denture and is problematic because: - Makes denture wearing difficult Thickness of the mucus is sufficient to dislodge the dentures. Complicates impression making by forming voids in the impression surface while the material sets. Causes gagging during impression making and after insertion of new dentures MANAGEMENT:- Palatal surface should be wiped free of saliva and mucus glands massaged with a piece of gauze before final impression to eliminate as much of the mucus as possible. Salivary substitutes or oral moisturizers may be prescribed.

102. The gag reflex is a normal defense mechanism designed to prevent foreign bodies from entering the trachea. In some individuals it can be active to the point where prosthodontic treatment may be compromised. The initiation of the gag reflex can be caused by systemic disorders, psychologic factors, extraoral and intraoral physiologic factors and iatrogenic factors. GAG REFLEX

103. Not very challenging to manage Patient should not be made conscious of this condition as it will worsen it. A conditioning appliance, or training plate, may be provided for home use for a patient who suffers from nausea or gagging when wearing a denture. Combination of clinical techniques, prosthodontic management, medication, and psychologist referral may be employed. MANAGEMENT

104. SUPPLEMENTAL DIAGNOSTIC AIDS

105. EXISTING DENTURES

106. Check the esthetics, the lip fullness and symmetry. Amount of display during smiling and talking. Phonetics are evaluated. Teeth size, shape, position, arrangement & condition are evaluated. Condition of denture is evaluated. Denture hygiene is evaluated. Vertical dimension is evaluated. Check for areas of redness and ulceration. Epulis fissuratum Angular cheilitis Papillary hyperplasia Flabby hyperplastic ridge often results from ill-fitting dentures.

107. INVESTIGATIONS RADIOGRAPHS PHOTOGRAPHS

108. RADIOGRAPHS Aids in evaluation of submucosal conditions. EXTRAORAL RADIOGRAPHS Orthopantomograph Cephalograph TMJ radiograph INTRAORAL RADIOGRAPHS IOPA Bitewing X- ray Occlusal X-ray Bone pathosis Cysts Tumors Retained roots or teeth Periodontal condition of the remaining teeth Bony fractures Extent of bone resorption Mandibular canal and its proximity to the ridge crest. Maxillary sinuses. Plan surgeries See remaining bone density and quality. As treatment records For patient education. Thickness of body of the mandible. Useful in the following instances:

109.   The amount of bone resorption can be classified as follows: BY WICAL & SWOOPE Class I : (mild resorption ) loss of upto one-third the vertical height Class II : (moderate resorption ) loss of upto two-third the vertical height Class III : (severe resorption ) loss of more than two-third the vertical height. RADIOGRAPHIC ASSESSMENT OF BONE RESORPTION

110. Effective tool in achieving proper esthetics & patient satisfaction Showing natural teeth relay much information regarding tooth size, position & color Observation of facial form and jaw relation For comparison, when the prosthetic works are completed Photographs useful as pre-extraction record are: Full face with lip closed Full face with smile, revealing the teeth Close up view of the teeth together with the lips separated Full face with mouth wide open Profile of the face with the teeth in the centric occlusion   PHOTOGRAPHS

111. On occasion, ridge relationships, interridge distance, or ridge shape and form cannot be adequately determined by clinical examination alone Allow evaluation of anatomy and relationships in the absence of the patient. Useful for viewing arch size and symmetry, interarch space, arch concentricity, anterioposterior jaw relationship, and lateral jaw relationships, especially posteriorly To see if space available for both denture bases between the tuberosities & retromolar pad Tendency of patient to change the relationship of the jaws when the lips are parted to view the available space, especially in the posterior region. Undercuts observed unaided, or their significance can be determined more precisely Soft tissue disease more obvious on cast than intraorally when saliva and color obscure it.     DIAGNOSTIC CASTS

112. The prediction or forecast as to the portable result of a disease or a course of therapy. -GPT 8 The International Prosthodontic Workshop identified the following factors which produce an adaptive or maladaptive response. Factors producing an adaptive response to complete dentures- trust & confidence in the dentist. previous experience. positive attitude & ability to cope with change realistic expectations of the patient. favorable physical conditions: youth & good general health good learning capacity. PROGNOSIS poor communication b/w dentist & pt. previous negative experience. unrealistic expectations of the pt. low tolerance for anxiety & pain. inadequate tissue tolerance. muscle incoordination. chronic dissatisfaction. poor learning ability & psychological disorders.

113. TREATMENT PLANNING

114. It 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 Treatment plan Addresses patient’s needs Lists specific treatment Specifies logical sequence Delivered care Patient specific Estimate Operating time Laboratory time fees Informed consent Treatment Time fees Enables patient to Dentist delivers Enables dentist to Patient receives

115. In treatment planning the following factors must be considered: Aesthetics and patient desires Amount of resorption and interarch space. Economics. Treatment planning includes: Adjunctive Care Prosthodontic Care

116. Meeting patient expectations are paramount when treatment planning. Promising a patient a fixed reconstruction when diagnostic considerations present otherwise may result in a disappointed patient. Patients are also satisfied with the aesthetic appearance of a complete denture in particular the appearance of the soft tissues. AESTHETIC & PATIENT’S DESIRES This parameter dictates the type of prosthesis to be fabricated. The clinician needs to evaluate if the patient exhibits, minimal, moderate or advanced resorption . Each type of prosthesis has a unique dimensional tolerance. AMOUNT OF RESORPTION AND INTERARCH SPACE Fabrication of a complete denture( implant supported) is costly. However cost needs to be considered not only during fabrication of the prosthesis but also during maintenance. ECONOMICS

117. Elimination of infection Elimination of pathology Pre-prosthetic surgery Tissue conditions Nutritional counseling ADJUNCTIVE CARE

118. Patient education

119. The type of prosthesis, denture base material, tooth material and teeth color should be decided as a part of treatment planning. For the edentulous patient, a soft tissue supported denture can be given. PROSTHODONTIC CARE

120. COMPLETE DENTURE Soft tissue supported Implant supported Fixed Removable EDENTULOUS PATIENT

121. Patient not prepared to undergo any kind of surgery or other dental procedures Cannot spare the time needed Sometimes a patients demand or request may have to be considered or incorporated and the recommended treatment plan altered accordingly (within limits). If suggested treatment plan too expensive for the patient, a cheaper alternative has to be considered. The alternative treatment plan may be less than ideal, but is often necessary for various rea sons. However, we must still try to achieve the best possible result. ALTERNATIVE TREATMENT PLAN

122. Respect patient’s wishes and include it in the treatment plan whenever possible. Sometimes, a patient’s demand unreasonable or against professional judgment or ethics. Dentist may refuse treatment or refer him to another dentist for a second opinion. REFUSAL OF TREATMENT

123. CONCLUSION “The eye cannot see what the mind does not know.” The physical and psychological status of the patient MUST be assessed prior to initiating treatment by performing a thorough diagnosis and formulating an appropriate treatment plan. A good clinician is the one who is able to diagnose potential problems during the initial examination & suggest the best possible treatment plan compatible with the age, physical, mental and financial status of the patient

124. CONCLUSION A successful treatment does not just happen- it is planned !!! Thorough diagnosis enables us to make a realistic prognosis . These data aid in outlining the treatment that is best suited for the individual patient, i.e., we plan success. A step-by-step outline is used to obtain this vital information. For the patient to be happier the dentist should not only require the skills of complete denture construction but also skills to treat a patient’s aspiration & expectations.

125. M. M. Devan said “we must meet the mind of the patient before we meet the mouth of the patient.”

126. REFERENCES Sheldon Winkler, Essential of complete denture prosthodontics, A.I.T.B.S. Publishers and Distributors, Ed:2 nd , pg 39-55. Misch CE:Dental Implant Prosthetics 2005;Mosby Inc. Engelmeier R.L. Complete Dentures. Dent Cl North Am 1996;40(1):1-18. Zarb G.A., Bolender C.L., Hickey J.C., Carlsson G.E. Prosthodontic treatment for edentulous patients.B.I.Publication PVT LTD, Ed:12 th , pg 73-99. Manapallil J.J. Complete denture prosthodontics. Arya publishing house, pg:25-52. Niiranen J.V. Diagnosis for complete denture. J Prosthet Dent 1954;4:726-38. Agarwal N.K., Tripathi Ruchir,complete denture prosthodontics, arora medical book distributor, Ed:1 st , pg 21-44. Barone J.V. Diagnosis and prognosis in complete denture prosthesis. J Prosthet Dent 1964;14:207-13. Nallaswamy D. Textbook of prosthodontics. Jaypee Brothers, pg:13-33. House M.M. The relationship of oral examination to dental diagnosis. J Prosthet Dent 1958;8(2)208-19.

127. REFERENCES Appleby R.C., Ludwig T.F. Patient evaluation for complete denture therapy. JProsthet Dent 1970;24:11-17. Syllabus of complete dentures by Heartwell & Rahn . Baylink DJ, Wergedal JE, Yamamoto K, Manzke E. Systemic factors in alveolar bone loss. The Journal of Prosthetic Dentistry. 1974 May 1;31(5):486-505. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH. Classification system for complete edentulism . Journal of Prosthodontics. 1999 Mar;8(1):27-39. House MM. The relationship of oral examination to dental diagnosis. The Journal of Prosthetic Dentistry. 1958 Mar 1;8(2):208-19. Chaconas SJ, Gonidis D. A cephalometric technique for prosthodontic diagnosis and treatment planning. The Journal of prosthetic dentistry. 1986 Nov 1;56(5):567-74. Friedman S. Diagnosis and treatment planning. Dental Clinics of North America. 1977 Apr 1;21(2):237-47.