Examination, Diagnosis

and Treatment Planning

RolaM.Shadid,BDS,MSc

ProceduresCarriedBeforeDenture
Treatment
General information
Chief complaint & patient
expectations
Medical history & current medication
Dental history
Visual & manual examination of the
mouth and head and neck
Radiographic examination

Continue
Referring for additional tests or
medical consultation
Referring for second opinion
Making alginate impressions &
preparing mounted study models
Discussion of diagnosis, treatment
planning & prognosis with patient
Finalizing the fees & obtaining a
signed consent

TheFirstMeeting
Most important
Prior to meeting, you should
review general information
Your confidence is as important
as the treatment itself
You should be a good listener
Your communication should be
in a simple & truthful manner

RecordingGeneralInformation
1. Name
2. Race
3. Occupation
4. Addressandtelephoneno.
5. Previousdentist

Age
With advancing age*:
1. Decrease capacity of tissue to tolerate
stress
2. Tissue takes longer time to heal
3. Many diseases are prevalent in older age
4. Women at postmenopause may have
psychological disturbances (exacting or
hysterical)
5. Men at this age may be concerned with
only comfort & function (indifferent)

PsychologicalEvaluation(House
ClassificationofDenturePatients)

Philosophical patient: well motivated,

Continue
Indifferent: not very interested
in treatment, blames the dentist
for any mishap, not follow
instructions, been coerced to
come by friend, relative.*

Continue
Hysterical: easily excited, highly
apprehensive, unrealistic expectations*
Skeptical: bad results from previous
treatment, doubtful, often have
severely resorbed ridges and poor
health, might have psychological
disturbances from recent personal
trajedy #

ChiefComplaint&Patient
Expectations
Patientsownwords
Whyheisseekingprosthodontic
treatment
Youshouldassessifpatientexpectations
arerealisticornot
Ifnotrealistic,youshouldeducateptand
scalethemdown

MedicalHistory*
Diabetes Mellitus
Cardiovascular diseases
Diseases of joints: osteoarthritis
Diseases of skin: pemphigus ?
Neurological disorders (Bells balsy
and Parkinson)
Sjogrens syndrome
Transmissible diseases

RadiationTherapyVs.Dentures

ConsequencesofRadiationtherapy
Preprostheticsurgery
Wearingofpreviousdenture*
DentureFabrication#

DentureFabricationinRadiation
TherapyPatient
Avoidimpressionmaterialthatdrytissue(impression
plaster)orheavilyflavoredmaterials(ZOE)
Considernonanatomicteeth
Teethsetinneutralzone
Slightreductioninverticaldimension
Softlinersarecontroversialduetoporosityand
possibilityofcandida

CurrentMedication
Insulin*
Anticoagulants
Antihypertensive:dryness&posturalhypotension
Corticosteroids:dryness,confusion&behavioral
changes
AntiparkinsonagentslikeNorflexandAkineton:
dryness,confusion&behavioralchanges

DentalHistory
History of tooth loss: cause,
time*
Edentulous period

BewareofPatientsWhoHaveA
BagofDentures*

ExtraoralExamination
General appearance (healthy,
signs of proper nourishment?)
Facial symmetry
Skin: color, deep wrinkles
Palpation of the head & neck
(lymph nodes & muscles)

ExtraoralExamination
Muscle tonus
Neuromuscular
coordination*
TMJ examination

ClassificationofFrontalFace
Forms(House,Frush&Fisher)*

ClassificationofLateralFace
Forms
Normal

Retrognathic

prognathic

Lips

Length*
Thickness
Mobility
Smile line

Lip(smile)line*

High smile line

Normal smile line

IntraoralExamination
Cheeks,tongue,floorofthe
mouth(FOM),maxillary
tuberosity,hardpalate,soft
palate,archrelationship,
residualridgeform,saliva,
undercuts

Cheeks
Draping of the cheeks over the buccal
flanges essential for peripheral seal
Opening of Stensons duct
Location for many lesions (lichen
planus, submucosal fibrosis,
leukoplakai, malignancies as
sqauamous cell carcinoma (SCC))

Leukoplakia

TheTongue
Favorable tongue is average sized,
moves freely, covered by healthy
mucosa
Normally, it should rest in a
relaxed position on lingual
flanges, this will retain denture &
contributes to denture stability by
controlling it during speech,
mastication & swallowing.

TongueSize

Normal
Large*

How to Manage Large

TonguePosition
Normal:normalsizeandfunction.
Lateralbordersrestatlevelof
mandibularocclusalplanewhile
dorsumisraisedaboveit.Apex
restsatorslightlybelowtheincisal
edgesofmandibularanteriors

TonguePosition
Retrudedtongueposition
deprivesptofbordersealof
lingualflangeinsublingual
crescentandalsomayproduce
dislodgingforcesondistalregions
oflingualflange

TongueMucosa
Thespecializedmucosacovering
thetongueissaidtobea
windowonsystemicdiseases.*

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

FlooroftheMouth
If FOM is near the level of the ridge crest,
retention & stability of denture is less.
Hyperactive FOM reduces retention &
stability
If great ridge resorption, FOM in
sublingual and mylohyoid regions spills on
the ridge
Patency of submandibular ducts *

MaxillaryTuberosity*
If enlarged:
the posterior
occlusal plane
may be placed
too low
no enough
space to set all
molars

MaxillaryTuberosity
Palpateforundercuts
ifextreme,denture
mightnotseat

TheHardPalate
ClassI:Ushaped,mostfavorablefor
retention&stability
ClassII:Vshaped:Notveryfavorable*
ClassIII:Flatorshallowvault:Notvery
favorable,accompaniedbyresorbed
ridges,poorresistancetolateralforces

Vshapedhardpalate

Tori*
Palataltorus

Mandibulartori

BonyProminences

Midpalatalraphe
Sharpridgecrest
Sharpmylohyoidridge
Prominentgenialtubercles
Bonyfragments&fracturedrootpieces
Tori

TheSoftPalate(PalatalThroatForm)
Housesclassification*

ClassI:thesoftpalateis
almosthorizontalcurving
gentlydownwards
ClassII:thesoftpalate
turnsdownwardatabout
45anglefromthehard
palte
ClassIII:thepalateturns
downwardsharplyatabout
70angletothehardpalate.

PalatalThroatForm
Maxilla
I
III

II

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

Undercuts
Unilateralorbilateral;labialorlingual;
mild,moderateorsevere
Commonlocations:
a) Labialportionofmaxillaryanteriorridge
b) Buccaltomaxillarytuberosity
c) Retromylohyoidareaofresidualridge
d) Labialorlingualslopesofmandibularanteriorridge

UndercutsManagement
1. Isolatedanteriorundercutnot
presentanyproblem

2. Unilateralposteriorundercutmay

notpresentmuchofaproblemaspath
ofinsertionisvaried
3. Bilateralundercutsurgicalremovalof
themoresevereoneisindicated

ResidualAlveolarRidge
Archform(Housesclassification)
ClassI:square
ClassII:tapered(Vshaped),
associatedwithhigharched
palate,lessretention&
stability
ClassIII:ovoid(lesscommon)

ResidualAlveolarRidge(CrossSectional
Contour)*
a. Ushaped
b. Vshaped
c. Knifeedged
d. Flat
e. Inverted
f. Undercut

SoftTissueSupportoftheRidge
Firm&resilient
Flappyandhypermobile:poorsupport
becausedenturebaseshiftsduring
masticatoryfunction
Managementofflappyridgeranges
frommodifiedimpressiontechniquesto
surgery

AnteriorArchRelationships*

IntraoralExamination
Posteriorarch
relationships
Interridgespace
Residualridgesize

Saliva*
Consistency:

Thinserous:providesaninsufficientfilmfordenture
retention.
Thickmucus:thickropysalivatendstodisplacedenture.
Mixed

Amount:

Normal:idealfordentureretention
Excessive:makedentureconst.messy
Reduced:reducedretentionandincreasedsoreness;
salivarysubstitutesmaybeprescribed

DrugsCausingXerostomia*

Diuretics
Antihistamines
Atropine
Anticholinergic
Antihypertensive
Antiparkinson(Norflex)
Corticosteroids

ExaminationofanOldDentureWearer
o Esthetics,lipfullness,symmetry,amountof
displayduringsmiling,phonetics,teeth
position,size,excessivewear
o Fracture,cracks,porosity,denturehygiene
o Occlusalverticaldimension(dueto
excessiveocclusalwear,OVDmayhave
reduced)

Reducedverticaldimension

ExaminationofanOldDentureWearer
Epulisfissuratum

Angular cheilitis
Papillary hyperplasia
Flappy hyperplastic ridge*
Combination syndrome

EpulisFissuratum

InflammatoryPapillary
Hyperplasia

Angular Cheilitis
(Perleche)

Combination(Kellys)Syndrome*

RadiographicExamination
Aroutineradiographicexam.
mustbeorderedtoruleoutany
bonyconditionsthatcouldaffect
thetreatment
Panomaricradiographisusually
orderedfordenturecases

RadiographicExamination
Fractured roots or roots lying close to the
surface should be removed if pt is fit for
surgery; deep seated retained teeth or root
fragments may be left if they are
asymptomatic
Supplemental radiographs may be
prescribed if required such as periapical,
occlusal, and lateral cephalometric

PanoramicRadiograph

AdditionalTests&Medical
Consultation

Routinebloodtest,blood&urinesugarlevels
Medicalconsultation
Dentalconsultation

Diagnosis
Aspecificevaluationofexistingconditions
Involvesthoroughexaminationofall
factorswhichareboundtoaffectthe
successoftreatment
Thisincludesbothsystemic&localfactors
&thementalconditionofthepatient

TreatmentPlan
Thesequenceofprocedures
plannedforthetreatmentofa
patientfollowingdiagnosis
Explainedtothepatientina
simpleandstraightforward
mannerincludingallofthefactors
thatmightcomplicatethe
treatment

AlternateTreatmentPlan
Maybelessthanidealbutisoften
necessaryforvariousreasons

RefusalofTreatment
Thepatientsdemandmaybe
unreasonableoragainst
professionaljudgmentorethics;
somayrefusetreatmentorrefer
him(bagofdentures)

Prognosis
Aforecasttotheprobableresultofa
diseaseoracourseoftherapy
Afterconsideringallthefactors,you
shouldbeabletopredictthedegree
ofsuccessthatcanbeexpected&
thepatientshouldknowofwhatcan
andcannotbeachieved.

Fees&SignedConsent
Whenpatientagreedon
treatmentincludingfees,hemust
signawrittenconsenttoprevent
latermisunderstanding

Prescription,NutritionalSupplements,
&TissueConditioning
Assessifnutritionaldeficiency
Recommendfingermassageoforaltissues
Ifolddenturewearer,tissueconditionerplaced
toconditionabusedsofttissue
Instructpatienttodiscontinuewearingdenture
48hrspriormakingfinalimpression

A good clinician is one who is able

References
I. CompleteDentureProsthodontics,1st
Edition,2006byJohnJoyManappallil,
Chapter2.
II.Zarb.ProsthodonticTreatmentfor
EdentulousPatients,12thedition.Chapter7.