Diagnosis and treatment plane for full denture patient

1. Diagnosis and Treatment
Planning for full denture
DR MOHAMED A. IBRAHIM

2.  Successful complete denture therapy begins with a thorough
assessment of the patient’s physical and psychological condition
and determining a treatment that will deliver a functional complete
denture that will satisfy the expectations of the patient.
 Diagnosis is the examination of the physical state, evaluation of the
mental or psychological makeup, and understanding the needs of
each patient to ensure a predictable result.
 Treatment planning means developing a course of action that
encompasses the ramifications and squealed of treatment to serve
the patient’s needs.

3. GENERAL INTRODUCTION TO THE
PATIENT
 The first appointment is perhaps the most important time the dentist will spend with
a complete denture patient.
 In this appointment you can develop the mutual understanding and trust between
you and your patient
 Getting the general information about the personal, social information.
 The patient might have an unique question and they might get an old denture, they
want to look like someone in picture or asking about the feel The dentist should
avoid immediate answer.
 It is important to know if the patient has recently become edentulous, has been
edentulous for a long time, or has teeth and is contemplating complete extraction
either on his own or at the suggestion of another dentist

4.  The intraoral examination will determine if any further surgical correction
will be necessary
 The dentist should inform the patient with the treatment plan so the
patient will not misunderstand any refitting at a later date
 The long time denture wearer knows what the problem might associate
with the denture the patient must be informed of any possible changes or
resorption of the residual ridges that may have occurred.
 Much information can be gained by the dentist before he ever looks into
the patient’s mouth. Time spent during the first appointment can lay the
groundwork of cooperation so necessary for a successful result.

5.  OBSERVATION OF THE PATIENT
 The observation and evaluation of the patient begins when he
or she enters the dental office
 Motor Skills
 Facial Features
 Attitude and Adaptive Response

6. Motor skills
 The observation of the patient’s physical abilities and motor skills is an
important part of the overall evaluation.
 Is the patient able to get out of the waiting room chair, or is there some difficulty
or assistance required?
 This may be the first indication of a bone, joint, or muscle problem.
 Upon rising is the patient steady or was time required to gain equilibrium?
 Dizziness may be a side effect of medication or a cerebrovascular accident.
 Vertigo
 may also be due to orthostatic hypotension or be a signal of low blood pressure,
overcorrected high blood pressure, or cerebral ischemia

7.  Is the patient out of breath after arriving at the
operatory?
 The dentist should suspect asthma, congestive heart problems,
or heavy smoking.
 After being seated in the dental chair, the patient’s
ankles should be observed for swelling?
 Ankle edema is often associated with congestive heart failure,
poor circulation, or kidney disease.

8. Facial Features
 The dentist should observe the face of the patient. Note the
1. length,
2. fullness,
3. and apparent support of the lips.
4. Observe the philtrum,
5. nasolabial fold,
6. and labiomental groove for hollowness or puffiness.

9.  The texture of the skin will help establish the tone of the
anterior setup.
 Rough textured skin deserves a more rugged tooth
arrangement than smooth light-colored skin.
 The size of the oral opening, activity of the lips, and width of
the vermilion border are directly related to the degree of
tooth display

10. Attitude and Adaptive Response
 Studies have shown that a patient’s attitude and level of
expectation can profoundly influence the treatment outcome.
Complete denture failures can result from a
misunderstanding between the dentist and the patient.

11. Factors which produce an adaptive response to
complete dentures
1. The acceptance of the dentist and confidence in the dentist,
which could also be described as trust.
2. Previous favorable experience with authority figures.
3. The capacity to cope favorably with change. A positive
attitude increases this capacity.
4. Favorable physical conditions: youth and good general health
were factors which produce an adaptive response to
complete dentures.
5. Realistic expectation of the patient.
6. Good learning capacity.

12. Factors which produce a maladaptive response
to complete dentures
1. Lack of trust in the dentist.
2. Poor communication between the dentist and his patient.
3. Unrealistic expectations of the denture patient.
4. Resistance to change arising from severe anxiety or
depression or hopelessness.
5. Low tolerance for anxiety or pain.
6. A high level of anxiety on the part of the patient.

13. HEALTH HISTORY
 The average complete denture patient has a more
complex health history than ever before

14. The complete health history should
include
(1) the name of the patient’s physician, including the date and
reason for the last appointment,
(2) a record of the status of all major body systems,
(3) a record of all medications within the last six months,
(4) a record of any hospitalization,
(5) a record of any complication that was a result of previous
dental treatment,
(6) a record of the patient’s opinion of his or her general health,
and

15. CLINICAL EXAMINATION
 The clinical examination should proceed in a logical
and orderly sequence so that nothing is overlooked.

16. Extraoral Examination
 The patient’s head and neck region should first be
examined in general for the presence of any
pathologic conditions relating to a non dental or
systemic condition.
 The face and neck are palpated for any masses or
enlarged nodes

17. Facial examination
 Facial form and profile can be useful aids in tooth selection
 Although direct correlation has never been shown, there
should be harmony between facial size, form, and shape, and
the artificial teeth selected
 A patient’s profile appears not only as fiat or curved so teeth
can be set accordingly, but can be an early indicator of the
patient’s jaw classification.
 A patient’s occluding vertical face height can easily be seen in
profile and a judgment made whether the occlusal vertical
dimension of an existing denture is open, closed, or within

19. Lip examination
 The lips should be examined for cracking, Assuring at the
corners, and ulceration.
 from organisms such as Candida albicans,
 The lips are then examined for support, fullness, thickness,
and length. The lack of proper lip support can lead to a
collapsed appearance and wrinkling.

20. Temporomandibular joint examination
 The temporomandibular joint should be evaluated for pain
by palpation or mandibular movement. The muscles of
mastication should also be palpated to attempt to elicit a
pain response

21. Intraoral Examination
 An overview of the oral mucosa should be obtained before a
specific examination of the denture-bearing area and
contiguous structures is conducted.
 The dentist should be looking for abnormalities or
pathological lesions. The inside surface of the cheeks and
lips, residual ridge, floor of the mouth, hard and soft palate,
and the tongue are closely examined.

22. Color of the mucosa
 The color of the mucosa may range from a healthy pink to an
angry red.
 The redness is indicative of inflammation and can be of varying
degrees.
 It can be related to an ill-fitting denture, underlying infection, a
systemic disease such as diabetes, or chronic smoking.
 It is important to determine the cause and remove the irritant
because successful impression making is not possible until the
inflammation is under control.

23. Saliva
 The amount and consistency of saliva will affect the denture
construction process and the quality of the final product
itself.
 If the mouth is dry, retention of the denture will be affected.
In addition, a dry mouth has an increased potential for
soreness.

24. Arch size
 The size of the maxilla and mandible ultimately will
determine the amount of basal seat available for the denture
foundation.

25. Arch form
 The arch may be square, .ovoid, or tap e red and opposing
arches may not necessarily have the same form.
 The form of the ridge will influence the support of the
denture and perhaps the tooth selection.

26. Ridge contour
 Ridge contour can vary widely. The ideal is a high ridge with
a flat crest and parallel or nearly parallel sides.
 This type of ridge will give a maximum amount of support
and stability
 In time, as the ridge resorbs, it may become flatter , V-
shaped, or knife-edged. Knife-edged ridges or ridges with
multiple bony spicules offer the poorest prognosis because
they are incapable of withstanding much occlusal force and
can easily become sore.

27. Ridge relation
 The maxillary and mandibular ridges should be observed at the
appropriate occlusal vertical dimension. The amount of interridge
distance should be noted first
 An excessive amount of space due to resorption will result in poor
stability and retention because of the increased leverage
 A small amount of inter ridge distance will lead to difficulty in
setting teeth and maintaining a proper freeway space

28. Hard palate
 The hard palate should be examined and its shape noted. The
T-shaped palatal vault is most favorable for retention and
lateral stability.
 A V-shaped vault is less favorable for retention. The slightest
movement of the denture base will cause the seal to be
broken with a resultant loss of retention

29. Soft palate
 There are three classifications of soft palate configurations
 A class I soft palate is rather horizontal and demonstrates little
muscular movement
 A class II soft palate turns downward at about a 45° angle to the hard
palate and the amount of potential tissue coverage for the palatal seal
is less than for a class I.
 A class III soft palate turns downward sharply at about a 70° angle just
posteriorly to the hard palate.

30. Bony undercuts
 Bony undercuts are frequently found on both the maxillary
and mandibular ridges.
 On the maxilla, the undercuts are usually present on the
anterior ridge and lateral to the tuberosities
 These usually pose no real problem with denture insertion,
and the rule should always be selective relief of the denture
rather than surgical reduction

31. Tori
 A torus palatinus and lingual tori are occasionally present.
 On the maxilla, the torus can range from a small prominence
on the midline to one that covers the entire hard palate.
 Generally surgical removal is contraindicated unless the torus
is so large as to preclude construction of the denture

32. Tongue
 The tongue size should be noted. If the patient has been
without teeth or prostheses for a long time or has worn a
maxillary denture against the lower anterior teeth only, the
tongue can become enlarged and powerful.

33. RADIOGRAPHIC EXAMINATION
 Radiographic examination is an essential part of diagnosis and
treatment planning for all dental patients.
 Screen jaws for defects in structure and reactive new bone
formation, bone enlargement, and displacement of jaw parts. The
screening should also include any unerupted teeth or retained root
fragments, foreign bodies, radiolucencies, radiopacities, rarefaction
or sclerosis, expansion or bulging, and any welldefined or ill-
defined lesions.
 The TMJ can be screened, although positive findings should
correlate with the history and physical examination.

34.  Describe the appearance of the lesion as well as any bone
changes adjoining the lesion
 Correlate the radiographic findings with the clinical, historical,
and laboratory findings.
 Perform a differential diagnosis which includes all the
diseases that could explain the findings.
 Estimate the growth of the lesion by the appearance of jaw
structures bordering the lesion

35. THE TREATMENT PLAN
 The treatment plan for an edentulous patient is simple; either a
complete denture is constructed or it is not.
 Assembling all the diagnostic criteria takes time, but it is time well
spent to assure a successful result. The treatment and expected
level of achievement is carefully explained to the patient. Fees,
manner of payment, duration of treatment, any necessary tissue
preparation and conditioning, and contemplated surgery are
discussed.
 The trained professional is acutely aware of these ramifications and
educates the patient to this end.