History & Examination

Prof. Dr. Abdel-Basit Mahmoud 8

CHAPTER I

History Taking, Examination, Prognosis and Treatment
Planning in Complete Denture Construction

Examination, diagnosis and treatment planning in complete denture
construction are one of the most important phases. The different possibilities and
limitations of the complete denture service may be determined in this phase.
Diagnosis is determination of the nature, location, and causes of diseases
Diagnosis includes:
I-Patients History
II-Clinical Examination
III-Investigations:
Radiographic Evaluations
Pre-extraction records
I- History Taking
1. The patient's age and sex:
In general, increasing age decreases the readiness to form new habits
and also muscular efficiency is often impaired. Young people adapt
themselves more readily than do the aged.
Young people are usually more demanding in esthetics.
Age has a definite relation to the selection of teeth, not only in their size,
shape and color, but also in various degrees of abrasion, attrition and
erosion.
Patients sex

Women are generally better patients than men. They seem to show more
pride with artificial dentures.
Factors such as menopause are an influencing factor in the overall
success of dentures. Menopause is often reflected in symptoms of a
burning mouth, which most patients will attribute to the prosthetic
appliance rather than to systemic disturbances.




History & Examination
Prof. Dr. Abdel-Basit Mahmoud 9
2. The patient's occupation:
With most professional men whose occupation entails intimate contact with
their fellows, appearance and retention are more important than efficiency.

Public speakers and singers require not only perfect retention but also particular
attention to palatal shape and thickness because of the importance of these in
phonation.

3. General health (medical history):
o In diabetic patient, bone loss is more rapid, tissues are slower to heal,
and are also much more sensitive to trauma.
In planning a denture for a diabetic, we should consider
a reduced occlusal table,
An increased amount of free way space together with frequent
scheduled adjustments and recalls.
The diabetic shows a tendency toward edema during periods of
imbalance. This must be considered in scheduling impression
procedures.

o The anemia results in poor nervous disorders reflecting lack of
coordination and extreme irritability.
o Parkinson's disease affects the ability of the patient to wear dentures,
and increase the hazards of denture procedures.
o Other common diseases in must be considered. These include
tempromandibular joint disturbances, facial neuralgias, various types of
neurosis, multiple sclerosis.

Dental history:
1. Information regarding the loss of the natural teeth:
o A history of difficult extractions should be followed by a radiographic
examination of the jaws to verify the absence of retained roots (Fig. 1: 1).

o The general order in which the teeth were lost. For example if all the
posterior teeth were extracted some years before the anterior ones and no
partial dentures were worn in the meantime, then a habit of eating with
the front teeth will have been formed which, if persistent, will have a
pronounced unstabilizing effect on complete dentures.

History & Examination
Prof. Dr. Abdel-Basit Mahmoud 10
o A similar condition will exist in individuals who have been edentulous
for a considerable length of time and have not worn dentures,
o When there is a history of abnormal mandibular function or
movement, then difficulty can be anticipated when registering the
anteroposterior occlusal relationship.
2. Patient's attitude to dentures:
o If a partial denture was worn with comfort and efficiency, the same
will be expected of complete dentures. It should be explained to such
patients that, although partial denture experience is helpful in relation to
complete dentures, the latter require a considerably greater degree of
control because they are not, as were the partial dentures, retained or
supported by the natural teeth.
o If complete dentures are already being worn and they have been
comfortable and efficient, the same will be expected of the new dentures.
If the old complete dentures were troublesome, the attitude may be
expectant of better results with the new dentures or pessimism that
nothing better can be hoped for.
o If no previous denture exists, friends may colored the patient's mind
with their own attitudes. In such cases use of complete dentures depends
to large extent on the formation of new habits and a new pattern of
muscular movement. This demands time and some patience.
3. The existence of complete dentures:
o Questions are directed to information regarding
the length of the time dentures have been worn,
how many sets have been made since the teeth were extracted,
The success of the existing or old dentures and the patients'
attitudes to their appearance.
o If the existing dentures have been satisfactory, any gross alteration of the
new dentures will almost certainly mean their failure. A person who has
worn comfortable dentures has developed a control of them which is
entirely reflex. If alterations in the dentures e.g. altering the occlusal
plane,this must be explained to the patient and must be told that
conscious control of the new dentures will be required until new reflex
habits are formed.

History & Examination
Prof. Dr. Abdel-Basit Mahmoud 11
II- Visual Examination
The visual examination includes both a facial examination and intra-oral visual
examination.

I. Facial Examination:
An edentulous patient should be examined facially in front and profile views. It
may be noted that:
1. The fullness and normal contour of the upper lip is lost due to the lack of
support by the loss of teeth.

2. The normal lip line and natural vermilion border of the upper lip is changed
due to this falling in and the philtrum looks unsupported.

3. The nasal folds are deepened, the mental tip is exaggerated and facial wrinkles
may result as the person has been without teeth for sometime (Fig. 1: 2).








Fig. 1; 2: With increasing age the natural creases of the face deepen,
especially the nasiolabial and labiomental grooves.

II. Intra-oral Examination:
A- Color of the mucous membrane:
Any variation from the normal must be investigated,
whitish patches or spots of hyperkeratinization are not uncommon,
The most usual variation found is an increased redness due to
inflammation caused by irritation, which may be due to mechanical,
chemical or bacteriological causes.

Common causes:
Overextension of the periphery of the denture

Dirty, ill fitting dentures

History & Examination
Prof. Dr. Abdel-Basit Mahmoud 12
Continuous wearing of the denture

Faulty articulation of teeth (traumatic occlusion)

Traumatic injury

Small spicules of alveolar bone

Allergy
some general systemic disturbances

B- Size and shape of the arches and alveolar ridges:
They play a role in the retention and stability of the denture.

C- Shape of the hard palate:
The relationship between the shape of the hard plate and the retention of
complete dentures has previously been described.

D- Depth of the sulci:
Whenever a very shallow sulcus is encountered a special impression
technique will be required in order to obtain an adequate peripheral seal.

E- Interference factors:
The size of the tongue, tightness of the lips and any abnormal muscular
or frenal attachments must be noted as they will influence the design of
the dentures and the type and position of the artificial teeth used.
The size of the tongue and constricted mouth opening may pose a
problem during impression making.

F- Un-extracted roots:
These may be flush with, or protruding above the surrounding mucous
membrane with or without an obvious area of inflammation round them.


G- Sinuses:
An infected area in the bone, usually communicates with the surface
through a channel known as a sinus.
H- Unilateral swellings:
Any abnormal swellings in the mouth must be investigated and
diagnosed.

History & Examination
Prof. Dr. Abdel-Basit Mahmoud 13
III- Digital Examination
Any area, which is painful to the pressure of a soft finger, is unlikely to tolerate
the pressure of a hard denture.

1- Firmness of the ridge:
Placing a finger on each side of the ridge and applying alternate lateral
pressure most conveniently tests this. Flabby fibrous ridge may be
encountered in all parts both of upper and lower jaws.
2- Regularities of the alveolar ridge:
Alveolar absorption is never uniform and hard nodules, sharp edges and
irregularities are frequently felt and pain on pressure over these areas is
common.

3- Variations of mucous membrane:
The ideal mucosa on which to seat complete dentures should be:
Firmly bound down to the sub-adjacent bone by union with the periosteum,
which will thus prevent the denture and mucosa moving together in relation to
the supporting bone.

Slightly compressible:
This will allow the denture to bed comfortably into place because the
mucosa will adjust itself slightly to the fitting surface of the denture.
This will increase the retention by adhesion and cohesion because the
film of saliva between the denture and the mucous membrane will be
very thin.
It will also allow maximum retention from atmospheric pressure
because the denture bedding slightly into the tissue will prevent air leaks.
In addition such mucosa will act as a cushion to the normal stresses of
mastication and prevent the development of sore spots and painful areas
from pressure on the underlying bone.

Even thickness:
Thin mucosa covering a well-defined torus palatinus will result in a
denture, which rocks during function causing pain to the patient and
frequently fracture of the denture due to the repeated flexure the base is
required to undergo during mastication.

History & Examination
Prof. Dr. Abdel-Basit Mahmoud 14
4- Maxillary tuberosities:
Maxillary tuberosities may be found bulbous and to have a definite
undercut area above them, but only by palpation it can be determined
whether the bulbous portion is composed of hard or soft tissues.

5- Mylohyoid ridges:
Some of these ridges are felt to be pronounced and sharp and others are felt
ill-defined and rounded.

6- Lingual pouch:
The extent of the pouch with the tongue at rest and with the tongue
protruded sufficiently to lick the lips and also during the act of
swallowing should be noted.
This is done by gently inserting the index finger into the pouch and
asking the patient to perform the above actions.

IV- X-ray Examination
Ideally a panoramic or cephalometric x-ray examination should be made of
every edentulous patient prior to starting denture construction. x-ray photographs
should still be taken to confirm or assist in diagnosis in the following cases:
1- Buried roots.
2- Sinuses.
3- Unilateral swellings.
4- Rough alveolar ridges.
5- Areas painful to pressure.
6- Impacted teeth.
7- Cysts.
V-Pre-extraction records
Using pre-extraction casts
Using profile template.
Using Willis gauge.
Using Sorenson scale
Using tattoos.
Profile radiographs ( the image must have 1:1ratio)
Photographs.
Measuring the distance between the upper and lower labial frenum when the
teeth are in centric occlusion.

History & Examination
Prof. Dr. Abdel-Basit Mahmoud 9
Mental Classification

During the period of examination and diagnosis, the operator must encourage
the patient to talk about his case and ask questions. Generally, it is important to
ascertain what the patient says and how he says it.

House's Classification for Mental Attitudes
Philosophical:
This is an optimistic, cheerful, cooperative and in reasonably good
health. He has a positive state of mind with confidence in himself and the
operator's ability.
He will accept advice, persevere, and cooperate in following instructions,
and not make unfair criticisms.
We can expect him to have a high degree of success with his dentures.

Exacting:
This is a meticulous, demanding patient who is somewhat
unreasonable.
If he is wearing previous dentures, they are usually unsatisfactory.
He may exhibit lack of confidence and discouragement.
With this type of patient we must encourage, but never guarantee or
promise anything. This is a very difficult patient to satisfy.
We can expect the patient to criticize what is being done and is very
careful about knowing details.

Hysterical or Antagonist:
This is a nervous, pessimistic patient who is usually hypercritical and is
usually in a negative frame of mind.
He is usually confident that he cannot wear dentures and dreads dental
service.
Generally, the patient has a neurotic frame of mind, which can be due to
worry, poor health or long neglected pathology.
Prior to the undertaking of dental procedures, you should spend a great
deal of time explaining what can and what cannot be done. When you
have assured yourself that the patient will exhibit a marked degree of
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Prof. Dr. Abdel-Basit Mahmoud 10
cooperativeness, only then under specified conditions, should we accept a
case of this nature.

Indifferent or Passive:
This patient is passive and has no concern for his teeth or health and is
unconcerned about personal appearance and feels no need of having
teeth.
He is not cooperative or interested and usually pushed to treatment by a
friend or family member.
He is not persevering and will not inconvenience himself to become
accustomed to wearing dentures.
The dentist must attempt to overcome this indifference without promises.

V- Development of the Treatment Plan
All information collected should be thoroughly studied and analyzed to develop
the optimum treatment plan. The methods, materials, procedures, time and
sequence of treatment and the cost should be determined and explained to the
patient.

Diagnosis is usually straightforward but treatment plans can be complex.
Include in the treatment plan any immediate temporary treatment (e.g. application
of temporary soft linings, treatment of soft tissue pathology etc.), and provision of
temporary appliances (e.g. transitional or immediate dentures, occlusal splints).
Indicate clearly if there is need for special techniques (e.g. cast metal
strengtheners, duplication, or special occlusal schemes) or special forms of
denture base (e.g. Impact-resistant resin).











History & Examination
Prof. Dr. Abdel-Basit Mahmoud 11
A Guide to Complete Denture Construction

Upon completion of diagnosis and treatment planning services, the sequence of
procedures for a complete maxillary and mandibular denture is as follows:

Patient's visit I
The preliminary impressions are made.

Laboratory:
The study casts are fabricated.
Special (individual) trays are made.

Patient visit II
The final impressions are made.
Laboratory:
The final (master or working) casts are formed.
Temporary (Trial) denture bases with wax occlusion rims are made on the final casts.

Patient visit III
1. A posterior palatal seal is developed.
2. The tentative plane of occlusion is established.
3. Maxillo-mandibular records are made,
a) Vertical dimension.
b) Face bow.
c) Centric relation.
4. Anterior teeth are selected.

Laboratory:
The casts with record block are mounted on articulator.
Anterior & posterior teeth are set-up.

Patient visit IV
1. Trial dentures are tried-in.
2. Centric relation is verified.
3. Patient's approval.

Laboratory:
Gingival contours are waxed-up.
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Remount matrix is made.
Dentures are invested, processed and polished.
Dentures are prepared for delivery.
1) Maxillary and mandibular remount casts are fabricated.
2) Maxillary complete denture and remount casts are mounted utilizing remount matrix.

Patient visit V
1. Dentures are inserted, occlusion is adjusted and patient is instructed on care of
dentures.
2. At least three post-insertion observations and adjustments are routinely scheduled.