..DIAGNOSIS AND TREATMENT PLANNING FOR COMPLETE DENTURE PROSTHESIS Diagnosis is the determination of the nature of disease process.

Treatment is any measure designed to remedy a disease. Competent treatment depends upon the careful evaluation of all available information, a definite diagnosis, and a realistic treatment plan that offers a favorable prognosis. The treatment plan follows the diagnosis, and no treatment other than emergency care should be performed without a comprehensive treatment plan. Diagnosis Diagnosis is the basis for a rational treatment plan and competent dental care is only possible with effective planning. Diagnosis involves the collection of facts obtained from a comprehensive patient history (medical and dental), a patient interview, through clinical examination, critical evaluation of mounted diagnostic casts and radiographic interpretation. Initial Meeting The examination begins with the first view of the patients overall physical makeup, gait, and general alertness or sluggishness. Which may be observed as the patient enters the office. Upon arrival the patient should be given the opportunity to relax and should be comfortably seated in a consultation room if one is available. A medical and dental history is taken with all pertinent information recorded. Listen attentively while the patient relates his hopes, expectations requests, and previous encounters with dentists and dentures. A meeting of the minds should always precede the examination of the mouth. Age, general health, diet, and the use of any medication, pills, drugs, tranquilizers, or vitamins are noted. Check specifically for any history of rheumatic fever, diabetes, epilepsy, hypertension, coronary disease, or hospitalization. Drugs such as cortisone, thyroid, or estrogen may perpetuate a state of chronic tissue soreness. It is common for older patients to be on high carbohydrate diets, they should be on high protein diets, rich in vitamins and minerals. The examination is then continued in the dental chair. A common error in a busy general practice is to begin making the impression at the initial visit after a flimsy and casual examination, and upon the patients acceptance of the fee quoted for the services. A course of this nature is unwise and may be the cause of subsequent failure, friction misunderstanding and loss of patients. DIAGNOSIS AND TREATMENT PLANNING FOR COMPLETE DENTURE THERAPY Diagnosis consists of planned observations to determine and evaluate the existing conditions, which lead to decision making based on conditions observed.

l. PERSONAL DATA NAME Significance: 1. For identification and maintaining records 2. To develop rapport with the patient 3. Give additional information about the patient like status, religion etc AGE Significance: 1. Indication of patients ability to wear to use dentures 2. A young person will be more adaptable to a new situation such as denture than an older person 3. The facility for learning and coordination appear to diminish with. 4. The oral and facial tissues become progressively less elastic resilient as a person grows older 5. Older people become more injured by the necessary manipulation for making impression and other records 6. Age may be associated with hearing loss which makes communication difficult 7. There is a characteristic loss tissue tone with age which makes the problems of tooth arrangement and positioning more difficult 8. Associated with excessive bone resorption which makes the dentures unstable SEX Significance: 1. Certain diseases are more predominant in males like haemophilia, etc 2. Generally appearance is a higher priority for women than for men RACE Significance: 1. Certain sexually transmitted diseases like AIDS are more common in negroid races 2. A critical factor in the characterization of dentures i.e, choice of denture base shade, teeth selection etc OCCUPATION Significance: 1. It determines the economic background and social status 2. Determines the value he or she places on oral health and esthetics 3. Has an effect on mental attitude of the patient 4. Aids in formulating treatment plan 5. Some professionals are prosthodontic risks MARITAL STATUS Significance: 1. Has an effect on the psychological make up of the patient

ADDRESS Significance: 1. Certain diseases may be endemic in certain areas 2. Aids in treatment planning and deciding appointments 3. Helpful in case of emergency recall or future references MENTAL ATTITUDE / PERSONALITY Classify patients according to House 1) Philosophic: These patients are easy going, congenial, mentally well adjusted, cooperative and confident in the dentist. Prognosis is excellent. 2) Exacting : These patients are precise above average in intelligence, immaculate in dress and appearance often dissatisfied with past treatment, doubt the ability of the practitioner to satisfy him or her and often want written guarantees or remakes at no additional charge 3) Hysterical : These patients submit to treatment as a last resort and have a negative attitude. They are often in poor health and are poorly adjusted Emotionally unstable, excitable, excessively apprehensive and hypertensive. Might have had bad result with previous treatment. Prognosis is poor. (Additional professional help is required prior to and during treatment) 4) Indifferent : Have little concern for their teeth or oral health. Not concerned with appearance, often go without dentures for years, do not preserve, and do not adopt well. Such patients have no desire to wear dentures and do not value the efforts or skills of the dentist. II. MEDICAL HISTORY No prosthodontic procedures should be planned until the systematic status of the patient is evaluated. Questions should be dignified and professional in character and tone. Significance: 1. Certain systemic diseases have a direct relation to denture success even though no local manifestations are apparent 2. Helps us to take precautions prior to and during treatment 3. Helps us to avoid post treatment complications 4. Aids in altering prosthodontic procedures and treatment plan 5. Determines the dental prognosis SYSTEMIC STATUS Did the patient ever had any of the following 1) Diabetes 2) Tuberculosis 3) Anemia Significance:

1) Require extra instruction in oral hygiene eating habits and tissue rest 2) Frequent recall appointments should be arranged to keep the denture bases adopted and occlusion corrected 4) Osteoarthritis (disease of joints) 1) A problem in complete denture construction for mandibular movements are painful 2) In some cases (extreme) surgery may be indicated 3) .Impression tray are often necessary..limited access.. 4) Jaw relation records are difficult to record and repeat 5) Occlusal correction must be made often because of subsequent changes in the joints 5) Heart diseases Significance: 1. Denture procedures of any nature may be contraindicated 2. Short appointments with premedication may be required 6) Skin diseases: eg: pemphigus Significance: 1. The constant use of denture is contraindicated 2. Their use is primarily for mental comfort 7) Neurological disorder: eg: Bells palsy, parkinsonism epilepsy, Fainting spells Significance: 1. Patient is made to understand their problem 2. Denture retention, maxillomandibular relation records and supporting the musculature are some of the added denture problems 3. Determines the mental attitude of the patient and there by prognosis 8) X-ray treatment / radiation treatment Significance: 1. To know any underlying malignancy 9) Jaundice 10) Syphilis 11) Rheumatic fever Significance: 1. Precaution and premedication is required 12) Hypertension Significance: 1. Appointments should be short and painless procedures employed 2. Certain precautions to be taken Has he been troubled with 1) High blood pressure ( hypertension)

2) Low blood pressure (hypotension) 3) Shortness of breath 4) Swollen Ankle 5) Pain over the heart 6) Pain under breast bone 7) Persistent cough 8) Skin condition or Rash 9) Burning tongue 10) Prolonged Bleeding 11) Reaction to medicine or Allergies anaesthesia (No Vacain) 12) Sweating at night 13) Loss of voice 14) Sinus involvement 15) Asthma or allergies 16) Excessive thirst 17) Any bladder or kidney Renal disorder involvement - Has he ever had any childhood or other disease of lasting effect? Significance: Could be congenital disease - Has he ever had any serious digestive disorders? - Has he ever been treated for any mental or nervous condition? Significance: To know the psychological status of the patient - Does he tire easily? Significance: Could be with a heart disease - Does he has trouble sleeping flat, or must be prop up with several pillows Significance: Could be associated with heart disease -How long since his/ her physician gave, a complete physical check up Significance: To know the present general health of the patient - Physicians name Address Phone Significance: To contact in case of emergency or in case of expert opinion - Is he taking any medicine now? If so, can he tell? Significance: 1. To know exactly, what the patient in suffering from i.e. Indication of systemic problem 2. To take certain precautions, regarding that 3. To know the side effect of the drugs and the success of treatment - If under the case of a physician for pregnancy, what is the expected date of delivery? Significance:

1. Any medication in first trimester is constaindicated 2. Any dental procedure in III trimester is not carried on - Has he ever had pencillin? If so, did he had any bad effect Significance: To know the drug allergy especially pencillin - Pathology A through head and neck examination should be performed. All pathology processes should be recorded. Appropriate diagnostic tests and surgical procedures should be performed or arranged. Significance: 1. They produce a state of mental and physical infirmity 2. Patient not subjected to extensive examination and diagnosis procedures 3. In certain cases, investigation of systemic status should be instituted prior to detailed dental diagnostic procedures III. DENTURE HISTORY Chief complaint: To determine the reason the patient is seeking prosthodontic treatment (i.e.) to receive the complaint about the area greatest concern to the patient. Significance: 1. If this is not done, chief complaint may be overlooked during therapy 2. The response allows the practitioner to assess weather the patient expectations are realistic or attainable 3. The response provides information regarding the patients psychological classification 4. To know which procedure or parts of procedure is most critical and 5. To decide how to overcome the difficulty if possible 6. To decide how to adjust the time schedule and fee properly EXPECTATION The reason the patient seeks prosthodontic treatment YEARS EDENTUTLOUS, MAX\MAND AND REASONS Significance: 1. Provides information about bone resorption patterns and progression as well as timing of tooth loss 2. Reasons to know whether due to periodontal disease gross caries trauma etc

PREVIOUS DENTURES MAX / MAND Regarding the number and type of previous dentures and the reasons for replacement. Significance: 1. Patients displaying consistent patterns of remarks should be educated regarding the realities of denture service 2. A patient with a history of several denture over a short period of time is a poor prosthodontic risk EXISTING OR CURRENT DENTURES Patient questioned about the length of time he or she has worn the current dentures. Response compared with clinical observation. Significance: 1. Provides valuable information about denture experience, denture care, dental knowledge parafunctional habits etc Denture success Patient asked about the aesthetics and function of existing dentures. Significance: 1. It indicates patients ability to wear or adjust to complete dentures. Pre extraction records: Pre extraction photographs, radiographs, casts and facial photographs help in denture therapy. Significance: 1. Used to recreate anterior aesthetics and facial support 2. Aids in the evaluation of vertical dimension of occlusion IV) CLINICAL EVALUATION EXTRAORAL EXAMINATION 1) Facial form a) Frontal square / tapering / square tapering / avoid Significance: Aids in teeth selection (esp shape and size) b) Profile class (normal) / class 2 (retrognathic) / class 3 (prognathic) Significance: 1. Indication of relative size of the upper and lower jaws and vertical jaw relation 2. Aids in teeth arrangement (over jet and over relation) 2) Muscle Tone Determines the age and health of the patient -

Class -1: Patient exhibits normal tension, tone and placement of the muscles of mastigation and facial expression. No degenerative changes are apparent. Significance 1. Majority of edentulous patients would have experienced some degree of degeneration 2. Immediate denture patients have normal musculature 3. Has good prognosis Class- 2: Patient displays approximately normal function but slightly impaired muscle tone Significance 1. Maximum Ms function cannot be used following the loss of all natural teeth Class -3: Patient exhibits greatly impaired muscle tone and function Significance 1. Poor prognosis 2. Usually coupled with poor health, inefficient denture, loss of vertical dimension, wrinkles, decreased biting force and drooping commisures 3) Muscle development Class-1 Heavy Class-2 Medium Class-3 Light Significance: Determines the adaptability and prognosis 4) Complexion: Hair, eye and skin color Significance 1. Provide useful guidelines for shade selection 2. Can also reveal underlying disease and pathology eg. Pale eyes Anemia Heavy wrinkles at commisures and nasolabial fold: a) Decreased vertical dimension of occlusion b) Poor support of facial muscles by denture 5) Lip a) Lip contour Support adequetly supported or unsupported Significance 1. Significant improvement can be expected if the tissue around the mouth has wrinkles and the rest of the face does bot 2. Wrinkles of long standing does not, disappear at once and so patients are warned about this

3. Needs extra time at the try in of wax dentures and aids in planning for it 4. Determine the amount of proclination of teeth b) Lip thickness Thin / thick Affected by . Tooth positions Significance 1. Variations in arch form and individual tooth arrangement are possible in case of thick lips before the changes are obvious in the lips c) Lip fullness Related to support from mucosa denture base and the teeth Significance 1. Determines the thickness of labial flange 2. Determines the tooth arrangement (labial / palatal) d) Lip mobility: Class I Normal Class II Reduced mobility Class III Paralysis Significance 1. Minimal lip mobility shows very little of anterior teeth 2. In case of paralysis of half the lip, unilateral mouth droop and facial asymmetry results of which patient must be counseled regarding treatment limitation e) Lip length : Long, normal or medium and short Significance 1. Important role in esthetics 2. Long lip reveals little of anterior teeth and a short lip allows the display of denture base 3. Special attention and care given to the color and form of the denture base and teeth in case of short lip 6) Temporomandibular joint ( TMJ) .. clicking locking Note the smoothness of mandibular movements and deviation of mandible Significance 1. Severe joint pain can indicate a severe discrepancy in .. dimension of occlusion 2. It complicates registration of jaw relation records 3. It affects scheduling of treatment appointments 7) Neuromuscular evaluation Speech: Normal /affected _with existing dentures or natural teeth Significance

1. In case of patient with speech impediments / who cannot articulate optimally with existing denture require special attention during anterior teeth placement and forms the palatal portion of denture base 2. To determine the optimum free way space to be provided Co-ordination Class I Excellent Class II- Fair Class III- Good Significance 1. Patient with poor coordination or neurologic deficit (stroke) may never adopt to a denture completely 2. It determines the prognosis of the treatment and success of denture therapy INTRAORAL EXAMINATION 1) Arch size: Class I Large Class II Medium Class III- Small Significance Class I- Best for retention stability and support Class II- Good retention and stability but not ideal Class III-Difficult to achieve good retention and stability 2) Arch form Class I- Square Class II- Tapering Class- III- Avoid Significance: Determines the arch form of the denture and the arrangement of teeth 3) Ridge form Maxillary Class I- Square to gently round Class II- Tapering or V Shaped Class III- Flat Mandibular Class I- Inverted U Shaped ( parallel walls from medium to tall with broad crest)

Class II- Inverted U Shaped ( short with flat crest) Class III- Unfavorable Inverted W Short inverted V Tall thin inverted V Undercut Significance 1. Determines the retention and stability of the complete denture 2. Class-I- Good retention and stability Class-II- Poor retention but good stability Class-iii- Poor retention and stability 3. Has an important influence on selection of impression procedure (Sharp ridge selective pressure technique) (Flat ridge minimum pressure technique) 4. Determines the need for surgery (like Alveoloplasty) esp. in case of undercuts and irregularities 4) Defects exostoses or divots Significance 1. Poses problem for complete denture patients 2. May warrant preprosthetic (surgery) 5) Tori: Maxillary / Mandibular Class I- Tori are absent or minimal in size. Existing tori do not interfere with denture construction Class-II-Tori of moderate size. Often mild difficulties in denture construction and use surgery is not required Class-III- Large tori are present. These tori compromise the fabncation and function of denture. Usually require surgical recountouring 6) Interarch space Class-I- Ideal interarch space to accommodate the artificial teeth (15-20 mm) Class-II- Excessive interarch space (20mm) Class-III- Insufficient interach space to accommodate the artificial teeth(<15mm) Significance: Indicates the difficulty in teeth arrangement and also jaw relation 7) Ridge parallelism Class-I- Both ridges are parallel to occlusal plane

Class-II- Mandibular ridge is divergent from the pccusal plane anteriorly Class-III- Maxillary ridge divergent from occlusal plane anteriorly or both ridges divergent anteriorly Significance 1. Occlusal contacts immediately above the incline at the posterior part of the residual ridge will cause a complete denture to skid forward 8) Ridge relationship Class-I- Normal Class-II-Retrognathic Class-III- Prognsthic Significance 1. Aids in planning for the resultant problem in leverage, occlusion and tooth position for esthetics 9) Radiographic examination a) Bone quantity b) Bone quality Significance 1. An idea for short term and long term support 2. Gives an idea about the pattern of bone resorption 10) Lateral Throat Form Class-I- Mild / No displacement of finger on protruding the tongue Class-II- Moderate displacement Class-III- Severe displacement Significance 1. Determines the length and thickness of disto lingual flange and there by retension and stability of a denture 11) Palatal throat form / soft palate Class-I- Large and normal in form, with a relatively immovable band of resilient tissue 5-12 mm distal to the line drawn across the distal edge of the tuberosities Class-II- Medium size 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 small maxilla. The curtain of soft tissue turn down abruptly 3-5 mm anterior to a line drawn across the palate at the distal edge of the tuberosities Significance Class-I- P.P.S easy to obtain Class-II- P.P.S difficult to obtain 12) Palatal sensitivity Class-I- Normal Class-II- Subnormal (hyposensitive) Class-III-Supernormal (hypersensitive) Significance 1. Gives an idea ogf gag reflex of patient and thereby its further management 13) Mucosa Thickness Class-I- Normal uniform density of mucosal tissue (approx-1 thickness mm) . Investing membrane is firm but not tense and form an idea cushion for basal seat of a denture Class-II a) Soft tissues have thin investing membranes and are highly susceptible to irritation under pressure b) Soft tissues have mucous membrane twice the normal thickness Class-III- Soft tissue have excessively thick investing membranes filled with redundant tissues. At the very least, this require tissue treatment such condition may require surgical correction Significance 1. Determine the retention and stability of a denture 2. Aids in preparing for surgical procedure in case of need 3. To know the time / span of edentulous condition 4. Variation in tissue thickness make it difficult to equalize prevance under the denture and to avoid soreness Determines the need for relief in certain areas 14) Mucosa condition Class-I- Healthy Class-II- Irritated Class-III- Pathologic Significance 1) Aids in planning for the treatment

2) Aids in determining the need for certain procedure like denture relining and tissue conditioning 3) To know the underlying pathology 15) Border attachments Class-I- Attachments are high in maxillary and low in mandible with relaton to ridge crest (0.5 inches or more) Class-II- Attachment height in relation to crest of ridge is0.25 0.5 inch Class-III- Less than 0.25 mm Significance 1. Determines the border moulding procedures 2. A factor in retention and stability 16) Frenum attachments Class-I- High in maxilla / low in mand Class-II-Medium Class-III-Ereni encroach on the crest of the ridge and may interfere with denture seal. Surgical correction needed Significance 1. Treatment plan for the surgery 2. In class III border seal is affected 3. The strength of the denture decrease (liable for fracture)due to deep labial notch 17) Alveolar Tubercle Class-I- Normal /Bulbous / Pendulour / Undercut Significance 1. To plan for surgical preparation 2. Determine the retention and stability of the denture 18) Saliva Class-I-Normal quality and quqntity Class-II- Excessive saliva mucous Class-III- Xerostimia, mucinous Significance 1. A major factor in denture retention 2. Could be a side effect of certain drugs and thereby help us to know the systemic status 3. Thick saliva complicates impression maxi by forming voids 4. Thick ropy saliva is factor for gagging

19) Tongue Class-I- Normal in size, development and function. Sufficient teeth are present to maintain normal form and function Class-II- Teeth have been absent long enough to permit a change in the form and function of tongue Class-III- Excessively large tongue Significance 1. To know the underlying cause if any 2. Denture stability and retention could be a problem in case of large tongue 20) Tongue position Normal: Tongue fills the floor of the mouth and is confined by the mandibular teeth lateral borders rest on the occlusal surface of posterior teeth and apex rests on the anterior teeth. There is no observation in tongue size or activity Retracted: Floor of the mouth pulled downward and is exposed back to the molar area. The lateral borders are raised above the occlusal plane and apex is pulled down into the floor of the mouth Retracted: Tongue very tense and pulled backward and upward. The apex is pulled back into body of the tongue and almost disappears. The lateral border rests above the mandibular occlusal plane. Floor of the mouth is raised and tense. Significance 1. Determines the difficulty in border moulding procedures 2. May affect the stability of the denture 3. To know the presence of any pathology 4. Helps as to know about the tonicity of tongue musculsture 5. In case of inadequate dentures and with larger tongue, may develop certain habits (like holding upper denture with tongue) 6. Proper training is to be given incase of improper positions of the tongue IV) EXISTING DENTURES 1) Anterior tooth shade, mold and material 2) Posterior tooth shade, mold and material Significance 1. To determine physical, esthetic and anatomic characteristics

3) Esthetics, Phonetics, Retention, Stability and contours Good /. Fair / poor Significance: To determine the factor deficient in existing denture and there by to take care in the fabrication of new dentures 4) Centric relation and vertical dimension of occlusion Acceptable / unacceptable and inadequate / excessive Significance 1. Unacceptable jaw relation might strain the muscles 2. Inadequqte VDO affects esthetic, phoetics, muscles martigation etc 5) Occlusal plane orientation Significance: To avoid reserve smile line and there by aids in taking steps to improve the smile and esthetics 6) Palate Regarding denture base material, thickness and anatomic features presence / absence of rugae on the polished surface Significance 1. Denture weares may have become accustomed to a particular palatal form and may resist change 2. Placement of rugae or a change in thickness may affect pronounciation 7) Post dam: Acceptable / unacceptable Significance 1. A major factor which determine the retention 8) Base adaptation: Acceptance / unacceptable Significance 1. A factor of retention 2. Helps in taking steps to improve it 9) Midline Max and Mand Significance 1. Discrepancies in midline placement create noticeable facial disharmonies 10) Buccal vertibule Significance

1. An important esthetic and functional component in complete denture service 2. To propose corrective action 11) Cross bite: None / unilateral / bilateral Significance 1. To know the relative size of the arches 2. To anticipate its effect on tooth placement 12) Characterization / Staining of denture bases To analyse its effect on esthetics and patients response 13) Comfort: acceptable / unacceptable Significance 1. To determine the nature and source of the discomfort 2. Aids to take steps to improve it 14) Hygine: Good / fair / poor Significance 1. Reflects the patients ability and motivation to clean the dentures 2. Denture cleaning regimen has an effect on denture base contouring and tooth arrangement ( closed / open interdental contour and presence / absence of diastema ) 15) Wear: Minimal / Moderate / Severe Significance 1. Indication of parafunctional habit 2. To know about the diet of the patient ( soft / abrasive) 3. To assess the life / age of the denture VII) TREATMENT PLANNING Treatment plan in done based on the analysis of the information collected during the diagnosis. - To know the time required during and after planning - To estimate the cost of the treatment 1. Tissue conditioning : Fingre massaging / medication, type of treatment material and frequence of soft retive changes etc 2. Multi sectorial approach to improving oral health In view of the mulifactored nature of dental disease improvements in oral health care only result from co-ordinated effects of health sector with other social and economic development sectors.

The control of oral disease like caries periodontal and mouth cancer depend on involving the agriculture ( mainly sugarcane and tobacco subsectors) engineering, pharmaceutical, food manufacturing, advertising health education, and health care sectors. Dental care need not be isolated, but should be integrated in general health care strategies for wider access and better utilization within resource constraints. In 1969 the WHO Global data Bank on oral health was stated. The goal for oral health for the year 2000 A.D (F.D.I) Goal 1- 50% of 5-6 yrs old will be carier free 2- The Global average will be not more than 3 DMFT at 12 yrs 3- 85% of the population should retain all the permanent teeth at the age of 18yrs. 4- A 50% reduction in present levels of endentalousness at the age of 35-40 yrs will be achieved. 5- A 25% reduction in present levels of endentalousness at the age of 65 and over will be achieved. 6- A data based system for monitoring changes in oral health will be established. These are relative goals The establishing of global goals for oral health in the year 2000AD need to collect epidemiological data on various oral health problems in specified age groups and on the prevalence of edentulousness among adults are available only in some countries where base line data are available. Continuous surveilance at suitable time. Intervals is required to monitor changes in oral health where base line data are not available. The man emphasis be put upon the classification of the present situation. The data on recent changes in oral health in some European industrialized countries are used to evaluate future trends. In developing countries very little information, in available on oral health, epidemiological research on oral health is highly essential in these countries. Factors affecting the oral health of the people -Availability -Accessibility -Affordability -Acceptability Preprosthetic surgery proposed preprosthetic procedures along with of these procedures. 3. Artuculator: Type of Artuculator Control settings Horizontal and lateral guidance Incisal anterior and lateral guide angle

1. 4. Tooth selection : Shade, mold and mater