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Diagnosis :It is the examination of the physical state , evaluation of the mentalor psychological makeup & understanding the needs of each patient to ensure a predictable result.Treatment Planning :It means developing a course of action that encompasses theramification & sequelae of treatment to serve the patients needs.
Patient Evaluation : Patient evaluation is the first step to be carried out in treating a patient. Gait : The dentist should note the way the patients walk into the clinic.People with neuromuscular disorders show a different gait. Suchpatients will have difficulty in adapting to the denture. Age : The decade , which the patients belong to , is important to predict the outcome of treatment. For eg. patients belonging to the 4thdecade of life will have good healing abilities & patients above the6th decade will have compromised healing.
Sex : Male patients are generally busy people who appear indifferent to the treatment. They are only bothered about comfort & nothingelse.On the other hand , female patients are more critical aboutaesthetics & they usually appear to overrule the dentist intreatment planning. Complexion & Personality : To determine the shade of the teeth. Executives require smaller teeth. Mental attitude : Based on there mental attitude , patients can be grouped under two classifications, House‟s classification - Class I : Philosophical Class II : Exacting Class III : Hysterical Class IV : Indifferent
History Taking : It is a systematic procedure for collecting the details of the patient to do aproper treatment planning. Name : The name should be asked to enter it in the record. Age : Some diseases are limited to certain age groups. Occupation : Executives & sales representatives require more idealistic teeth. While other people who work in places with high physical exertion require rugged teeth.
Race : It helps to select the shade of the teeth.Location : Some endemic disorders like fluorosis are confined to certain localities.Religion & Community : Gives an idea about the dietary habits & helps to design the denture accordingly.Medical History : The following medical conditions should be ruled out before beginning the prosthetic treatment.
Debilitating Disease - Complete denture patients , most of whom are geriatric, arebound to be suffering from debilitating diseases like diabetes, blood dyscrasias & tuberculosis. These patientsrequire specific instructions on denture /tissue care.Diabetic patients show excessive rate of bone resorption ,hence, frequent relining may be necessary. Disease of the Joints – The most common disease of the joint in old age isosteoarthritis. Disease of the Skin - Skin disease like Pemphigus have oral manifestations, which vary from ulcers to bullae. Neurological Disorders - Diseases such as Bell‟s palsy & Parkinson‟s disease can influence denture retention & jaw relation records.
Oral Malignancies - Some complete denture patients with oral malignancies may require radiation therapy before prosthetic treatment. Climacteric Conditions - Like menopause can cause glandular changes,osteoporosis & psychiatric changes in the patient. Dental History : It is most important part of Diagnosis. Chief Complaint - It should be recorded in the patients on words.It givs ideaabout the patients on words. Expectations - The dentist should evaluate the patient‟s expectations &classify them as realistic or attainable & unrealistic.
Period of Edentulous ness - It gives information about the amount & pattern of boneresorption. Pre-treatment Records - It includes information about the previous denture ,currentdenture, pre-extractions records & diagnostic casts.
Clinical Examination : Extraoral Examination The patients head & neck region should first be examined in general forthe presence of any pathologic conditions relating to a nondental or systemicconditions.Facial Examinations : It includes the evaluation of facial features, facial form, facial profile &lower facial height. Facial features – The following features on the face should be noted,
Perioral features : - Length of the lips - Lip fullness - Apparent support of the lips - Philtrum - Nasolabial fold - Mentolabial sulcus - Labial commissures & modiolus - Width of the vermilion border - Size of the oral opening - Texture of the skinFacial form - House & Loop, Frush & Fisher & Williams classified facial form based on the outline of the face as square, tapering, square tapering & ovoid. It helps in teeth selection.
Facial profile - It determine the jaw relation & occlusion. Angle classifiedfacial profile as, Class I : Normal or straight profile Class II : Retrognathic profile Class III : Prognathic profile Lower facial height - It is important to determine the vertical jaw relation. Muscle Tone : It can affect the stability of the denture. House classified muscletone as, Class I : Normal tension, tone & placement of the muscle of mastication & facial expression. Nodegeneration. Class II : Normal muscle function but slightly decreased muscle tone.
Muscle Development : People with excessive muscle development have more bitingforce. House classified muscle development as, Class I : Heavy Class II : Medium Class III : Light Complexion : The color of the eye, hair & the skin guide the selection ofartificial teeth. Lip Examination : Lip support – Based on the amount of lip support, lips can beclassified as adequately supported or unsupported.
Lip mobility – Based on the mobility, lips are classified as normal ,reduced mobility & paralyzed. Thickness of the lips – Thick lips need lesser support from the artificial teeth & thelabial flange. Thus on the other hand thin lips rely on theappropriate labiolingual position of the teeth, for theirfullness & support. Length of the lips – It is an important determinant in anterior teeth selection. Based on the length, lips are classified long, normal or medium & short. Health of the lips – The lips are examined for fissures, cracks or ulcers at the corners of the mouth.
TMJ Examination : - The movements may be of three types, 1) coordinated 2) jerky 3) restrictive - The abnormality usually seen is clicking sound, pain of tendons,deviation to one side & dislocation. Neuromuscular Examination : It includes the examination of speech & neuromuscularcoordination. Speech – It is classified based on the ability of the patients to articulate & coordinate it. Type I – Normal Type II – Affected
Neuromuscular coordination – It can be classified as, Class I – Excellent Class II – Fair Class III - Poor Intraoral Examination Color of the mucosa : The mucosa should have a healthy pink color. Any amountof redness indicates an inflammatory changes. Othercolor changes such as white patches should be noted asthis might indicate an area of frictional keratosis.
Saliva : - The amount & Consistency of saliva will affect the dentureconstruction process & the quality of the final product itself. - The consistency of saliva can range from a thin, serous type toa thick, ropy consistency. It is best to work with serous type. Thickropy saliva alters the seat of the denture. - All salivary duct orifices should be examined. Residual Alveolar Ridge : Arch size – a) The size of the maxilla & mandible will determine theamount of basal seat available for the denture foundation. Thegreater the size, the more the support the larger thecontact surface, the greater the retention.
b) Discrepancy b/w the mandibular & maxillary arch sizes can lead to difficulties in artificial teeth arrangement &decreases the stability of the denture resting in the smallerone of the two arches. - It can be classified as, Class I – Large Class II – Medium Class III – Small Arch form - The arch may be square, ovoid or tapered & opposing arches may not necessarily have the same form. Ridge contour - Ridges can be classified as based on their contour as, - High ridge with flat crest & parallel sides - Flat ridge - Knife edged or „v‟ shaped ridge
Ridge relation - - It is defined as, “ The positional relation of the mandibularridge to the maxillary ridge” - Inter ridge relationship, Anterior : Class I – Normal Class II – Prognathic Class III – Retrognathic Posterior : - Normal - Cross arch - Inter arch space, Class I – Adequate Class II – Excessive Class III - Reduced
Redundant tissue : Any excessive amount of flabby tissue will cause the denturebase to shift & move as force is applied, this will result ininstability & decreases retention of the denture. Hard palate : The shape of the vault of the palate should be examined. Itcan be classified as, - „U‟ shaped : Ideal for both retention & stability
Hyperplastic tissue : The most common hyperplastic lesions are epulis fissuratumrelated to a denture border, papillary hyperplasia orhyperplastic folds under the denture base.
- ‘V’ shaped : Retention is less, as the peripheral seal is easily broken - Flat : Reduced resistance to lateral & rotatory forces Soft palate : While examine the soft palate, it is important to observe the relationship of the soft palate to the hard palate. Thisrelationship is called palatal throat form. On this bases, softpalate can be classified as, Class I : It is horizontal & demonstrates little muscular movement Class II : Soft palate turns downwards at about a 45.angle to the hard palate Class III : Soft palate turns downwards sharply atabout a 70. angle just posterior to the hardpalate
Bony undercuts : - On the maxilla, the undercuts are usually present on theanterior ridge & lateral to the tuberosities. - On the mandibular arch, the only undercut that can poses areal problem, sharp mylohyoid ridge.
Tori : - A torus palatinus & lingual tori are occasionally present. - On the maxilla, the torus can range from a smallprominence on the midline to one that covers the entirehard palate. - On the mandible, lingual tori can present lingually to the premoral region.
Muscles & Frenal attachments : Muscle & Frenal attachments should be examined for favorable or unfavorable position in relation to the crest of the ridge. Tongue : Wright classified the tongue position as follows, Class I : The tongue lies in the floor of the mouth withthe tip forward & slightly below the incisal edgesof the mandibular anterior teeth. Class II : The tongue is flattened & brodened but tip isin a normal position. Class III : The tongue is retracted & depressed intothe floor of the mouth with the tipcurled upward, downward orassimilated into the body of the tongue.
Floor Of The Mouth : The relationship of the floor of the mouth to the crest of theridge is crucial in determining the prognosis of the lowercomplete denture. Gag reflex : - “The gag reflex is a normal defense mechanism designed toprevent foreign bodies from entering the trachea.” - The initiation of gag reflex can be caused by systemicdisorders, psychological factors & iatrogenic factors.
Radiographic Examination : - Periapical surveys of the edentulous jaws are acceptable, but panoramic radiographs are faster, reduce the patient exposure to radiation & imagethe entire mandible & maxilla. - The interpretation of the panoramic radiograph should follow a fivesteps analysis as outlined by Chomenko, 1) Screen jaws for defects in structure & reactive new bone formation, bone enlargement, displacement of the jawparts,retained root fragments, unerupted teeth, rarefaction,sclerosis, cysts, tumors & TMJ disorders. 2) Describe the apperearance of the lesion as well as any bone changes adjoining the lesion.
3) Correlate the radiographic findings with the clinical,historical & laboratory findings. 4) Perform a differential diagnosis which includes all thediseases that could explain the findings. 5) Estimate the growth of the lesions by the apperearance ofjaw structures bordering the lesion. The amount of resorption can be classified by Wical & Swoope, Class I : Mild resorption Class II : Moderateresorption Class III : Severe resorption
TREATMENT PLANNINGTreatment planning is the process of matching possible treatment option withpatient needs & systematically arranging the treatment in order of priority butin keeping with a logical or technically necessary sequence.# A primer on treatment option