Diagnosis and Treatment plan of Complete Denture

Diagnosis and Treatment plan of Complete Denture

Question. Discuss the significance of diagnosis and treatment plans in complete denture patients.

• Diagnosis is the examination of the physical state, evaluation of the mental or psychological makeup, and understanding of the needs of each patient to ensure a predictable result.
• Treatment planning means developing a course of action that encompasses the ramifications and sequelae of treatment to serve the patient’s needs.

General Details Of The Patient

The patient’s name, address, telephone number, age, occupation, and other required general information such as how long the patient was edentulous is obtained.

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Observation Of The Patient

1. Motor Skills

Patient’s gait, level of coordination, and steadiness. Problems in motor skills can be due to Parkinsonism, Bell’s palsy, nervous habits, or possibly drug-induced.

2. Facial Features

Observe the philtrum, nasolabial fold, and labiodental groove for hollowness or puffiness. Noting the profile view gives an indication of the patient’s occlusal classification.

3. Attitude and Adaptive Response

Previous experience with Dentists, a positive attitude, good general health, realistic expectation of the patient, good learning capacity, and cooperative effort from the patient.

Health History

1. The name of the patient’s physician
2. A record of the status of all major body systems
3. A record of all medications the patient is currently taking
4. A record of any hospitalization
5. A record of any complication that was a result of previous dental treatment.

Clinical Examination

1. Extraoral examination:

1. Head and neck region: Examine for any existing facial lesions, nodules, nevi, or ulcerations, and the duration of the same is noted.
2. Lip Examination: The lips are examined for cracking, fissuring at the corners, and ulceration. The lips are then examined for support, fullness, thickness, and length. This is needed for the proper placement of anterior teeth.
3. Temporomandibular joint: It is examined for pain, and any joint sounds such as clicking, popping, or crepitus upon opening and closing.

2. Intraoral examination of soft tissues:

1. The inside surface of the cheeks, lips, residual ridge, floor of the mouth, hard and soft palate, and tongue are examined for abnormalities or pathological lesions.
   • The anterior and posterior tonsillar pillars, oropharynx, and nasopharynx should also be examined. Redundant tissue in the maxilla and mandible should be examined. If present can cause shifting in denture bases leading to excessive ridge resorption.
2. Saliva: The amount and consistency of saliva will affect the denture construction process Xerostomia will affect denture retention and can cause soreness.
3. Floor of the mouth: If the floor of the mouth in the sublingual gland and mylohyoid areas are high and close to the ridge this crest can eliminate the alveololingual sulcus.
   • The retro mylohyoid space (lateral throat form) should be evaluated if this space can be filled, and the mandibular denture will have a good lingual seal and lateral stability.
4. Muscle and frenal attachments: The attachments most often surgically corrected are the maxillary labial and mandibular lingual frena. If not relieved in the denture can cause soreness in that region.
5. Tongue: The tongue size should be noted. In patients with a long period of edentulism without replacement of teeth or for patients who have worn a maxillary denture against the lower anterior teeth without replacement of lower posteriors, the tongue can become enlarged and powerful.
   • Tongue movement and muscular coordination are important for border molding impressions and during normal physiological activities such as speech, mastication, and deglutition.

Wright classified tongue positions as follows:

Class 1 the tongue lies on the floor of the mouth with the tip forward and slightly below the
incisal edges of the mandibular anterior teeth.

Class 2 the tongue is flattened and broadened but the tip is in a normal position and

Class 3 the tongue is retracted and depressed into the floor of the mouth with the tip curled upward, downward, or assimilated into the body of the tongue.

Class I is favorable.

3. Intraoral examination of hard tissues:

1. Arch form: Square, ovoid, or tapered (opposing arches may not have the same form).
2. Ridge contour: The ideal ridge contour is a high ridge with flat-crested parallel sides.
3. Parallelism of ridges: As the maxilla resorb the crest appears to move upward and inward. As the mandible resorbs, the crest of the ridge appears to move downward forward and laterally because it is wide at its inferior border than at its occlusal border.
4. Hard palate: The hard palate should be examined and its shape noticed. The U-shaped palatal vault is most favorable for retention.
5. Soft palate: There are three classifications of soft palate

Class 1: Large and normal with an immovable band of resilient tissue, 5 to 12 mm distal to
the line drawn across the distal edge of tuberosities. Ideal for denture retention.

Class 2 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 3 to 5 mm.

Class 3 soft palate turns downward sharply at about a 70° angle just posteriorly to the hard palate. The available space for coverage by the posterior palatal seal is at a minimum. A ‘V-shaped palatal vault is usually associated with a Class III soft palate.

• Bony undercuts: Bony undercuts in maxillary are commonly seen on the anterior ridge and lateral to the tuberosities and in mandibular ridges is a prominent sharp mylohyoid ridge. Here surgical reduction and reattachment of the mylohyoid muscle can have beneficial results.
• Torus palatinus in the maxilla is occasionally present on the midline to one that covers the entire hard palate. Generally, surgical removal is contraindicated unless the torus is so large. Lingual tori are seen in the mandibular premolar region.

Gag reflex: The oral examination, medical history, and conversation with the patient are important in identifying the existence of a problem and determining the treatment.

Radiographic Examination

Panoramic examination of edentulous patients includes a five-step analysis as outlined by Chomenko.

1. Screen jaws for defects, bone enlargement and displacement of jaw parts, any unerupted teeth or retained root fragments, foreign bodies, radiolucencies radio-opacities, rarefaction or sclerosis, expansion or bulging, and any well-defined or ill-defined lesions.
2. TMJ can be screened. In addition, the maxillary sinus can be checked for inflammation, cysts, polyps, tumors, infection, or inflammation.
3. Describe the appearance of the lesion and include location, size, shape, number, and a description of the radiographic pattern.
4. Correlate the radiographic findings with the clinical, historical, and laboratory findings.
5. Perform a differential diagnosis that includes all the diseases that could explain the findings.
6. Estimate the growth of the lesion.
7. Document the amount of ridge resorption which is classified as:

• • Class 1 (mild resorption) is a loss of up to one-third of the original vertical height,
  • Class 2 (moderate resorption) is a loss of from one-third to two-thirds of the vertical height,
  • Class 3 (severe resorption) is a loss of two-thirds or more of vertical height

Examination Of The Present Prostheses

If the patient has an existing prosthesis then check for:

1. If the present prosthesis is acceptable or unacceptable.
2. Verify centric relation in which the first occlusal contact should be bilateral and distributed
   evenly anteroposteriorly to rate as acceptable.
3. Evaluate the occlusal vertical dimension in occlusion and speech.
4. Evaluate for proper basal seat coverage.
5. Examine the artificial teeth for wear or breakage.
6. Check for retention and stability of the complete dentures.
7. Evaluate the residual ridges and the patient’s chief complaint.

Pre-Treatment Records

Diagnostic casts can detect the ridge relationships interridge distance or ridge shape and form. Pre-extraction Records and Photographs showing natural teeth aid in determining tooth size, position, and arrangement. Old radiographs are also helpful in determining tooth size and bony changes.

Treatment Plan

• After thorough history taking, examination of the patient, and verifying all diagnostic records, the treatment plan is decided. The treatment and expected level of achievement is explained to the patient.
• The fees for the procedure, the manner of payment, the duration of treatment, and any necessary tissue preparation, conditioning, and corrective surgery are discussed.
• Limitations are pointed out if the complete denture patients present with different problems as in Hysterical or Critical patients, then medical consultation is always advisable before treatment is started.
• A trained professional is aware of all the patient’s needs and educates the patient to overcome problems related to treatment procedures.