Dr Aaryas Vlogs Dental Prosthetics Guide

INTRODUCTION
DIAGNOSIS: the determination of
the nature of the disease.
TREATMENT PLAN: the sequence
of procedures planned for the
treatment of a patient after
diagnosis.
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FIRST VISIT
De Van stated, “ meet the
mind of the patient before
meeting the mouth of the
patient”
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FIRST VISIT
 Develop mutual understanding and trust
 Treatment plan should be based on realism rather
than hope otherwise it may result in disappointment
and frustration
 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 co-operation so necessary for a
successful result
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PRINCIPLES OF PERCEPTION
 Visual perception is the primary mode of data gathering in
the examination
 Simplest of it is seeing with eyes and interpreting with
the brain
 Tasks identified in this process are:
 Detection
 Discrimination
 Recognition
 Identification
 Judgment
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COSMETIC INDEX
Class I – High Cosmetic Index
Class II – Moderate Cosmetic Index
Class III – Low Cosmetic Index
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MENTAL ATTITUDE
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House classification
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Dr M.M. House (1950) classified patients as
 Philosophical
 Exacting
 Indifferent
 Hysterical
This is the most widely used classification.
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Philosophical Patient
 The philosophical type is the best mental attitude
for denture acceptance
 Patient is rational, sensible, calm and composed in
difficult situations
 Overcomes conflicts and organizes his time and
habits in an orderly manner
 Eliminates frustrations and learns to adjust rapidly
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Exacting Patient
 May have all of the good attributes of the
philosophical patient
 However he may require extreme care, effort and
patience on Prosthodontist’s part
 Patient is very methodical, precise and accurate and
makes several demands
 Patient is comfortable when each procedure is
explained and discussed with them in detail.
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Indifferent Patient
 Presents a questionable or unfavorable prognosis
 These patients are identified by their lack of concern
and motivation and apathetic attitudes.
 Pays no attention to instructions, will not cooperate and
is prone to blame the dentist for poor dental health.
 An education program in dental conditions and dental
treatment is the recommended treatment plan before
denture construction.
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Hysterical Patient
 Emotionally unstable, excitable, excessively
apprehensive and hypertensive
 Prognosis is often unfavorable and additional
professional help (psychiatric) is required prior to
and during treatment
 Patient must be made aware that his/her problem is
primarily systemic and that many of his symptoms
are not result of dentures
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Facial expression
 This provides information about the mental attitude
and presence of any disorders.
 Absence of any expression indicates loss of muscle
tone, trigeminal neuralgia, plastic surgery or
disorders of central nervous system.
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Complexion
 Used to select the colour of the teeth.
 It may also be indicative of the following conditions:
• Pale—anaemia, lack of nourishment.
• Ruddy—polycythaemia, chronic alcoholic.
• Bronze—radiation therapy, Addison disease.
• Bluish-purple—vitamin deficiency, cyanosis.
• Lemon-yellow—jaundice.
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Speech
 The fluency and quality of the speech should be noted, as it will
help in arranging artificial teeth.
 If speech is altered due to poor denture construction, it should
be rectified.
 Speech can also be altered due to the following pathologies:
• Hypernasality—paralysis of palatal musculature.
• Hoarseness—paralysis of both vocal cords, excessive smoking.
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Breathing pattern
Abnormal breathing patterns may indicate the following:
 Heavy sighing—emotionally disturbed
 Wheezing—asthma
 Shortness of breath—lung disease, heart failure
 Shallow breathing at rapid rate—pulmonary fibrosis
 Erratic breathing—continuous hyperventilation
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NAME
 Documentation
 Confidence and psychological security
 Makes them comfortable
 Idea about the patient’s family and
community
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AGE
 Important to predict the outcome of the treatment
 Refers to the physiologic age and provides information about the
patient’s expectations and care for the dentures.
 Used to rule out certain systemic conditions apart from
determining the prognosis.
 4th decade of life- good healing abilities
 Greater than 6th decade- compromised healing
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GENDER
 Generally, appearance is a higher priority for women than for
men.
 Though younger men often are concerned with esthetics,
males often grow indifferent to their own appearances as
they age. During this process, men shift their concerns to
the comfort and function of dentures.
 Women facing the physiologic and psychological problems of
menopause often present as exacting or hysterical patients
who are very concerned with esthetics.
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OCCUPATION
 Executives in high stress jobs may exhibit bruxism.
 For professionals, appearance and retention may be more important than
efficiency.
 Public speakers and singers may need greater attention to palatal shape and
thickness and perfect retention.
 Wind instrument players may require special positioning of anterior teeth.
 Patients in high socioeconomic groups may be more demanding and critical,
while those of low economic status may show disinterest and poor hygiene
maintenance.

LOCATION
 Fluorosis endemic areas,-may need characterization
HABITS
 Pan chewing, smoking, chronic alcoholism
 Pencil biting and nail biting
 Parafunctional habits like clenching and bruxism

NUTRITIONAL HISTORY
 It is important to obtain a record of food intake of the
patient over a 3–5 days period. This helps in evaluating the
nutritional status of the patient.
 The ability of the oral tissues to withstand the stress of
dentures is greater in a well-nourished patient. Dietary
counselling is necessary in malnourished patients.
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General Health And
Dental History

Successful treatment requires
 An Understanding Of
 Patient’s general health
 Dental history
 Thorough appreciation of the status of
 Oral and perioral tissues
 Any existing prostheses, be they successful or
unsatisfactory

Health Questionnaire
 Convenient method of collecting basic information and
personal data
 Can be sent to the patient before the appointment or
administered in the reception area if facilities permit its
confidential completion
 Dentist can then review and clarify the information as
necessary in the private operatory as part of the clinical
examination

MEDICAL HISTORY
 Debilitating diseases: Diabetes mellitus, candidiasis,
blood dyscrasias, tuberculosis
 Diseases of the joints: Rheumatoid arthritis and
Osteoarthritis
 Cardiovascular diseases
 Diseases of the skin: Pemphigus
 Neurological disorders: Bell’s Palsy, Parkinson’s disease

 Oral malignancies
 Epilepsy
 Climacteric conditions
 Medications

DENTAL HISTORY
Chief complaint
 The chief complaint is recorded in patient’s own words.
 It should be determined if the complaint is justified and realistic.
 It gives ideas about the patient’s psychology.
Patient’s desires and expectations
 It is important to find out what the patient expects from the
treatment.
 The patient should be asked about his/her expectations.
 Unrealistic expectations will be detrimental to success of treatment.
 Patient education regarding what is possible is very important in such
cases.

PAST DENTAL HISTORY
The following information should be elicited:
1.Reason for tooth loss:
If periodontal disease was the reason, more bone loss is
anticipated. It also helps in prognosis.
2. Period and sequence of edentulousness:
Longer the period, more will be the bone loss. By understanding the
sequence, bone resorption pattern can be identified.

3. Previous dental and denture experience:
 Traumatic experiences will affect the attitude of the
patient towards dental treatment
 They will require more counselling and education.
 Patient’s experience with previous dentures will give
an insight into their attitude, desire and
expectations.

Existing or Current Dentures:
 The patient should be questioned about the length of
time he or she has worn the current dentures.
Responses should be compared with clinical
observations.
 Careful observation may provide valuable information
about denture experience, denture care, dental
knowledge, parafunctional habits, etc.

Denture Success
 Patient should be asked about the esthetics and function
of existing maxillary and mandibular dentures. Responses
may indicate the patient's ability to wear or adjust to
complete dentures.
 Denture success for each arch should be rated
"favorable" or "unfavorable."

PRE-TREATMENT RECORDS:
 The pre-treatment record is a very valuable information.
 Pre-treatment records include information about the previous
denture, current denture, pre-extraction records and diagnostic
casts.
 Pre-extraction photographs, radiographs, casts, and facial
measurements may prove helpful in denture therapy.
 These adjuncts may be used to recreate anterior esthetics and
facial support, as well as to aid in the evaluation of vertical
dimension of occlusion.

CLINICAL EVALUATION
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EXTRA ORAL EXAMINATION
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Concerned principally with
 Facial contours and
symmetries
 Appearance of the teeth and
their relationships with the
lips in repose
 Palpation of the
temporomandibular joints
and of the submandibular
and cervical lymph nodes
 Masticatory and facial
muscles
FACIAL EXAMINATION
MUSCLE TONE AND DEVELOPMENT
LIP EXAMINATION
TMJ EXAMINATION
NEUROMUSCULAR EXAMINATION

FACIAL EXAMINATION
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FACIAL FEATURES
LOWER FACIAL HEIGHT
FACIAL FORM
FACIAL PROFILE

FACIAL FEATURES
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LENGTH OF THE LIPS
LIP FULLNESS
MOUTH OPENING
VERMILION BORDER
MENTOLABIAL SULCUS
NASOLABIAL FOLD
PHILTRUM
LIP SUPPORT
SKIN TEXTURE
LABIAL COMMISSURES
AND MODIOLUS

LOWER FACIAL HEIGHT
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Class I: Heavy
Class II: Medium
Class III: Light

COMPLEXION
 Hair, eye, and skin color provide useful guides in shade selection.
 Skin color also can reveal underlying disease and pathology.
 Patients with significant sun damage need referral to a dermatologist.
 Pale, anemic-looking patients may have underlying systemic diseases
and may require longer adjustment periods.
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NASO-LABIAL ANGLE
Naso-labial angle for a normal individual varies from
90-110 degrees which is decreased in an edentulous
patient as the upper lip loses support from the
maxillary incisors.
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LIP EXAMINATION
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Length
Thickness
Support
Mobility
Commisure

LIP LENGTH
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Upper lip length- measured from base of nose to
inferior part of upper lip.
MALES- 22 to 26 mm
FEMALES- 20 to 22mm
- affect how much teeth would be exposed
- short lip tend to reveal more of tooth structure
and denture base

PAPILLAMETER
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A papillameter comprises a vestibule shield, an
incisive papilla rest, and a vertical handle for
measuring lip length.

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THIS IS THE
WAY TO
MEASURE THE
LIP LENGTH

LIP FULLNESS
 Apparent fullness of the lip is directly related to the
support provided by the teeth and alveolar bone or
denture base
 Lip fullness should not be confused with lip thickness,
which involves the intrinsic structure of the lip.
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INADEQUATE LIP SUPPORT
 If anterior maxillary denture teeth are set
excessively palatally to reduce the overjet can lead
to a lack of lip support
 Producing vertical wrinkles in the face
 Results in the teeth appearing to be “too short”—a
problem usually best corrected not by lowering the
occlusal plane but by increasing lip support
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EXCESSIVE LIP SUPPORT
 Prominence of the residual alveolar ridge or excessive
thickness of labial flange can result in excessive lip
support
 Make the lip appear to be too full rather than
displaced
 Also can make the lip appear thick or short
 An obliterated philtrum or mentolabial fold suggests
excessive support
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CORRECTION OF LIP SUPPORT
 Problem with lip fullness is in the patient’s reaction to
changes
 If the existing dentures have the teeth set too far palatally,
the patient may feel that the new and corrected tooth
arrangement makes the lip too full
 Extra time will be needed at the try-in of the wax dentures
to ensure that the patient is comfortable with the agreed
design
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THIN & THICK LIPS
 Patients with thin lips present special problems
 Any slight change in the labiolingual tooth position makes an evident
change in the lip contour
 critical that even overlapping of teeth may distort the surface of the lip
 Both the arch form and the individual tooth positions can have effect on
lip contour
 Thick lips give the dentist a little more opportunity for variations in the
arch form and individual tooth arrangement before the changes are
obvious in the lip contour
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LIP MOBILITY
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CLASS 1
CLASS 2
CLASS 3

TMJS & MASTICATORY MUSCLES
EXAMINATION
 TMJ plays a major role in the fabrication of a CD.
 The joint should be examined for range of movements,
pain, muscles of mastication, joint sounds upon opening
and closing.
 Severe pain in the TMJ indicates increased or
decreased VD.
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• Class I: Co-ordinated
• Class II: Jerky
• Class III: Restricted

NEUROMUSCULAR EVALUATION
 Patients gait, coordination of movements, ease with
which he moves noted
 Uncontrolled tremors of mandible and tongue may
lead to prosthesis instability.
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SPEECH
COORDINATION

SPEECH
 Should have a basic knowledge of speech, particularly its articulatory
component
 Articulation is the modification of speech sounds by structures of the
throat, mouth, and nose
 Fortunately, the neuromuscular activity that produces speech can adapt
to, or accommodate, a certain amount of structural change
 Relationship of the positions of the teeth, lips, and tongue in the
articulation of speech are very important
 Assessment should be made during the diagnosis appointment to identify
existing problems and determine the potential for improvement
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COORDINATION
• Patients with good neuromuscular coordination can be expected to
learn to manipulate dentures relatively quickly and likewise adapt
readily to new dentures.
• Patients with poor coordination or a neurologic deficit (such as
from a stroke) may never adapt to a denture completely.
Classify neuromuscular coordination as follows:
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Class 1: Excellent
Class 2: Fair
Class 3: Poor

INTRA ORAL EXAMINATION
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EXISTING TEETH
Immediate
denture
Overdenture
Single complete
denture
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MUCOSA
Color
Thickness
Condition
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CONDITION
Class I- Healthy
Class II- Irritated
Class III- Pathological
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RESIDUAL ALVEOLAR RIDGE
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ARCH SIZE
CLASS I LARGE BEST FOR RETENTION AND STABILITY
CLASS II MEDIUM GOOD RETENTION AND STABILITY BUT
NOT IDEAL
CLASS III SMALL DIFFICULT TO ACHIEVE GOOD RETENTION
AND STABILITY
• Arch size = amount of basal seat available
• Increased Arch Size → More Stability & Retention
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ARCH FORM
CLASS I SQUARE Best form
to prevent
rotational
movement
CLASS II TAPERED Offers
resistance to
movement but
to a lesser
degree
CLASS III OVOID -------
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CLASS I NORMAL Anterior segment of
mandibular ridge directly below
or slightly posterior to the
maxillary anterior ridge
CLASS II RETROGNATHIC Anterior segment of mandibular
ridge retruded beyond the
normal position
CLASS III PROGNATHIC Anterior segment of mandibular
ridge protruded beyond the
normal position
RIDGE RELATIONSHIP
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RIDGE FORMS
CLASS I SQUARE
CLASS II TAPERING
CLASS III FLAT
CLASS I INVERTED U SHAPED- TALL
TO MEDIUM WITH BROAD
CREST
CLASS II INVERTED U SHAPED-SHORT
WITH FLAT CREST
CLASS III UNFAVOURABLE
• TALL THIN INVERTED V
• SHORT THIN INVERTED V
• INVERTED W
• UNDERCUT
MAXILLA MANDIBLE
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INTER RIDGE DISTANCE
CLASS I Ideal inter-arch space to
accommodate the artificial
teeth
CLASS II Excessive inter-arch space
CLASS III Insufficient inter-arch space
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RIDGE PARALLELISM
Class I Both ridges are
parallel to the
occlusal plane
Class II Mandibular ridge is
divergent from
occlusal plane
anteriorly
Class III Maxillary ridge is
divergent from the
occlusal plane
anteriorly and/or
both ridges are
divergent anteriorly
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POSITIONAL RELATION
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PALATAL THROAT FORM
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PALATAL SENSITIVITY
Evaluated by running a mouth mirror over the soft palate
Gagging controlled by:
 Careful handling of impression procedure
 Constant reassurance
 Diverting the patient attention from the procedure
○ Class I: Normal
○ Class II: Hyposensitive
○ Class III: Hypersensitive
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LATERAL THROAT FORM
Distance between the floor of the
mouth and the middle of the
retromolar pad when the patient
protrudes the tongue ¼ inch beyond
the edge of the lower lip
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BORDER ATTACHMENTS
Height of
attachment
Ridge crest
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BORDER ATTACHMENTS
Class I: Attachments are high in
maxilla and low in mandible
with relation to ridge crest
0.5 inches or greater
Class II: 0.25 to 0.5 inches
Class III: < 0.25 inches
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FRENAL ATTACHMENTS
CLASS I ATTACHMENTS IN
MAXILLA → HIGH
MANDIBLE → LOW
CLASS II MEDIUM
CLASS III ENCROACHING CREST OF THE
RIDGE MAY INTERFERE WITH
THE DENTURE SEAL
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SALIVA
 Quality and quantity of saliva are crucial factors in a
patient’s ability to tolerate dentures
 Both the flow rate and the viscosity are important to
denture success.
 Normal resting salivary flow is about 1 ml/min.
 A flow of medium viscosity at this rate lubricates the
mucosa and assists retention of complete dentures
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SALIVA
Quantity
 If dry- decreased retention, potential for
soreness
 If excess- complicates denture
construction, especially impression making.
Quality
 Thin, watery type
 Thick, ropy - denture wearing more difficult
(scanty, thin saliva interferes with seal of
complete dentures)
To check consistency of saliva, string test
Class 1: Normal quality and quantity
of saliva. Cohesive and adhesive
properties of saliva are ideal.
Class 2: Excessive saliva; contains
much mucus.
Class 3: Xerostomia
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TONGUE
POSITION
SIZE
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SIZE
NORMAL
ENLARGED
SMALL
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ACCORDING TO HOUSE
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TORI
TORUS PALATINUS
• Found at midline of hard palate
• Small ones may be accommodated by
relief of denture base
• Surgical excision if fills palate to
occlusal level, or extends beyond
vibrating line
• Treatment deferred for 2-6 months
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MANDIBULAR TORI
• Lingual premolar region
• Difficult to provide relief without
breaking border seal of denture
• Surgical removal is necessary for
successful denture construction
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RIDGE DEFECTS AND
REDUNDANT TISSUES
It is common to find flabby tissue covering the
crest of the residual ridges.
These movable tissues tend to cause movement
of the denture when forces are applied.
This leads to loss of retention.
Ridge defects include exostosis that may pose
a problem while fabricating a complete
denture.
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ENLARGED TUBEROSITIES
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EPULIS FISSURATUM
Border tissues may be chronically
traumatized by flanges that were originally
overextended or have become so as a result
of lost ridge support, producing a reactive
hyperplasia
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PAPILLARY HYPERPLASIA
 Cauliflower-like in appearance and tends to
occur on the anterior region of the palate in
long term denture wearers.
 Often this tissue is inflamed when it is
referred to as inflammatory papillary
hyperplasia
 Deep crevices of papillary hyperplasia are
prone to infection, frequently with C.
Albicans.
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INFECTION
 Oral fungal infections are common in
edentulous patients, particularly in
maxillary denture-related stomatitis
 Concomitant inflammation of the
corners of the mouth—angular
cheilitis—should raise suspicions of
candida albicans infection
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Radiographic Examination
Panoramic
Radiograph
Any pathologies
Ridge resorption
Lateral
Cephalometry
Ridge relation
Facial profile
Intraoral
Radiography
To evaluate any
suspicious areas
specifically
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INTERPRETATION OF OPG
 Defects in structure /
reactive new bone formation
 Bone expansion
 Unerupted teeth / retained roots
 Foreign bodies
 Radiolucencies and radiopacities
 Maxillary sinus checked for
inflammation, cysts, polyps,
tumors
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RIDGE RESORPTION
Class I Mild resorption – Loss of 1/3 of
original height
Class II Moderate – loss of 1/3rd to 2/3rd
Class III Severe – Loss of 2/3rd or more
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PHOTOGRAPHIC IMAGES
 Preextraction photographs can be useful for
determining teeth selection and arrangement
 Observations on face form and jaw relations
also can be made
 Circumoral support and smile lines may be
usually gleaned from a series of old pictures
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DIAGNOSTIC/STUDY CASTS
 3D analogue of available denture-
bearing areas
 Provide accurate information on
tooth size and arrangement
 When articulated, reveal jaw
relationships, interarch tooth
relationships
 Under-cuts can be observed
directly or determined precisely
with the aid of a dental surveyor
 Assist in making decisions on
preprosthetic surgery
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Classification for the Completely
Edentulous Patient
(ACP-1999)
Class I
Class II
Class III
Class IV
Ideal or minimally
compromised
Moderately
compromised
Substantially
compromised
Severely
compromised
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Potential Benefits Of The System
 Better patient care
 Improved professional communication
 Better screening tool to assist dental school
admission clinics
 Standardized criteria for outcomes
assessment
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DIAGNOSTIC CRITERIA
1. BONE HEIGHT (MANDIBULAR)
2. RESIDUAL RIDGE MORPHOLOGY (MAXILLA)
3. MUSCLE ATTACHMENTS (MANDIBLE)
4. MAXILLOMANDIBULAR RELATIONSHIP
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DIAGNOSTIC CRITERIA
IN DETAIL
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DEVELOPMENT OF
THE TREATMENT PLAN
 After all the intraoral and general physical and
dental conditions have been recorded and
radiographs, casts, and other visual aids are in hand,
they can be interpreted and the treatment plan
developed
 Details of the specific observations determine the
details of the treatment required
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A PRIMER ON
TREATMENT OPTIONS
1. Adjunctive care
2. Prosthodontic care
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ADJUNCTIVE CARE
 Elimination of infection
 Elimination of pathoses
 Surgical improvement of
denture support and space
 Tissue conditioning
 Nutritional counselling
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PROSTHODONTIC CARE
For a patient destined to become
edentulous
For an edentulous patient
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 Removable partial denture
 Conventional
 Interim
 Hybrid complete denture/removable
partial denture
 Transitional
 Complete denture
 Immediate or conventional
 Definitive or interim
 Tooth, implant, or soft tissue supported
FOR A PATIENT DESTINED TO
BECOME EDENTULOUS
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FOR AN EDENTULOUS
PATIENT
 Complete denture
 Soft tissue supported
 Implant retained
 Implant supported
• Fixed
• Removable
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Clinical Conditions That Suggest
Need for Teeth Extractions
 Advanced periodontal disease with severe
bone loss around the teeth
 Severely broken-down crowns with subgingival
residual tooth tissue that cannot be
adequately restored
 Fractured roots
 Periapical or periodontal abscesses that
cannot be successfully treated
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Treatment plan decisions
 Tissue conditioning / finger massage
• Type of treatment material, frequency
 Preprosthetic surgery
• Procedures proposed and staging
 Impression procedure
• Primary / final, material
 Jaw relation and articulator
• Face bow transfer, articulator & its control settings
 Tooth selection
• Shade, mold, material and number
 Denture base material
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Why treatment plan??
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FINANCIAL IMPLICATIONS
 Must consider the financial implications of any
selected treatment plan
 Optimal treatment plan is useless if the patient
cannot afford it
 Prioritize the need for different treatments based on
the significance of the identified problems
 Treatment plan should balance the patient’s needs
and ability to pay
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SUMMARY FOR THE TREATMENT PLAN
 Requires a broad knowledge of treatment possibilities and detailed
knowledge of patient needs determined by a careful diagnosis
 Treatment beyond the competency of the treatment planner should
be referred to more experienced
 Treatment planning must have a parallel process of developing a
prognosis
Treatment planning is the process of matching
possible treatment options with patients’ needs
and systematically arranging the treatment in
order of priority but in keeping with a logical
or technically necessary sequence.
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