EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

EXAMINATION, PLANNING 1,7,10,16,17,21

DIAGNOSIS

AND

TREATMENT

Examination, diagnosis and treatment planning are usually most neglected phases of complete denture construction process. The fact is that the success in complete denture construction is frequently dependant on what is done prior to construction of denture as much as or more than skill and meticulous care utilized in actual construction of denture. Many denture failures could have been avoided, if adequate consideration had been given to proper examination and diagnostic procedures. Examination, diagnosis and treatment planning of complete denture fabrication procedure should includes, - Initial interview and psychologic evaluation - Complete medical history. - Complete dental history. - Complete clinical examination. - Complete series of radiographs. - Diagnostic casts. - Centric relation records for mounting casts on articulator.

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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

As far as neutral zone is concerned during examination and diagnosis special consideration should be given to, 1] INITIAL INTERVIEW: Enough time must be given to it, to allow the dentist and the patient to appraise and asses each other properly. Our objective at this point is to help the patient to talk about his problems and more he talks, the more we learn not only of his specific denture problems but the patient as an individual. DeVan in 1942 has said the dentist should meet the mind of patient before he meet the mouth of the patient.

2] MEDICAL HISTORY: A complete and through evaluation of prior and existing health status of patient is of primary importance in determining the possibilities of success in complete denture. In medical conditions such as, - Diabetes - Hormonal imbalance eg. Menopause, Osteoporosis Bone resoption is fast hence it is mandatory to locate the neutral zone and arrange the teeth accordingly which prevent lateral forces on the ridge and hence prevent further excessive ridge resorption.
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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

Medical history should include dietary evaluation because in conditions such as protein deficiency, patients muscles are weak, which affect the neutral zone. Various diseases of nerves and muscles may affect the neutral zone and subsequently the treatment plan. Such as, - Bells palsy. - Bulbar palsy. - Muscle dystrophies. - Myotonias. - Myasthenias. - Muscular atrophy/dystrophy. - Known case of surgical reconstruction eg. Hemimandibulectomy, Glossectomy.

3] DENTAL HISTORY: The looseness of denture may in no way, be caused by any technical failure on the part of dentist, but rather to some systemic disease or poor bone factor. In dental history we are particularly interested in knowing if the patient lost his teeth because of caries or periodontal disease. The observation has frequently being made that the patient who lost their teeth as a result of caries will generally have a stable ridge, where as those whose teeth were lost because of periodontal disease will manifest more rapid ridge resoption and
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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

recording neutral zone and fabricating denture by neutral zone approach will be more helpful in patient who lost teeth due to periodontal disease. - ORAL HABIT: All bad oral habits should be thoroughly investigated such as, - Bruxism - Lip/cheek biting. - Subconscious lifting of dentures. - Clicking of teeth during speech. - Tongue thrusting. - Reverse swallowing. All these habits creates imbalance in forces generated by lips, cheeks and tongue and subsequently affects stability of denture. 4] CLINICAL EXAMINATION: Complete and through clinical examination after complete medical and dental history is very important for treatment planning and success of denture. It is important to first carefully inspect the existing dentures both inside and outside the mouth, for examination of occlusion, contour, design, extension and teeth arrangement.

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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

RIDGE FORM: Smaller one or both arches causes inadequate tongue space, which encroaches the tongue, producing excessive outward force affecting the neutral zone. Three common types of ridge forms are 1) U shaped. 2) V shaped. 3) Square shaped. PALATAL VAULT: Three common types are, 1) V shaped. 2) U shaped. 3) Flat. U shaped palatal vault provides adequate ridge size and tongue space so it is most favorable. MUSCLE ATTACHMENT AND TONICITY: The height of muscle and frenum attachment, and tonicity of muscle may affect the retention and stability of denture. Lammie 16 in 1959 has shown that as the ridge resorbs the ridge crest falls below the origin of mentalis muscle. As a result the muscle attachment folds over the alveolar ridge and comes to rest at superior surface of the crest. The result of this situation is the posterior positioning of the neutral zone, so need to place the
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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

lower anterior teeth more lingually than the position of natural teeth.

The tonicity of muscle is probably of greater importance than the actual position of the attachment because; flaccid, hypotonic musculature with attachment close to the crest may not necessarily affect the denture, on the other hand hypertonic musculature even though with low attachment creates hazard. Imbalance between inner and outer musculature tonicity that is tongue and lip/cheek affect the neutral zone location. For example, if the tongue musculature is hypotonic than the lip/cheek musculature the neutral zone shifts medially and vice versa. Every patient requires conditioning of the supporting tissue and musculature. The stretch and relax exercises used to condition the mandibular muscles are open wide and return to rest, left to rest, right to rest, forward to rest, back to rest and various tongue movements.10

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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

The dentures may fail or at least less successful than they might have been without proper conditioning. The stretch-relax and tongue exercises make the patient a participant in the endeavor and not merely a spectator. The patient must realize from the start that achievement of success in his denture experience is a joint venture and that some of the responsibility for success is on his shoulder.10 TONGUE POSITION: Tongue size and tongue position should be care fully evaluated. An excessively large and broad tongue is unfavorable both for impression procedure and for proper teeth positioning. Retromylohyoid space (Lateral throat form) is the potential space that is partially or totally obliterated by the tongue movement. To a large extent the success of denture will depend on how much of this space can be utilized, because this area is critical for lingual seal and lateral stability. Various structures of the oral cavity changes considerably, when a patient becomes edentulous. Thus edentulous status, whether the patient is provided with denture or not, will be characterized by the destruction of residual ridge for remainder of patients life. Because of these changes the lips and cheeks no longer be supported by the teeth and bone, and therefore show the tendency to full into the oral cavity. At the same time the tongue will expand into the space formerly occupied by the teeth.
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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

This lost phenomenon is partly due to growth of tongue and has been named PROPTOSIS LINGUALIS.7 More important than tongue size is the tongue position. To determine the tongue position it is important that the patient may not be aware of what we are looking for. The patient should simply be told to open the mouth to a normal width for evaluation of tongue size and position. Wright, Swartz, and Godwin classified the tongue position as normal or abnormal, retracted or awkward. Wright21 also classified tongue position as, - Class I: The tongue lies in the floor of mouth with the tip forward and slightly below the Incisal edges of the mandibular anterior teeth. - Class II: The tongue is flattened and broadened but the tip is in a normal position. - Class III: The tongue is retracted and depressed into the floor of mouth, with the tip curled upward, downward or assimilated into body of tongue.

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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

Class I position of tongue has the most favorable prognosis. The floor of mouth will be high enough to provide border seal with lingual flange. Class II and Class III are unfavorable positions as they drop the level of floor of mouth and do not provide an adequate lingual seal. An attempt to extend the flange to gain border seal will result in overextended flanges that would dislodge the denture during tongue movement. The retracted tongue not only does not provide a seal but as the tongue retracts, it broadens and contacts the lower posterior teeth and creates excessive outward pressure, which constantly unseat the denture. TONGUE HABITS: Tongue position should always be correlated with abnormal swallowing pattern and tongue thrusting habit. In normal swallowing the teeth are in occlusal contact and dorsum of tongue exerts force essentially against the palate and rugae area. This action exerts an essentially vertical and stabilizing force on upper denture. Tongue thrusting is an old term that refers to Reverse swallowing a habit in which the tongue is positioned incorrectly
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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

during the process of swallowing and deglutition, and results in detrimental consequences.17 In abnormal swallowing pattern tongue exerts a very powerful horizontal force against the upper and lower anterior teeth, which shift the neutral zone anteriorly and affect the denture stability. A patient, who has difficulty in positioning the tongue out of the way for routine dental care, is often a reverse swallower. Lip constriction was associated with reverse swallowing in 98% of a sampling of the 270 patients that were studied. In most of the patients this constriction is not evident unless the dentist, without explaining to the patient holds the center of the lower lip gently away from upper lip with his finger, and ask the patient to swallow. The response varies from inability to swallow to a forceful rejection of a finger as the lips contracts and press together.17 A varying, but definitive degree in lack of tongue control can be observed in all patients who exhibit reverse swallowing. When patient has asked to hold the tongue in the back of mouth, they may do anything with it (including sticking it out of mouth and saying I cant).17 If we uncover these problems during diagnostic examination, we can discuss this with patient and accordingly can plan the treatment.
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EXAMINATION, DIAGNOSIS AND TREATMENT PLANNING

In order to obtain a complete picture of all the problems that exist in patients mouth, it would be advisable to make a complete diagnostic study. This would includes, - Radiographs. - Diagnostic impressions to obtain diagnostic casts. - Centric relation record. - Diagnostic mounting on articulator.

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