CHAPTER 3

Diagnosis and treatment planning for the patient

with some teeth remaining

Dentists have been very successful in treat- made. Only then can treatment plans be devel-
ing edentulous patients with complete den- oped to best serve the needs of each individual
tures. However, the profession's commitment patient.
to avoiding the edentulous state continues, and Those patients with some teeth remaining
this commitment has led to expanded knowl- who may need complete denture service tend
edge and clinical skills. As a result, earlier and to fall into the following three groups, each of
improved operative and prosthodontic treat- which poses special problems and decisions:
ment, combined with the effectiveness of mod- 1. Patients with severely depleted dentitions
ern endodontic and_ periodontal therapy, characterized by extensive caries or ad-
usurped the old myth that tooth loss inevitably vanced periodontal disease (Fig. 3-1); im-
accompanies old age. The same therapeutic mediate dentures are usually prescribed
modalities can also be applied to persons who, for such patients, and this topic is de-
as a result of earlier neglect, come for treat- scribed in Chapter 26
ment with broken-down dentitions. These pa- 2. Patients with depleted dentitions (Fig. 3-
tients can frequently have their masticatory 2) or, infrequently, failed reconstructions
systems restored to near normal without having with one or more teeth that can serve as
to consider prosthodontic intervention as an in- overdenture abutments; these potential
terim postponement of the edentulous state. abutments may require minimal prepara-
Patients with some teeth remaining who re- tion or else entail several procedures
quest complete dentures should be carefully di- (such as endodontic or periodontal ther-
agnosed to ensure that treatment alternatives apy or gold coping) to enhance their lon-
to complete dentures are thoroughly consid- gevity
ered. The decision to retain or remove even The objective in retaining teeth under
one tooth is serious, and all alternatives must complete dentures is alveolar bone pres-
be explored before a final decision is made. ervation (Fig. 3-3) and is discussed in
The removal of teeth is an irreversible proce- Chapter 25. The overdenture or tooth-
dure, underscoring the significance and impor- supported complete denture concept has
tance of a correct diagnosis. led to a dramatic increase in the number
Diagnosis consists of planned observations to of patients who have been spared the
determine and evaluate the existing conditions, edentulous predicament.
which lead to decision making based on the 3. Patients who are edentulous in only one
conditions observed. All the facts must be arch, most frequently the maxillary; a
known before they can be correlated in such a characteristic clinical picture emerges in
way that judgments and decisions can be such patients and includes one or more of

51
52 Preparing the patient for complete dentures

Fig. 3-1 Advanced neglect makes both patients, A and B, candidates for immediate
denture therapy. The full-mouth radiographic survey, C, of the patient in B, combined
with an assessment of poor patient motivation, confirms the decision to prescribe total
extraction for this individual.
 Diagnosis and treatment planning for the patient with some teeth remaining 53

Fig. 3-1, cont'd For legend see opposite page.

the following: (a) few anterior mandibular the mandible appears to be very sus-
teeth present, (b) variable hyperplastic ceptible to residual ridge resorption
replacement of the anterior maxillary (Fig. 3-5). In previous editions of this
ridge secondary to anterior upward set- text, we favored sacrificing the remaining
tling of the maxillary denture, (c) the teeth in such situations. However, experi-
presence of pendulous enlarged maxillary ence has demonstrated that such drastic
tuberosities, or (d) loss of the vertical di- action is only rarely needed, and modifi-
mension of occlusion (Figs. 3-4, 3-7, and cations in technique and the materials
3-9) used allow for a more conservative ap-
Infrequently an intact or restored max- proach. The single denture opposing a
illary dentition is opposed by an eden- natural dentition is discussed in Chap-
tulous mandible, and in these patients ter 27.
Text continued on p. 58.
54 Preparing the patient for complete dentures

Fig. 3-2 A and B, This middle-aged patient had complaints of mandibular dysfunction
and dissatisfaction with his appearance. Recovery of the lost vertical dimension of occlu-
sion and bilateral function was easily accomplished by treatment with overdentures. C
and D, The results of such treatment in another patient are illustrated.
 Diagnosis and treatment planning for the patient with some teeth remaining 55

Fig. 3-3. The level of alveolar bone around retained teeth contrasts dramatically with
the absence (due to resorption) of bone around the site of the former natural teeth.
56 Preparing the patient for complete dentures

Fig. 3-4 A, Single maxillary denture opposing a partially edentulous mandible with an
unserviced bilateral distal extension prosthesis. B, The vertical dimension
of occlusion
has collapsed, and the anterior maxillary ridge is now replaced by hyperplasti
c tissue.
 Diagnosis and treatment planning for the patient with some teeth remaining 57

Fig. 3-5 A, This patient never wore a lower denture, and the edentulous mandibular
ridge opposed a restored maxillary dentition for several years. Usually the mandibular
ridge demonstrates advanced resorption in such patients, especially if a denture is worn,
B. (See Chapter 27.)
58 Preparing the patient for complete dentures

DIAGNOSTIC PROCEDURES 3. The type of treatment the patient is seek-

To make correct decisions, the dentist needs ing will make it possible to arrange ade-
to follow certain steps in an orderly sequence, quate time for the first appointment. If it
and this is preferably done in two appoint- is treatment for a toothache, an emer-
ments. The first appointment should allow the gency visit can be arranged. If it is for
dentist and the patient to become acquainted new dentures, an appointment for making
with each other and allow the dentist to obtain preliminary records can be made.
essential information from the patient. This in-
formation consists of a thorough history, a ra- The first appointment
diographic survey, and diagnostic casts. After The purpose of the first appointment is to al-
thorough consideration of the diagnostic infor- low the dentist to become acquainted with the
mation, the dentist discusses the proposed patient so an evaluation of the problems in-
treatment with the patient at the second ap- volved in diagnosis and treatment can begin. It
pointment, along with the sequence in which also provides an opportunity for the patient to
this treatment will be carried out and the antic- become acquainted with and evaluate the den-
ipated fee for service. tist. Since the success or failure of prosthodon-
The first contact of the patient with the den- tic treatment depends greatly on mutual confi-
tal office is usually by telephone. The call may dence and rapport between the dentist and the
be received by an assistant, a secretary, a re- patient, this appointment is extremely impor-
ceptionist, or the dentist. At this time certain tant. The things that are said and the questions
general, but important, information can be ob- that are asked and answered will determine to
tained, such as the following: a great extent the way the dentist and patient
1. The patient's name, address, and tele- will react to each other. Therefore the first
phone number are important for making contact should be pleasant but serious and dig-
future contacts as may be necessary. This nified. The dentist’s attitude should be one of
information also can be an indication of kindness and concern for all patients and their
the socioeconomic status of the patient problems. A planned office procedure will help
and may provide a clue to the desires and to put patients at ease and develop the mutual
expectations of the patient. respect that is essential.
2. The means by which the patient selected The patient is met by the receptionist, assis-
you as the dentist is important. Was the tant, or dentist at the reception room and con-
patient referred by a dentist? Another pa- ducted to the dental chair. After being comfort-
tient? A physician? Or was your name ob- ably seated, the patient is asked for the infor-
tained from the telephone book or other mation that is necessary for the business
listing? The information about the way records. This will verify or correct the informa-
the patient found you will guide you in tion that had been received by telephone when
discussions regarding office policy, ar- the appointment was made. At this time the
rangement of appointments, and the type patient can supply information about age and
of service that will be expected. If the pa- general health by filling out a questionnaire de-
tient was referred by a dentist, radio- vised for this purpose (Fig. 3-6).
graphs and diagnostic casts may be avail- When the dentist meets the patient for the
able from that dentist. If not, the patient first time, the receptionist or assistant makes
may wish to have that dentist make them the necessary introduction. Then the dentist
so that they will be available to you at the carries on some conversation on general topics
first appointment. Otherwise, these for a few moments and tries to avoid answering
records should be made at the first ap- questions about the patient’s dental problems
pointment with you. at this time. Instead, this time is for making
 Diagnosis and treatment planning for the patient with some teeth remaining 59

certain observations of the patient. These in- Table 3-1 Common symptoms associated
clude the apparent age (i.e., physiologic age with TMJ disorders
rather than chronologic age), facial appearance Reported by patient Clinical findings
and expression (esthetics), speech (phonetics),
Joint noise(s) Clicking, crepitation
lip support, vertical jaw relations, and gener-
Pain in face, jaw, Pain, tenderness with palpation
al health and attitude of the patient as de- ears; headache of masticatory muscles and
termined from an analysis of the health ques- TMJ
tionnaire. Each of these observations will be Pain on mouth TM arthralgia
taken into consideration as the diagnosis is opening
Difficulty opening Impaired mandibular mobility;
made.
wide and chew- irregularity or deviation of
Temporomandibular joint disorders. Signs ing opening; locking of mandible
and symptoms associated with TM] disorders
or problems of mandibular dysfunction are fre-
quently encountered in patients with depleted
dentitions. Although the cause of mandibular trol or reduction of contributory factors, and (3)
dysfunction appears to be multifactorial, it treatment of pathologic sequelae. A relatively
seems that occlusion is a contributory factor simple and reasonable way to achieve these ob-
that can be best controlled and adjusted by the jectives is by patient counseling about the na-
dentist. Research suggests that the temporo- ture of TMJ disorders and by the use of a bite
mandibular joints of patients who are candi- plane.
dates for immediate or tooth-supported com- The making of maxillomandibular relation
plete dentures often demonstrate arthritic or records is one of the most critical procedures in
degenerative changes. Although hard research providing prosthodontic treatment for patients.
evidence is lacking to support the claim that The health of the temporomandibular joints is a
occlusal therapy by itself is of value in the key factor in the assessment of the ability of pa-
treatment of all types of mandibular dysfunc- tients to cooperate with the dentist when jaw
tion, an understanding of the pathogenesis of relation records are made. The health of the
degenerative arthritis gives strength to the be- temporomandibular joints can be estimated by
lief that the arthritic process is influenced by a simple test. The patient is asked to open the
adverse joint loading, which can result from mouth wide and relax, then to move the jaw to
depleted dentitions. the left and relax, and finally to move the jaw
A nonarthritic mandibular dysfunction is di- forward and relax. If the patient has difficulty
agnosed on the basis of reported symptoms and coordinating these movements or following the
clinical findings (Table 3-1). A degenerative ar- instructions correctly, problems in recording
thritis is similarly recognized but usually is the jaw relations can be anticipated.
confirmed by means of TMJ radiographs. The The next test consists in placing a fingertip
dentist's treatment strategies will generally on the face over each of the condyles and in-
emphasize rest for the masticatory system plus structing the patient to open the mouth slightly
the elimination of occlusal discrepancies and and move the jaw rapidly from side to side and
the restoration of support for the vertical di- then to open wide and close rapidly. Any pos-
mension of occlusion. Quite frequently, record- sible clicking or crepitus in the joints can be
ing jaw relations accurately will be a problem detected by the fingers. If these conditions ex-
with these patients, and this fact must be taken ist, more difficulty in recording jaw relations
into consideration when the treatment plan is can be anticipated. Naturally, this means that
made and appointments are scheduled. Recom- more time will be required for making jaw re-
mended strategies are fairly routine, and tend lation records and that changes in maxilloman-
to include (1) symptomatic treatment, (2) con- Text continued on p. 64
Instructions:

This history is designed to assist us in finding out more about you and your problems (if any). Please circle the correct
answer YES or NO. We will check your answers with you.

Mr. Mrs. Miss Ms

Address

City

Phone (HOME) (BUSINESS)

Occupation

Bus. Address Birth date

Referring doctor

Address & phone

Name of spouse

Occupation

Number of children

Ages

Family physician: (name, address, tel.)

When did you last see him and why?

Do you take any medication? (how much and why)

Other doctors?

SECTIONI MEDICAL
Has a doctor ever told you that you have a heart condition (heart murmur, heart leakage, heart attack ...
Or angina pectoris, for example)?

Do you bleed abnormally following a cut, a tooth extraction, or other operation?

Do you have any allergies (hay fever, asthma, for example)?

Are you allergic to any drug or medicine (aspirin, sulfas, penicillin, or Novocaine, for example)?

Have you ever had a lung, liver, or kidney disease?

Have you ever had syphilis?

Fig. 3-6 Sample of a health questionnaire.

SECTION II CARDIOVASCULAR
Do you get out of breath easily?

Do you have difficulty breathing when you are lying down?

Are your ankles often badly swollen?

Have you ever had a stroke?

Nervous system
Have you ever been treated for an emotional disturbance?

Have you fainted more than twice in your life?

Have you ever been treated for any other disease of the nerves?
Respiratory system
Have you ever had a sinusitis?

Have you ever coughed up blood?

Have you ever lived with anyone who had tuberculosis?

Gastrointestinal
DOWOUMAVeTLeEGUCHUSPEIISOLGlaltheagre «exert cas cane cua ee areas Cn Ah ata cee ee een estes

AVE VOUUCVCIVOM| LEC tot OOCI2 saree, ner ekcage chem cine esmtnep uti nse Scr Hs RE ioe ATE rt cps SS oO

Have you suffered from any other stomach trouble?

Have you ever had jaundice? .......

Endocrine system
Doesaibioodirelativeiofivours nave diabetes? in cred wane « A eee Ne ah tae aaa qi eee ee

Have you ever taken thyroid tablets?

Are you taking, or have you ever taken, ACTH or cortisone?

Blood
TIAVE VOULEVE TALAGhAN CIDA Giewe: aapetraeh alae aiten-tasckn cues UNG Nota lant tts are oenGA semen rn, nwa iusdeyts cNnieg reeae

Are you a hemophiliac?

PAVE OULCVETNaclanyiothenblOOdCISCASCS 7a. mi smeetn atseusn spencer

eyeyoo iphoman itsbesae a nina
Bones and joints
DO Wow) MAE AUNTS: ¢ used mee da exe BO Bop on Oc Ae ho Ron 6 Bomb eo okee mo a Gk ot osha Goa ao mo

Have you ever had more than one fractured bone?

Have you ever had more than one dislocation?

Have you ever had a bone infection?

Have you gained or lost much weight recently

Has your doctor given you a special diet?

Fig. 3-6, cont’d Sample of a health questionnaire. Continued.

62 Preparing the patient for complete dentures

Bones and joints—cont’d

Have you ever had radiation treatments for any disease?

HavevourevenhadiatumomomcamCeie errata sic sakeacces etre ee aeausten nteee eters eta ee es aeae

Havevyourevernhadian ODeratOm?. .okere ktvts oe ane Matec heer Petra) cesarean et te eee oe ee

DOMWOUSIMOKE? Sees aie stacy. ee. event each sie ean cos aloes UE a Ro en Re hme ere eee ae Pato

Alcoholicibeverages?.suc.. wetsein Aca trace ee tet ew oe re Se i eon ree eos

PHYSICAL ACTIVITIOS 2 ctu ere 3 ine ohS.n Seem are od oN day aeeiert dske eushee tsSrceen ene etaD eee ane Meee Cre tae

Do you feel you are in good health at the present time? If not, please specify:

Summary of medical history

Do you have dental insurance?

Cali Chee COUP FPolicyiNO! Cert. or Soc. Ins. No.
Dental history:
How often do you brush your teeth?

Do you wear a prosthesis: (denture or bridge)?

Complete upper Partial upper Bridges Upper Right

Complete lower Partial lower Lower Left

Have you received treatment by a dentist in the past year?

Have you ever experienced prolonged bleeding following a tooth extraction?

Have you ever experienced dizziness, or have you ever fainted, while undergoing dental treatment?

Fig. 3-6, cont'd Sample of a health questionnaire.

 Diagnosis and treatment planning for the patient with some teeth remaining 63

CURRENT COMPLAINT, HISTORY OF PRESENT CONDITION, PAST DENTAL HISTORY

ON EXAMINATION (Extra-oral, functional analysis, soft and hard tissues, prostheses)

IMPRESSION AND DIAGNOSIS PROPOSED TREATMENT AND PROGNOSIS

Fig. 3-6, cont’d Sample of a health questionnaire.

64 Preparing the patient for complete dentures

dibular relations may occur after the dentures Any disharmony in the occlusion or between
have been in use for some time. Such changes centric relation and centric occlusion should be
are especially likely if the patient reports ten- noted because it could explain some of the dif-
derness when fingertip pressure is applied by ficulties that the patient has been experiencing.
the dentist. These observations also provide information
Dental history. It is important that the den- about the patient's coordination and ability to
tist know about the patient's dental history, move his mandible to the centric position as
and this can be determined when the right well as to perform multidirectional contact
kinds of questions are asked. Some of these are movements when instructed to do so.
general, and some are specific. Some will re- Existing prostheses should be cleaned and
veal simple but important facts, and others will laid aside while the teeth and oral cavity are
stimulate or encourage the patient to discuss examined. The mobility of the remaining teeth
dental problems, troubles, and complaints. should be tested, and the depth of the gingival
Any significant comments should be noted on sulcus should be measured. The clinical crowns
the patient's record card for further study and should be inspected visually and by use of a
consideration at the next appointment. Up to sharp explorer. If teeth have restorations, the
this point, the questions are preliminary. margins of the restorations, the occlusal surface
After the preliminary conversation, in which contours, the general shape of each tooth and
the patient is encouraged to talk and the den- its restorations, and the materials of which the
tist and assistant are good listeners, the discus- restorations are made should be observed and
sion can be directed toward the patient’s recorded. This information provides evidence
present dental problem by the question, What of the quality of home care and _professional
do you have in mind for us to do for you? The care that the teeth and mouth have received. If
response will indicate considerations that are of this care has been inadequate, the decision to
major concern to the patient. It may be to ob- retain or remove remaining teeth becomes eas-
tain new dentures for one or more reasons such ier to make. If the patient cannot be trained
as to improve his/her appearance or to eat bet- and motivated to give his teeth adequate care,
ter. These should be carefully noted because their restoration by crowns, inlays, and other
they could influence the diagnosis and the operative dentistry procedures will be futile.
treatment procedures to be used. For example, This problem should be thoroughly discussed
if a patient’s major concern is appearance, it with the patient so that a similar observation
will most likely require more time to solve the and evaluation can be made at the second ap-
problem at the try-in stage than if the concern pointment, at which time the final decision can
is only about eating. be made.
As each of the patient's objectives or com- Diagnostic casts and a radiographic survey
plaints is mentioned, it should be carefully are essential for the completion of the diagno-
noted on the patient’s chart, but the dentist Sis.
should refrain from making any comments Diagnostic casts. Diagnostic casts that may
about them in relation to the previous treat- be used as part of the preextraction records are
ment received by the patient. essential if the correct decisions are to be
Intraoral examination. With this background made. Therefore diagnostic casts must be avail-
information recorded, the dentist should carry able before the final decision is made regarding
out an intraoral examination. The remaining the removal of any teeth. The impressions for
teeth are charted to show their location and making diagnostic casts can be made in alginate
condition. If the patient is wearing removable (irreversible hydrocolloid) impression material
prostheses, the occlusion of these restorations in stock trays.
should be observed before they are removed. The making of the impressions for diagnostic
 Diagnosis and treatment planning for the patient with some teeth remaining 65

Fig. 3-7 Mounted diagnostic casts reveal existing conditions and potential problems.
A, The mandibular occlusa! plane is unfavorable and needs to be leveled; the tuberosity
encroaches on the interarch space. B, A Class Ill jaw relationship is evident. Notice that
this mounting on a semiadjustable articulator necessitated the use of occlusion rims.

casts is an important diagnostic procedure in it- ping forces on opposing, usually maxillary,
self. It will reveal unusual sensitivity of the dentures.
mucous membranes, a tendency toward gag- A third molar that is tipped forward can ex-
ging, tolerance of the patient to procedures in ert horizontal forces against its opposing tooth
the oral cavity, coordination of tongue activity, in eccentric occlusions, and this can dislodge a
and other factors important to the diagnosis. maxillary denture (Fig. 3-7). If the occlusal sur-
When teeth remain in both dental arches, face cannot be reshaped so it is parallel to and
the casts made in these impressions are prefer- on the occlusal plane, the tooth should be re-
ably mounted on a simple hinge articulator. A moved. This can be done by grinding on its oc-
wax interocclusal record can serve for relating clusal surface or by making a full coverage
the casts to each other on the instrument. If crown. Endodontic therapy may be necessary if
the impressions and interocclusal record are the tooth is to be saved.
made at the first appointment, the casts can be Interarch space problems. Diagnostic casts,
mounted and studied before the second ap- which are mounted or hand held, will reveal
pointment (Fig. 3-7). When bilateral centric the amount of interarch space. This is impor-
stops are absent, an articulator mounting is im- tant information because a lack of space in this
practical and casts can be examined in a hand- part of the mouth has caused many dentures to
held relationship. fail. If a tooth is so extruded that its occlusal
Perhaps the most important diagnostic infor- surface is above the occlusal plane, it should be
mation to be obtained from mounted diagnostic removed unless it can be shortened sufficiently
casts is related to the occlusion. This informa- to be on the same plane with the other teeth in
tion is essential because it will determine for that dental arch.
many patients whether teeth that might be Extremely large maxillary tuberosities make
saved should be saved. For example, periodon- it necessary to locate the back end of the oc-
tal therapy may be able to save some teeth that clusal plane too low, to omit some posterior
actually should be removed to develop a favor- teeth, or more frequently to shorten the den-
able occlusal plane or to avoid rotating or tip- ture bases from their correct border extent and
66 Preparing the patient for complete dentures

Fig. 3-8 Retention of this large tuberosity (arrows) would compromise the occlusal
plane and distal extension of a mandibular denture. If reduction is feasible, it should be
done.

Fig. 3-9 A thick layer of fibrous connective tissue on the tuberosity does not provide a
firm foundation for a denture. The bulk of the tissue will cause interference between the
denture bases and prevent proper location of the back end of the occlusal plane. These
lilms also emphasize the fact that the external ridge contours (as observed in Fig. 3-8)
are not necessarily reflected in an identical morphology of the underlying bone.
 Diagnosis and treatment planning for the patient with some teeth remaining 67

contour (Fig. 3-8). If there is insufficient space toms. Abnormalities can and do occur, how-
between the residual ridges, the denture bases ever, and have been demonstrated in a high
will interfere with each other and cause the percentage of patients on radiographic exami-
dentures to tip away from the basal seats in the nation. These may be foreign bodies, retained
anterior part of the mouth. In this situation the tooth roots, unerupted teeth, or varied pa-
lower denture base will wear away over the thoses of developmental, inflammatory, or neo-
retromolar pads and holes will be worn through plastic origin (Fig. 3-10). Of these, the retained
the maxillary denture base, leading to reduced root is most commonly present. A_ histologic
retention in both dentures. The fact that a pa- survey of a series of retained tooth roots sug-
tient may have been wearing dentures does not gests that in the absence of clinical or radio-
rule out this difficulty. graphic abnormality, the retained tooth root
Although lack of adequate space between the can be regarded as having been accepted by
ridges is easily recognized on the mounted the tissues. The decision to extract such roots
casts, radiographs will show whether large tu- preprosthetically tends to be an elective one.
berosities are bone or are simply an over- However, some situations are specific indica-
growth of fibrous connective tissue in the tu- tions for their removal (for example, the root's
berosity region (Fig. 3-9). occupying a superficial submucosal position af-
The large fibrous tuberosity can usually be ter progressive alveolar ridge resorption).
moved from side to side when grasped by a Radiographs also confirm the depth of peri-
thumb and forefinger. If it is movable in this odontal pockets and provide information about
test, it should be removed. pulpless teeth. They can show the amount of
If the tuberosity is firm and hard and radio- bone lost around the remaining teeth and in
graphs show that it is composed of a thin layer the edentulous regions (Fig. 3-10). They also
of soft tissue over bone, it may have to be ac- can show the relative thickness of the submu-
commodated in the design of the denture. If it cosa covering the bone in edentulous regions,
seems necessary to shorten a large bony tuber- the location of the mandibular canal, and the
osity, care must be taken to avoid opening into mental foramen in relation to the basal seat for
the maxillary sinus. Such a surgical procedure dentures. They can give an indication of the
may be contraindicated by a patient's systemic quality of the bone that supports the teeth and
health. will support the dentures, though this is not as
The problem of insufficient interarch space reliable as it should be because of variations in
in the posterior part of the mouth can be radiographic techniques, since variations in ex-
avoided for most people if the soft tissue distal posure time and developing procedures cause
to the last upper and lower molars is excised at difficulty. In general, however, the more dense
the same time those teeth are removed. (radiopaque) the bone appears to be, the better
Radiographs. Radiographs are essential for the bony foundation and the less likelihood
evaluating the conditions existing in every pa- there is for rapid change in the basal seat when
tient needing prosthodontic service. The den- dentures are worn.
tist must know the conditions under the mu- Sharp spicules of bone on ridge crests are
cous membrane and the condition of the sur- also apparent on properly exposed dental radio-
faces that can be seen. graphs, and these conditions may affect deci-
The presence of abnormalities in edentulous sions about the location of the occlusal plane
jaws or in the edentulous segments of partially and about the types of impressions and denture
edentulous jaws is most often unsuspected be- base design that have to be used. A panoramic
cause of the absence of clinical signs or symp- radiograph should be taken routinely. It is also
68 Preparing the patient for complete dentures

Fig. 3-10 Radiographic evidence can be combined with clinical observations to enable
the dentist to prescribe optimal treatment. The patients in A and B are both partially
edentulous and each requested complete denture treatment. In A, it is clear that all the
teeth can be retained and removable partial dentures can be prescribed rather than
complete dentures. In B, a minimum of two bilaterally located and suitable abutments to
support an overdenture are not present. This mandible was therefore treated with an im-
mediate denture.
 Diagnosis and treatment planning for the patient with some teeth remaining 69

advisable to compensate for the unreliability of The answer so far as the dentist is concerned
radiographic interpretation of the anterior re- is simple: to get all the facts and consider all
gions where distortions frequently occur. This possibilities before making the decision to re-
can be achieved by adjunctive use of periapical move the remaining teeth. Many diagnostic
or standard occlusal films. factors are involved. To ignore or fail to recog-
nize any of them could lead to incorrect deci-
TREATMENT PLAN sions.
Once all the intraoral and general physical The facts to be learned before the remaining
and mental conditions have been noted on ap- teeth are removed include the following:
propriate record cards or sheets, the treatment 1. General health of the patient
plan can be developed. This includes which This will determine the extent and se-
teeth are to be saved and how, the sequence in quence of any surgical procedures that
which teeth should be removed, the amount may be necessary. In most instances it
and type of oral surgery that might be re- may be more desirable for the patient to
quired, and the type of prosthesis that is indi- retain loose or broken teeth than to have
cated. Should it be an overdenture, an imme- them removed. In other patients it may
diate overdenture (some teeth are extracted at be that their health can be improved if in-
the same time as the immediate denture is in- fected teeth are removed.
serted), or an immediate denture? Or should 2. Age of the patient
all of the teeth be removed and a waiting time This can be a determining factor in the
arranged so that the tissues can heal somewhat decision to have the remaining teeth re-
before impressions are made or the dentures moved. If the patient is young and the
are inserted? Only in the rare cases of serious bone is not fully calcified, the remaining
systemic health problems is the latter treat- teeth should probably be saved regardless
ment chosen. (See Chapter 26.) of the cost of restoring them or the atti-
tude of the patient toward the discomfort
Deciding whether to extract involved. The experience of many eden-
the remaining teeth tulous young people is that they lose
The loss of all remaining teeth can be a terri- much too much alveolar bone in a short
ble psychologic shock to patients, even though time after they lose their teeth.
some of them may not admit it. Consequently If the patient is old and feeble, it may
the dentist should be empathic for patients be better to save the few remaining teeth.
who must lose their teeth. Every possibility for If, however, elderly persons have loose,
saving them should be explored. It is when pa- extruded teeth that are endangering their
tients recognize that the dentist does not want health, the teeth should be removed.
them to lose their teeth that the necessary feel- 3. Tooth mobility
ing of confidence can be developed. Highly mobile teeth that have been ex-
Even patients who say that they want to get truded from their sockets and teeth with
rid of their teeth so that they will not have to radiographic evidence of infection either
see dentists anymore really do not want to lose at their apices or along their sides should
their teeth. They are only trying to prepare be removed.
their defenses against future difficulties they do It is essential that natural teeth not be re-
not understand. If the dentist removes the moved unless there is a valid reason for doing
teeth without adequate reason, physical, men- so. These reasons may include one or more of
tal, and even legal problems may arise. the conditions listed on the next page.
70 Preparing the patient for complete dentures

1. Advanced periodontal disease with severe The color of the natural teeth should be re-
bone loss around the teeth corded on the patient's record card. This will
o
Severely broken-down clinical crowns (subgin- reassure the patient of the dentist's interest in
gival) that cannot be adequately restored; frac- the patient's well-being, but equally important,
tured roots this record made before the teeth are removed
Periapical or lateral abscesses that cannot be
Oo
will be valuable to the dentist. It will save time
successfully treated
and help to avoid errors in tooth color selection
4. Unfavorably tipped or inclined teeth that pose
problems for their use as abutments for fixed when the dentures are made.
or removable prostheses Photographs of the patient will be most help-
Ot. Extruded or tipped teeth that interfere with ful when the prosthetic work is completed, and
the proper location of the occlusal plane they will be even more helpful as years go by
and the patient needs modification or replace-
It must be emphasized that a number of ment of the dentures. The photographs are eas-
techniques and skills are available to the den- ily made in the dental office. Most useful are
tist to cope with conditions 4 and 5, reducing the following: (1) full face with the lips closed,
the numbers of candidates for total extractions (2) full face with a smile, (3) close-up with the
and immediate dentures. There has been a cor- teeth together and the lips separated, (4) full
responding increase in the number of overden- face with the mouth open wide, and (5) profile
ture patients as a result, attesting to the profes- of the face with the teeth in centric occlusion
sions growing awareness that alveolar bone and the lips relaxed.
must be preserved at all costs.

Preextraction records BIBLIOGRAPHY

No patient should ever be made completely Axelsson G: Orthopantomographic examination of the
edentulous mouth, J Prosthet Dent 59:592-598, 1988.
edentulous or treated with complete overden- Carlsson GE, Kopp S, Oberg T: Arthritis and allied dis-
tures without first having preextraction records eases. In Zarb GA, Carlsson GE, editors: Temporoman-
of the existing dental and facial conditions dibular joint—function and dysfunction, St. Louis,
1979, The CV Mosby Co, Chapter 10.
made. It requires only a few minutes to make Herd JR: The retained tooth root, Aust Dent J 18:125-131,
diagnostic impressions and casts if these have 1973.
not been made before. The diagnostic casts Rugh JD: Psychological factors in the etiology of mastica-
may or may not be mounted on an articulator, tory pain and dysfunction. In Report of the President's
Conference on the Examination, Diagnosis, and Man-
but failure to make them is a serious breach of agement of Temporomandibular Disorders, J]Am Dent
the trust placed in the dentist by the patient. Assoc 106:75-77, 1982.
In fact, it is probably valid to suggest that fail- Zarb GA, Bergman B, Clayton JA, MacKay HF, editors:
Prosthodontic treatment for partially edentulous pa-
ure to make preextraction records may consti- tients, St. Louis, 1978, The CV Mosby Co.
tute professional negligence.