INTRODUCTION

Complete edentulism can be defined as ―the physical state of the jaw(s) following
removal of all erupted teeth and the condition of the supporting structures available
for reconstructive or replacement therapies.‖1 Edentulism is considered a handicap
having a strong negative impact on the quality of life. Apart from the compromised
oral function, loss of teeth potentially leads to decreased self esteem and psychosocial
well being leading to poor quality of life.

Despite the advancement in preventive dentistry, the rate of complete edentulism has
still a major prevalence worldwide. Viewed in a global perspective, notably in
industrialized countries, a rapid overall decline in the rate of edentulism has occurred
over the last three decades due to marked oral health awareness, increased care and
adequate oral health service resources. Further the introduction of osseointegrated
dental implants has revolutionized prosthodontics, and a plethora of scientifically
robust articles have given implant supported and ⁄ or -retained prostheses a significant
evidence base as a treatment for edentulous jaws. It is suggested that the demand for
solutions other than conventional removable dentures for the management of the
edentulous predicament runs increasingly in parallel with improved standards of
living. Additionally, it would not be unrealistic to suppose that such a development is
also occurring in other countries, driven as it appears to be by commercial interests
and increasing consumerism among more informed patients.

Nevertheless, implant treatment remains an unrealistic option for the vast majority of
edentulous subjects. Economy, oral healthcare system, availability of dental services,
dental awareness, cultural tradition, education and other psychosocial factors has
overriding influence on the oral health status of the people, especially in developing
Asian countries as Nepal. Hence, in most societies, Prosthodontic Rehabilitation of
completely edentulous patient with complete denture remains a staple treatment
option, potentially facilitating the oral health related quality of life. Therefore,
improving the conventional management of edentulous patients is a necessity and
requires a keener focus by researchers, educators and clinicians in the developed
world on the needs of populations with fewer resources.2

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The edentulous patient presents with both anatomical and psychosocial factors which
affect the treatment and the ultimate prognosis of prosthetic rehabilitation. Besides the
socioeconomic factors, patient may present with various clinical scenarios. Based on
the severity of completely edentulous predicament, McGarry TJ, Nimmo A, Skiba
JF et al in 1999 classified the complete edentulism into following classes :

 Class I : Ideal or minimally compromised

 Class II : Moderately compromised
 Class III : Substantially compromised
 Class IV : Severely compromised

The correct identification and thorough assessment regarding various forms of

complete edentulism along with its etiological and psychosocial factors becomes
essential for the successful outcome of the complete denture therapy. A thorough
examination and consultation ensures that the patient understands his or her problem
and responsibility for a successful outcome. For this reason, thorough collection of
relevant information needs to precede the initiation of rehabilitative therapy.
Diagnosis and treatment planning thus are the two most important parameters in the
successful management of a patient. Inadequate diagnosis and treatment planning are
the major reasons behind the failure of a complete denture.1,3

Diagnosis, in a proper term, can be defined as the examination of the physical state,
evaluation of the mental or psychological makeup and understanding the need of each
patient to ensure a predictable result.4 It is the basis or a rationale for the effective
treatment plan. Successful therapeutic treatment becomes possible only with the
planned observations to determine and evaluate the existing conditions, ultimately
leading to decision making based on the condition observed Diagnosis involves the
collection of facts obtained from a comprehensive patient history, patient interview
and thorough clinical assessment thereby determining the nature of disease process.5

Treatment planning can be defined as developing a course of action that comprises the
ramification and sequelae of treatment to save the patient need. In a general term, it
is any measure designed to remedy a disease. The treatment plan is based on careful
evaluation of all available information and a definitive diagnosis. No treatment other
than emergency care should be performed without comprehensive treatment plan.

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The clinician is responsible for the diagnosis and treatment of a variety of basic
parameters in respect to the provision of a complete denture service. These include the
recognition of a broad spectrum of the relevant and applied anatomical, physiological
and psychological conditions of each patient, with an understanding of the
significance of each patient‘s medical status. The development of a treatment plan
that leads to the prescription of appropriate prostheses follows and, finally, the
clinician must ensure that the technical requirements for each prosthesis are clearly
communicated to the technician.6 Existing complete dentures which, ideally, have
been considered to be satisfactory by the patient, should also be carefully assessed as
an essential aid to diagnosis and treatment planning. Only by assembling all the
diagnostic information, considering all factors of the patient‘s problem, and reviewing
every aspect in detail can the dentist arrive at a plan of treatment that best assures a
successful result.

Diagnostic record for completely edentulous patient begins with sequential recording
of following basic factors:

1. General information about the patient

2. Patient‘s systemic status

3. Dental History

4. Clinical Evaluation

5. Radiographic Examination

6. Pre-operative records

7. Treatment Planning

8. Prognosis

Diagnostic record obtained must be

 Easily retrievable

 In a logical sequence

 Should be kept confidential

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Methods of gathering general information of the patient:

I) Direct interrogation by the dentist:

Advantages Disadvantages
It offers greatest latitude Time consuming
Questions asked are brief & general Relies heavily on skill & experience
in nature of dentist
Can be probing & overlapping on It is easy to forget necessary
points, dentist deems important questions to be posed.
Helps in developing rapport with
patient and to evaluate patient
attitude towards previous treatment.

(II) A comprehensive questionnaire:

Advantages Disadvantages
It is quick & filled by patient in Patient may not read it carefully
waiting room
May overlook important information

May give it to companions to fill

which lead to errors.

(III) A combination of both:

Advantages Disadvantages
Form filled by pt. can be verbally Time consuming
reviewed

Any +ve/-ve response may be noted

& clarified
Chance to correlate between
examination, observation & pt.‘s
health history
Any conflicting information may be
thoroughly probed

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General Information About The Patient

1. Name
a. Name Proper
 Record keeping
 Identification
 Rapport building
 Easy communication
 Confidence/Psychological security
b. Surname
 Additional information about patient status, race, religion
 Helps in knowing dietary habits ensuring the post insertion
instructions accordingly

Besides the record keeping purpose and easy identification, addressing the patient
by his/her name gives a rather personal touch to the dentist patient relationship.
For the dentist, it enhances building up the rapport with the patient creating the
comfortable zone to work with. It will create a ambient atmosphere for the patient
too in the clinic building up a confidence and psychological security. Knowing the
surname of the patient helps to know the psychosocial factors as the status, race
and religion of the patient. This, in turn, helps in knowing the food patterns/habits
of the patient so that it will facilitate in giving the post insertion instructions and
counseling the patient regarding the limitations of the artificial substitute too.

2. Age
 Adaptability
 Medical condition
 Dependence of patient
 Selection & arrangement of teeth
 Change in the nutritional status
 Age changes
- Resorption
- Tonicity of muscle
- Hearing loss

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a. Adaptability
Age is an indicator of the patient‘s ability to wear and use a prosthesis.
The fourth decade of life is considered as the changing point for capacity to
heal and offer good resistance. During the fourth decade of life, tissues heal
rapidly and are relatively resilient. Patient can adapt readily to newer
conditions and the esthetics is of prime concern followed by comfort and
masticatory efficiency. With increase in age reaching to fifth to sixth decade
of life, there is increased difficulty in adapting to newer situations. There is
often increased tissue sensitivity and decreased healing capacity requiring very
careful handling of tissues.

b. Medical condition
Systemic health status of the patient associated with age is one of the major
determining factor affecting the treatment plan and the ultimate prognosis of
the therapy. As compared to younger age group, the elder people are more
often predisposed to many systemic diseases such as diabetes, hypertension,
arthritis, osteoporosis etc which can directly or indirectly compromise oral
tissues. The World Health Organization's International Classification of
Diseases and Stomatology currently lists more than 120 specific diseases,
distributed in 10 or more classes, that have manifestations in the oral cavity.7

c. Dependence of patient
With the increasing age the elder group of people become more dependent
on other member of family both physically and emotionally. They are
dependent on dominant member of the family for the approval of the treatment
plan, transportation and for the financial factor. In case of completely
dependent elder patient, the appointment scheduling should be in accordance
with the member bringing them for the treatment. Moreover, they want the
presence of some family members during the treatment phase for the feeling of
being psychologically secured.

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d. Selection and arrangement of teeth
Based on dentogenic concept the dignity of advancing age is
appropriately portrayed in the denture by careful tooth color selection and by
mold refinement, also by the intervention of such characterization, as would
be fitting for the age of the patient. For e.g, With the increasing age, the mould
refinement could be done by incorporating wear, less incisal translucency and
darker shades of teeth. Spacing or diastemas could also be incorporated.

e. Changes in the nutritional status of the patient

With the increase in age as the dietary habits of the people are often altered
(non vegetarian turning into vegetarian etc). This change in food habits will
definitely signify the oral health status of the patient, while on the other hand,
facilitates in giving post insertion instructions.

f. Age changes

Age may be associated with hearing loss which makes communication

difficult. There is a characteristic loss of tissue tone with age which may
pose difficulty during jaw relation and teeth arrangement procedure.
Increased age is frequently asssociated with excessive bone resorption which,
if severe, marks the question in the stability of denture.

3. Sex
 Esthetics
 Treatment planning
 Affordability
 Selection of teeth – shape ,shade & form
 Arrangement of teeth
 Physiological & psychological changes
(e.g., menopause in females)
 Predominant disease
(e.g., haemophilia in males)

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a. Esthetics
Generally appearance is a higher priority for women than for men.
Female candidates are more esthetically demanding as compared to male. Though
younger men are concerned with esthetics, they often grow indifferent to their own
appearances as they age and are concerned with comfort and function of dentures.

b. Treatment Planning & Affordability

With the advancing society, females are growing independent day by day.
Despite this fact, particularly the non working females are more dependent on the
dominant member of family, especially the husband for the approval of treatment
plan regarding the choice of treatment planned, cost factor and sometimes even for
the transportation.

c. Selection & Arrangement of Teeth

Based on dentogenic concept the careful tooth size, shape and color
selection, mold refinement and the characterization could be done as would be
fitting for the gender of the patient. For e.g, Feminity is generally associated with
smaller teeth i.e. narrower central and laterals incisors while large sized teeth i.e.
large centrals, prominent canine and broad laterals are associated with masculinity.
Females generally have lighter shade of teeth while male have darker shades. The
incisal edges of maxillary anterior teeth follow the curve of lower lip in females
while the incisal edges of maxillary anteriors form a flat smile line.

d. Physiological and Psychological changes

In females, physiological changes such as menopause present them as

exacting or hysterical patient. They also pose psychological problems with other
problems like dry mouth, burning mouth syndrome & general vague pain.

4. Marital Status

 Treatment planning – dependence

 Selection and approval of teeth and arrangement
 Psychological state of the patient

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 Married females are usually dependent on their male counterparts
(husband) for the approval of the treatment plan. The decision of agreeing
treatment option regarding the financial factor along with the approval of
procedures as the selection and arrangement of teeth are more dependent on
male. Moreover, married females are quite often psychologically dependent
and affected by the decision of their husband.

5. Occupation

 Financial status
 Formulating treatment plan- cost & time
 Esthetic demand
 Determines the patient dental status and concern for an oral health
 Mental attitude of the patient
 Appointments

The occupation reflects the economic background and social status of the
patient which is a deciding factor in formulating the treatment plan regarding
the cost and time. Knowledge of patient‘s social status helps the dentist to
understand the value he/she places on oral health and the patient expectations
from the treatment. It determines the degree of importance of factors to be
incorporated during the rehabilitative therapy like esthetics, phonetics and
functional factors as retention. For professionals, who are in intimate contact
with people in their public life, appearance and retention of denture is more
important than masticatory efficiency. Public speakers, singers and musicians
who play wind instrument require perfect retention and particular attention to
shape and position of teeth and palatal form and thickness. In addition a
question about the work hours will allow the dentist to fix appointments at
time convenient for the patient. Additionally it helps us to know that if the
patient is in high risk area (frequent eating or not) that helps in giving post
insertion instructions. Above all occupation has a direct influence on the
mental attitude of the patient, according to which the personality
characterization can be incorporated during the teeth arrangement.

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6. Address/Telephone/Mob no.

 Treatment planning
 Appointment arrangement
 Recall/future correspondence
The significance of knowing the address of patient is in
determining the choice of treatment plan as well as appointment arrangement.
If the patient is from far distance, the frequency of appointments can be
reduced by giving longer treatment time in a single day. It helps in future
correspondence for recall/follow up. Moreover certain type of diseases are
more common in particular area e.g., fluorosis is common in endemic areas so
that characterization can be done accordingly.

CHIEF COMPLAIN

The chief complain can be defined as a subjective statement made by a

patient describing the most significant or serious symptoms or signs of illness or
dysfunction that caused him or her to seek the health care. It signifies the principal
reason for a person seeking therapeutic intervention.8
Complete denture rehabilitation is a piece of work fabricated by the
dentist but the patient becomes its real owner after insertion. Dentist can no more be
proud of, or satisfied with the dentures fabricated by them as wonderful products by
themselves alone. It is important to make the denture suit the patient so that the new
dentures can truly become his/her own. The denture should never be a ‗stranger‘ to
the patient. This is possible only when the patient‘s requests have been adequately
addressed in the denture.9

M M De Van 1942 stated that “The dentist should meet the mind of the patient
before he meets the mouth of the patient.” According to this statement, for the
proper diagnosis the chief complain or a primary reason of patient for seeking
prosthodontic treatment becomes equally as important as the examination protocol
for arriving at the best possible final treatment plan.

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The concern of patient seeking the prosthodontic treatment should be written in
patient own words so that

 Chief complain may not be overlooked.

 Expectation of the patient can be determined and assessed whether the
expectations are realistic or attainable. The practitioner should not make
unrealistic promises regarding treatment outcome.
 Reflects the patients psychological classification.

The frequently encountered chief complaint could be :

a) Lost all teeth and need denture

The patient with this chief complain signifies that the patient is the first
time denture wearer. Regarding the positive aspect of such patient is that they can
be often motivated as the dentist want whereas on the other hand as the procedure
is completely new to them, hence they should be explained in detail about every
clinical steps as well as the time and cost needed for the treatment. More
reinforcement/ motivation might be required for accepting the treatment procedure
and understanding the limitations of the outcome.

b) Old denture are unsatisfactory/ill fitting

Two factors are needed to be considered in a patient presenting with this
chief complain. They are
i) Denture factor : First of all, the overall intraoral and extraoral evaluation of
the existing denture should be done. If the denture is ill fitting regarding the
physiological and functional factors that is closely matching with patient
chief complain then the new denture has to be fabricated without question.

ii) Patient factor : If the existing denture is upto the mark but the patient is still
unsatisfied with the denture, it is obvious that the patient might have
unrealistic expectations from the denture. In such a case the patient should be
explained properly about the limitations/ realities of denture and motivated
accordingly.

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 c) Old denture worn out/broken/lost
The patient presenting with this chief complain are the most difficult
ones to treat with. Patient under this category are usually satisfied with their old
dentures and seek the treatment only after damage to their old dentures.
Moreover they have been adapted to their old dentures since a varying long time
which they are comfortable with. As a role of prosthodontist, the old denture are
needed to be evaluated for the both favorable as well as unfavourable factors for
the patient. After the evaluation, the good qualities of old denture that is
favorable for the patient should be incorporated in the newer denture. On the
contrary, the qualities of old denture that are unfavorable for the patient required
to be changed for the better prognosis. In such case, despite the patient
satisfaction for the old denture, the patient has to be motivated enough for the
adaptation to the changes to be made in newer denture.

HISTORY OF PRESENTING ILLNESS

The history of presenting illness helps in obtaining an accurate/relevant

information regarding the onset, duration and character of the present illness, as well
as of any acts or factors that aggravate or ameliorate the symptoms. With the
complete denture therapy, the history of etiology of the loss of tooth, sequence of
tooth loss and the duration of edentulous state becomes rather important in
ascertaining a proper diagnosis and treatment plan for the patient.

MEDICAL HISTORY

Oral health is an integral part of general systemic status of the patient. Dental
disease has often oral manifestation of acute, chronic, and systemic disease.
Additionally Medical emergencies can occur at any time during a dental visit.
Therefore, to ensure patient safety and minimise the development of dental or medical
complications, it is important that an up-to-date medical and drug history is available
to identify patients at particular risk.10

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A. Diabetes Mellitus
Diabetes mellitus is an endocrine disorder characterized by
hyperglycaemia which may be caused by an absolute or relative lack of insulin
secretion and insulin resistance or both.
There can be a low output of insulin from the pancreatic beta cells, or
the peripheral tissues may resist insulin. Diabetes Mellitus is a common chronic
metabolic disease worldwide affecting all age groups, particularly the older age
group. The WHO has recently declared it to be a pandemic. Apart from many
chronic macrovascular and microvascular complications of diabetes reported in
the literature, oral manifestations and complications in patients with diabetes
mellitus have been recognised and reported recently as a major complication of
diabetes mellitus. There is increasing evidence that chronic oral complications in
patients with diabetes adversely affect blood glucose control.

 The major clinical symptoms of DM denoted by 3 P‘s

Polyphagia
Polydypsia
Polyurea

Oral manifestations of DM

Various inflammatory diseases and soft tissue pathologies in oral cavities

are associated with diabetes mellitus. Periodontal diseases have been proposed as
the sixth most prevalent complication of diabetes mellitus following the other
diabetic complications.It has been reported as a more frequent oral complication
of diabetes compared to other oral manifestations. Symptoms such as
hyposalivation or xerostomia associated to burning mouth, loss of taste/altered
taste sensation, enlargement of salivary glands (parotid mainly), mycotic
infections represented by candidiasis, stomatitis, benign migratory glossitis and
other less frequent lesions such as lichen planus are reported (Russoto, 1981;
Murrah et al., 1985; Gibson et al., 1990; Albrecht et al., 1992). In addition,
traumatic ulcer, delayed mucosal wound healing, angular chelitis, mucosal neuro-
sensory disorders, infectious root stumps and tooth loss has been reported in
patients with diabetes. The prevalence and the chance of developing oral mucosal

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lesions were found to be higher in patients with diabetes compared to healthy
controls. The use of antidiabetic drugs such as chlorpropamide may result in oral
mucosal lichenoid reaction.11,12
Early identification and/or management of these oral manifestations may
help in the early diagnosis of diabetes and in attaining better glycaemic control
which in turn ultimately enhance the prosthetic rehabilitation.

Diabetes (long term insulin dependent) Oral Lichen Planus

Epithelium is thinner and less keratinized Erosive lesions and subsequent scarring in
Compromised support and impaired tolerance the buccal shelf area limit denture extension
of complete dentures and tolerates mucosa

Clinical significance of Diabetes Mellitus in Prosthodontics

a. Delayed oral wound healing

 Poor soft tissue regeneration and delayed osseous healing in patients

with diabetes complicates the prosthetic rehabilitation.
 If preprosthetic surgery is to be planned for favourable prognosis of
prosthesis, wound healing capacity in DM becomes rather important
 Additionally, denture fabrication should be delayed by a minimum of 6
weeks in order to facilitate the complete healing of wound.

b. Appointment schedule

 The emergency condition that could arise due to DM is hypoglycaemia

during dental treatment procedure.

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  Appointment should be given early to mid-morning after a normal
breakfast and antidiabetic medication. An early morning appointment
will minimize the risk of stress induced hypoglycaemia.

c. Procedure

 For primary impression of diabetic patient, the impression procedure

should be altered from regular technique. As the patient are prone to
infection and the mucosa are easily traumatized, the tray to be used for
impression should not have sharp edges and impression technique must
be mucostatic with alginate.
 The secondary impression should be made on light body or eugenol
free impression paste that would reduce the burning sensation of
patient during the procedure.
 Jaw relation procedure particularly vertical dimension and centric
relation must be recorded properly in order to not traumatize the
underlying tissue.
 As the oral mucosa of diabetic patient is quite friable, finishing and
polishing of complete denture must be done properly to avoid trauma
to mucosa

d. Hyposalivation
 Due to hyposalivation, physical factors of retention are compromised
leading to loss of retention and frequent irritation of mucosa.
 Lubricatory mechanism reduced requiring lot of force for mastication
 Due to reduced flushing mechanism of food, poor oral hygiene
maintenance

e. Transient effect of polyuria may cause immediate effect on retention.i.e.,

due to dehydration there is looseness of denture in early morning and
fitting of the denture in the late afternoon.

f. Due to weight loss and excessive bone resorption, frequent relining might
be necessary.

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B. TUBERCULOSIS

Tuberculosis is a chronic granulomatous disease caused by

various strains of mycobacteria, usually Mycobacterium Tuberculosis in
humans.TB is a major global health problem. According the most recent
report of WHO (2013), nearly 8.6 million people around the world (one-third
of the world‘s population) become infected with TB disease with the
extremely higher prevalence in Asian countries. An estimated 1.1 million
(13%) of the 8.6 million people who developed TB in 2012 were HIV-
positive.13,14

Clinical Diagnostic feature of Tuberculosis

i.Cough
ii.Weight loss
iii.Weakness
iv.Low grade evening fever

Oral manifestation of TB has a rare occurrence, accounting for 0.5 – 1% of

all TB infections. Hence they are frequently overlooked in differential
diagnosis of oral lesions but dental identification of TB lesions serves as an
important aid in early diagnosis and interception of primary TB.
Oral manifestation of Tuberculosis
Primary lesion Secondary lesion
i. Younger age group i. Any age group (often
middle/elder age group)
ii. Uncommon ii. Common

iii. Single painless ulcer with iii. Single, indurated,

regional lymph node irregular, painful ulcer
enlargement

The clinical criteria for diagnosis of oral lesions such as tuberculous

ulcers consist of a stellate ulcer, undermined edges, a granulating floor, ragged
and not indurated and is often painful. Tongue is the commonest site for oral

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tuberculous lesions(lateral margin, dorsum). Besides they may also occur on
the gingiva, floor of mouth, palate, lips and buccal mucosa. The diagnosis of
these lesions usually becomes difficult as other lesions like apthous ulcer,
traumatic ulcer, syphilitic ulcer or squamous cell carcinoma are expected in the
first thought, in our differential diagnosis before inclusion of tuberculosis,
leading to misdiagnosis. Regardless of the fact that, laboratory investigations
have the prime role (presence of Acid Fast bacilli in the specimen) in
confirming the disease.15

Clinical significance of Tuberculosis in Prosthodontics

Though treatment procedure in Prosthodontics is, most often, non-invasive but

TB is highly infectious disease that can be transmitted in dental settings
through
i. direct contact with small droplet of blood, oral fluids, or other patient
materials
ii. indirect contact with contaminated objects (e.g., instruments, equipment)
iii. contact of conjunctival, nasal or oral mucosa with droplets (e.g.,spatter)
from infected person
iv. inhalation of airborne microorganisms

Dental healthcare professionals are at the constant risk of getting exposed to

TB by the means of splatter, aerosols or infected blood. Clinical Dental
Practice has a potential for transmission of various infections from patient to
Dentist, patient to patient as well as Dentist to patient due to close proximity to
the nasal and oral cavities of the patient. Thus, a barrier should be created to
prevent the transmission of infections and to make the clinical procedures safe
from the threat of cross infections. Before beginning with even the oral
examination, a thorough medical history including specific questions about
medications, current/repeating illnesses, unintentional weight loss,
lymphadenopathy, oral soft tissue lesions or other infections must be asked. A
detailed history of TB should prompt the dental practitioner to discern whether
the person is an active case under treatment, active case without treatment or
previously infected but currently disease free. The non-treated active cases pose

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maximum risk to the dental healthcare personnel.16 Dental treatment for those
with active Tuberculosis should be limited to urgent and essential procedures.
Medical consultation is indicated must when a history of active infection or
systemic disease is elicited.

Effective infection control strategy prevent disease transmission by

 Gloves and mask must be worn during oral examination
 Repeated use of single pair of gloves or once wet is not recommended as it
won‘t serve as an effective barrier.
 Extraordinary care must be used to avoid hand injuries during procedures.
However if the gloves are torn, cut or punctured, they are discarded
immediately, hands thoroughly washed, and regloving accomplished before
completion of procedure.
 Double gloves is recommended during the procedure
 Mycobacteria are highly resistant to disinfectants, hence heat sterilization of
impression tray is must before and after the impression procedure.

Consequences of TB in prosthetic rehabilitation

i. Frequent coughing might cause the denture to be unstable
ii. Due to severe weight loss, retention might be compromised requiring
frequent relining
iii. Use of antitubercular drugs causes xerostomia which affects the
retention of denture, lubricatory mechanism etc.

C. CARDIOVASCULAR DISEASES

Cardiovascular diseases refers to a condition involving the

narrowing of blood vessels leading to chest pain (angina) or stroke. CVD
is a cause of significant morbidity in the developed countries having a
luxurious and sedentary lifestyle. The appropriate management of dental
patients with cardiovascular diseases is contingent on appropriate
assessment and evaluation. Baseline vital signs, a good medical history

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 and medical evaluation are all essential for safe delivery of dental
treatment procedure.
The most common cardiovascular diseases to be taken into consideration
during dental procedure are

i. Hypertension
ii. Ischaemic heart disease
iii. Rheumatic fever/Endocarditis

I. HYPERTENSION
Hypertension is a persistently raised blood pressure resulting from raised
peripheral arteriolar resistance. When either or both systolic or diastolic blood
pressures are persistently raised, and on remeasurement, with systolic pressure
over 140 and diastolic over 90mmHg, it is generally regarded as hypertension.
In practice, the diagnosis of hypertension that requires active treatment is often
made when blood pressure at rest exceeds 160/90mmHg (systolic/diastolic).

Clinical Diagnostic feature of Hypertension

General High BP symptoms Emergency High BP symptoms

(Hypertensive crisis)
a. Dull headache a. Severe headache
b. Dizzy spells b. Severe anxiety
c. Frequent nosebleed c. Nosebleed
d. Irritability d. Shortness of breath

Hypertensive crisis is defined as a blood pressure reading of 180 or above

for the systolic pressure or 110 or above for the diastolic pressure. It is usually
only when blood pressure spikes suddenly and extremely enough to be
considered a medical emergency. It is usually due to secondary high blood
pressure.

There are no recognized oral manifestations of hypertension but

antihypertensive drugs can often cause side-effects, such as xerostomia, gingival

19
overgrowth, salivary gland swelling or pain, lichenoid drug reactions, erythema
multiforme, taste sense alteration, and parasthesia.17, 18

Clinical significance of Hypertension in Prosthodontics

a. Appointment schedule

Hypertensive patient are best treated in the late morning. Endogenous

epinephrine levels peak during morning hours and adverse cardiac events
are most likely in the early morning. BP monitoring is essential before
every appointment during the treatment phase.

b. Anxiety Reduction

Patient with stable hypertension may receive dental care in short,

minimally stressful appointments. It is essential to avoid anxiety and pain,
since endogenous epinephrine released in response to pain or fear may
induce dysrhythmias. Since Prosthodontic procedures are completely new
for the patient, preprocedural reassurance becomes rather important in
order to minimize the anxiety and unknown fear of the patient.

c. Avoid rapid postural change

Raising the patient suddenly from the supine position may cause postural
hypotension and loss of consciousness if the patient is using
antihypertensive drugs such as thiazides, furosemide, or a calcium channel
blocker. Hence rapid postural change should be avoided.

d. Local anaesthesia without epinephrine

In case of patient with severe gag reflex, if LA has to be given while

making an impression then LA without epinephrine should be given in
patient taking beta blockers since interactions between epinephrine and
beta blocking agents may induce HTN and cardiovascular complications.
Lidocaine should be used with caution in patients taking beta blockers.10

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II. ANGINA PECTORIS
Angina pectoris refers to paroxysms of severe chest pain caused by
higher myocardial oxygen demands. Angina affects around 1% of adult
population and is increasingly common with advancing age. The mortality rate
in angina is about 4% per year.

Variants of Angina
Stable Angina Unstable Angina
i. Pain only on exertion and relieved i. Sudden onset of pain even at rest
by rest within 10 min for prolonged period
ii. No changes in frequency or ii. Changes in pattern, frequency or
duration of symptoms, or duration of symptoms or
precipitating factors within the precipitating factors
previous 60 days.

The most common precipitating factor for angina is the physical exertion
and relieved by rest. Emotion and stress caused by fear or pain, leading to
adrenal release of catecholamines (epinephrine and norepinephrine) and
consequent tachycardia, vasoconstriction and raised blood pressure can
induce attacks which are relieved by rest. Thus anxiety reduction protocol
is the most important aid in the management of patient with angina during
dental procedure.10

Anxiety Reduction Protocol

i. Patient should receive dental care in short, minimally stressful
appointments.
ii. Late morning appointments are recommended
iii. Patient should be explained about the procedure to avoid the unknown
fear
iv. Frequent verbal reassurance is required during the procedure
v. Avoid unnecessary noise
vi. Effective painless plain LA should be given if required

21
 vii. Nitroglycerin tablets or sprays should be readily accessible (if required
0.3-0.6mg placed sublingually before anticipated physical activity or
stress
viii. Ready access to medical help and oxygen

Emergency management during the procedure

If patient with history of angina experience chest pain during dental
procedure, Stop the procedure.

 Give glyceryl trinitrate 0.3-0.6mg sublingually and oxygen. Vitals are

monitored.

 If pain not relieved within 3min, give second dose of glyceryl trinitrate.

 If pain persist after 3min of 2nd dose, give 3rd dose, and summon medical
help.

III. INFECTIVE ENDOCARDITIS

Infective Endocarditis is a potentially lethal infection, predominantly
affecting heart valves.IE results from two main predisposing factors –
bacteremia and a cardiac lesion where there is turbulent blood flow. The most
common type of bacteremia implicated in patients with IE involves viridians
streptococci, which are present in enormous numbers in oral cavity. Lack of
proper oral hygiene causes the proliferation of Viridans streptococci into the
bloodstream in large numbers particularly during tooth extraction or any of
preprosthetic surgery for prosthetic rehabilitation.

Clinical Diagnostic feature of Infective Endocarditis

i. Insidious onset of low fever and malaise
ii. Pallor (anaemia) or light pigmentation of skin (café-au-lait spot)
iii. Joint pain
iv. Hepatosplenomegaly

22
Clinical significance of Infective Endocarditis in Prosthodontics

i. Infection control
Active stage of IE should be always under medical consultation and
effective antibiotic prophylactic regimen as indicated by WHO.
Procedure should be delayed till the infection control particularly the
preprosthetic surgery.

ii. Atraumatic procedure

Prosthetic procedure should be atraumatic as far as possible. Impression
tray should be properly sterilized with no sharp edges. Severe Undercut areas
should be properly relieved in order to prevent the trauma of underlying tissue.

iii. Oral hygiene maintenance

Patient should be advised for effective maintenance of oral hygiene and
chlorhexidine mouthwash indicated if needed.

D. BRONCHIAL ASTHMA
Bronchial asthma is a chronic inflammatory disorder of airways caused by
narrowing and bronchospasm of smooth muscle tone and mucus
hypersecretion.

Types of asthma
Extrinsic asthma Intrinsic asthma
i. Caused by allergen i. Idiosyncratic
ii. Most common ii. Least common
iii. Allergens in house dust,animal iii. Emotional stress, gastro-
hairs, oesophageal reflux,vagally mediated
milk,eggs,nuts,NSAIDS response

Clinical Diagnostic feature of Bronchial asthma

 Dyspnea (shortness of breath)

 Cough

23
  Wheeziness with labored expiration
 Nasal polyps are common in aspirin-sensitive asthmatics

Clinical significance of Bronchial asthma in Prosthodontics

 Patient should receive dental care in short, minimally stressful

appointments.
 Morning appointments are recommended and procedure should be
explained thoroughly in order to avoid anxiety of unknown situation which
may precipitate an asthmatic attack
 Patients are advised to bring their regular medication/inhaler with them
 The position of patient during every procedure should be upright
 Patient might be allergic to latex gloves (due to sulphur) hence vinyl
gloves can be used
 During the impression procedure, dustless alginate must be used to prevent
the allergy from dust of alginate
 Trimming of custom tray, denture base should be done away from patient
in order to prevent irritation allergy from acrylic.
 Treatment should be postponed in case of sickness e.g. flu like symptoms

E. NEUROLOGICAL DISORDER

Neurological disorders describes a set of condition associated

with paroxysmal neurologic function observed as facial sensory loss, facial
paralysis and condition as epilepsy, Parkinsons disease, Bells palsy,
myasthenia gravis. According to study conducted by Schneider Jay S.,
Shirley G. and Charles H. Markham in 2004, it was stated that neurological
disorder as Parkinson‘s disease consists of complex deficits in utilization of
specific sensory inputs to organize and guide movements.19 Hence patients
with neurological disease require special management considerations. These
include pretreatment treatment planning, therapeutic techniques, and
posttreatment requirements.

24
a. Parkinson disease
Parkinson disease, resulting from the degeneration of cells in
the substantia nigra, causes a number of motor symptoms as tremors,
involuntary movements, facial and limb rigidity, bradykinesia (particularly as
it relates to swallowing), and akathisia (i.e, restlessness) that can complicate
dental management from the initial phase. During treatment planning of
prosthodontic rehabilitation, these disabilities must be taken into prime
consideration.

Clinical significance of Parkinson disease in Prosthodontics

 Patients with Parkinson disease may not be able to effectively communicate

their needs, so a family member or caregiver should be present when the
treatment plan is presented to the patient. If there is cognitive decline, this
is particularly important to ensure understanding in full of the risks and
benefits of proposed treatment plan.
 Uncoordinated/Compromised muscle activities may pose difficulty in
recording all three type of jaw relation including orientation, vertical and
most importantly horizontal jaw relation. Bradykinesia that causes
swallowing difficulty is also a potential problem for Parkinson disease
patients during treatment.
 Retention and stability of the complete denture may be compromised, hence
neutral zone concept can be utilized during the fabrication in order to
enhance the stability of the denture.
 Patient should be made understand about the difficulty in clinical procedure
during fabrication and usage. They may take longer time for the
adaptability of denture.
 Maintenance of oral hygiene should be emphasized more.
 Care should be taken to not overstress the patient with Parkinson disease.
Short appointments are helpful.

25
b. Bells Palsy

In addition to the clinical consideration as parkinsonism, in bells palsy

patient leaking of saliva at the corners of the mouth may predispose the patient to
angular cheilitis. Facial dyskinesias can lead to abnormal tongue or jaw
movement that causes difficulty during dental procedure.

c. Epilepsy/Fainting spells

Before the treatment plan proper medication history of the patient and the
frequency of seizures should be ensured. The clinical signs associated with tonic-
clonic convulsions of epilepsy are quite distinctive. During dental treatment, be
aware that a grand mal seizure could occur. If a seizure occurs, place the chair
back to a supine position, turn the patient to the side to prevent tongue falling
back avoiding the respiratory block and keep the patient comfortable without
restraint until it has passed. Gingival hyperplasia secondary to the use of
anticonvulsant medication (e.g, phenytoin) should be monitored. Oral hygiene
status should be monitored and provide educational information to facilitate the
patient‘s ability to manage his or her oral health effectively; evidence suggests
meticulous oral hygiene may reduce or prevent gingival hyperplasia.20

F. OSTEOARTHRITIS

Osteoarthritis is common chronic form of joint disease leading to pain

and stiffness of various joints in the body, most often common in old age. Of
clinical significance from prosthodontics rehabilitation point of view is pain of
TMJ joint, finger joint.

 Joint pain of legs in patient demands for the fewer number of appointments

 TMJ joint if affected may result in limited mouth opening which may
require the use of sectional custom trays. In presence of painful jaw
movements, jaw relation records becomes difficult. Additionally more post
insertion occlusal adjustment appointment required
 Pain in finger joint poses difficulty during insertion and removal of
denture.

26
  Patient may neglect the proper hygiene maintenance due to difficulty in
insertion and removal of denture, hence strict instructions should be given
for the maintenance part.

G. RADIATION THERAPY

With over 1.4 million new cases of cancer diagnosed each year, the
frequency of oral complications from radiation to the head and neck for any
malignancy also increases in great number that can compromise patients‘ oral
health and quality of life.

Oral complications of radiation therapy and its clinical significance in

Prosthodontics

During active stage of radiation therapy, the patient may have following
oral complications:

 Oral mucositis: Mucositis, characterized by inflammation and ulceration

of the oral mucosa, is the most significant acute side effect reported by
patients and is a potential source of life-threatening infection. Almost all
patients undergoing head and neck radiation therapy experience confluent
mucositis by approximately the third week of treatment.

 Infection: Viral, bacterial, and fungal infection may result from

myelosuppression, xerostomia, and/or damage to the mucosa from
radiotherapy.

 Xerostomia/salivary gland dysfunction: Dryness of the mouth due to

thickened, reduced, or absent salivary flow; increases the risk of infection
and compromises speaking, chewing, and swallowing along with the
retention. Pilocarpine (Salagen) has shown promising effects in increasing
saliva but is only effective for salivary glands with residual function. Two
alternative medications that may be beneficial in stimulating salivary
glands include anethole trithione (Sialor) and bethanechol (Urecholine)
Artificial saliva can be used or saliva reservoir can be incorporated in the
denture.21, 22

27
  Functional disabilities: Impaired ability to eat, taste, swallow, and speak
because of mucositis, dry mouth, trismus, and infection. Oral exercises should
be continued or introduced to reduce the risk and severity of trismus.

 Nutritional compromise/ Taste alterations: Poor nutrition from eating

difficulties caused by mucositis, dry mouth, dysphagia, and loss of taste.
Changes in taste perception of foods, ranging from unpleasant to tasteless.

The long-term effects are due to changes in the vascularity and cellularity of
soft tissue and bone, damage to the salivary glands and increased collagen
synthesis resulting in fibrosis. These changes lead to hypovascularity,
hypocellularity and hypoxia of the tissues known as Osteoradionecrosis
(Most cases of ORN occur in the mandible, where vascularization is poor and
bone density is high)

Due to following complications during the active phase of radiation therapy,

there may be difficulty in preceding the treatment procedure along with poor
prognosis of prosthesis hence the prosthetic rehabilitation of the patient should
be delayed by 4-6 months after therapy in order to facilitate the resolution of
acute oral complications and assume the normal healthy mucosa.23, 24

4. DENTURE HISTORY

Successful complete denture rehabilitation always precedes the denture

history, if any. The number, types and duration of wear of the previous denture
should be investigated comprehensively. The primary reason for the replacement of
the denture should be evaluated carefully.

Nevalainen Mj, Rantanen T, Närhi T et al in 1997 used five different

criterias to evaluate the need for replacement of Complete dentures in the
prosthetic rehabilitation of elderly persons:
(I) criteria based on Oral Health Surveys – Basic Methods (WHO, 1987)
(II) criteria based only on the clinical data collected during the examination

28
 (III) criteria based only on examiners' subjective opinion of the condition of the
dentures
(IV) criteria based on clinical data as well as examiners' experience and
consultation with the patient
(V) criteria based only on patients' subjective opinion.

Depending on the evaluation method used, the most justifiable criteria

of evaluating replacement need was achieved when the dentist assessed treatment
need together with the patient emphasizing the fact that successful treatment
decisions cannot be made solely on the basis of clinical examination or a dentist's
subjective opinion, but should be formulated in close consultation with the
patient.25

Patient displaying frequent consistent pattern of remakes might have

unrealistic expectations from dentures. They should be educated regarding the
realities and limitations of the denture. The assessment of duration of wear of
previous denture becomes equally important in signifying the adaptability of the
patient.

EXISTING /CURRENT DENTURE

The patient‘s existing denture should be examined very carefully. The objective
of this examination are to determine exactly the quality of the dentures and
how that relates to the experiences cited earlier by the patient and to determine
the potential for improvement. The evaluation of existing denture helps in
unveiling the expectation of the patient from the denture, assessing the denture
knowledge, care and experience of the patient, any parafunctional habits. The
patient presented with the worn out/broken/lost old denture always require
more re-inforcement for the adaptation to the newer favorable changes to be
made in new denture.

29
5. DIET AND PERSONAL HISTORY

The dietary habits of an edentulous patient is significant for two reasons:

 Health & integrity of denture bearing mucosa

 Post insertion instructions

After the complete loss of natural teeth, the patient on edentulous

state are particularly vulnerable to compromised nutritional health. Apart from
presence of chronic disease, nutritional deficiency mainly result from low food
intake due to poor chewing and swallowing efficiency. Consequently, the
nutritional status of the patient affects the health of the oral tissues. Dietary
guidance, based on the assessment of the edentulous patient‘s nutrition history
and diet, should be an integral part of comprehensive prosthodontic treatment.
Compliance of patient with effective dietary habits improves the quality of
denture bearing foundation.
For edentulous patients at risk of nutritional deficits, the
American Dietetic Association recommends a multi-vitamin mineral
supplement. On basis of nutrient deficiencies reported, it may be reasonable to
prescribe a low-dose multi-vitamin mineral supplement for certain patients
even though clinical signs of a nutrient deficiency are lacking.
Complete denture rehabilitation has reduced the risk of nutritional deficiency
by enhancing the masticatory efficiency as compared to non denture wearer.
The great majority (70% to 80%) of edentulous patients has also
acknowledged the benefit of complete denture treatment and declared
themselves satisfied with their dentures.26-28
After complete denture insertion it becomes important in giving post insertion
instructions to start chewing with liquid diet and soft foods, then only slowly
with hard foods after being habituated with denture.

SMOKING
There are many literatures regarding the association of smoking with the oral
health status of the patient. Based on literature data it is obvious that there is a
connection between smoking and periodontal diseases which in turn causes
alveolar bone loss. According to study conducted by Markovic D, Jefic B,

30
 Blagojevic D et al in 2003 smoking does not directly affect the degree of
resorption of edentulous alveolar ridge with complete denture wearers.29
However, there are several direct consequences of smoking on edentulous
ridge that could be pointed out as :
 Hyposalivation
 Decreased resiliency of mucosa
 Delayed wound healing
 Precancerous lesion
 Esthetic compromised due to staining
 Negative pressure during smoking may compromise the retention; hence
recording and relieving of peripheral limiting structures becomes optimal.
 Keratinization of mucosa increases providing better support, however due
to poor quality of keratinization retention and stability are compromised.

ALCOHOLISM
The impact of alcoholism on the complete denture rehabilitation of
edentulous patient is the dehydration, poor nutritional status, less wound
healing capacity. These features directly or indirectly affects the replacement
therapy. Additionally severe alcoholic patient cannot provide adequate care
and maintenance of denture leading to frequent fractures.

MENTAL STATUS

Emel in 2002 concluded that most complains of complete dentures are those
related to appearance, pain, difficulties during eating, stability and retention.
The causes of dissatisfaction with complete dentures are complex. They
include not only the quality of the dentures and the oral conditions, but also
patients‘ related factors such as their attitude towards the dentures, as well as
the interpersonal relationship between the patient and Prosthodontist.

M M De Van 1942 stated that “The dentist should meet the mind of the
patient before he meets the mouth of the patient.” Understanding the mental

31
attitude of patient helps the clinician in anticipating the patient attitude
towards the dental treatment which affects the patient cooperation and
satisfaction with oral rehabilitation, eventually manipulating overall success of
treatment rendered. Krochak stated that many patients with favorable
anatomy cannot tolerate a well-fabricated denture, and yet other patients with
unfavorable anatomy willingly endure dentures that may be ill-fitting. He
correlated such adaptive response of the patient‘s psychological state. Thus for
the success of complete denture rehabilitation, mental attitude of patient is
equally significant as the treatment procedure.

Dr. Edward Neil first described the mental classification of

complete denture patient in his textbook Full Denture Practice, published in
1932. Later in 1950 Dr. Milus M. House contributed to a detailed expansion
of the classification system and subsequent popularization of the system.
Patient seeking prosthodontics care arrive with an accumulation of
experiences and resulting attitudes. In a classification system devised by
House, he classified the patient‘s psychological responses to becoming
edentulous and adapting to dentures into following four types.30

a. Philosophical mind

These patients anticipate the need for treatment with complete

dentures and are willing to rely on the dentist‘s advice for diagnosis
and treatment. These patients are easy going, congenial, mentally well
adjusted, cooperative and confident in the dentist. Philosophical
patients are rationale, sensible, calm and composed in different
situations. They will follow the dentist‘s advice when advised to
replace their dentures. The best mental attitude for denture acceptance
is the philosophical type. Hence the prognosis is excellent.

b. Exacting mind

Exacting-mind patients usually have poor health and show

resistance to accommodate suggestions given by the clinician. These
patients are precise above average in intelligence, immaculate in dress

32
 and appearance often dissatisfied with past treatment. Exacting-mind
patients also doubt the dentist‘s ability to make dentures that would
satisfy their esthetic and functional needs and even try to direct them
regarding the treatment procedure. Often, the exacting-mind patient
demands extraordinary efforts and guarantees of treatment outcome at
no additional cost.

c. Hysterical mind

These patients are neglectful of their oral health, dentophobic,

and unwilling to try to adapt to wearing dentures. These patients
submit to treatment as a last resort and have a negative attitude.
Emotionally unstable, excitable, excessively apprehensive and
hypertensive. The prognosis is unfavorable.

d. Indifferent mind

Indifferent patients are unconcerned with appearance, have no

desire to wear dentures. They have managed to survive without
wearing dentures. Hence they are uncooperative and do not value the
efforts or skills of the dentist.

Patients with an exacting mind, hysterical mind, or indifferent mind respond

to the prospect of becoming edentulous and the experience of wearing
dentures in less than ideal ways. Careful observation and listening in a
structured interview and questionnaire provide ample information to the
dentist regarding the patient‘s mental attitude. To supplement this, the
additional aid of graphoanalysis has also been advised to identify the
behavior of the patients. Knowledge of patient‘s mental attitude may provide
insight into patient behavior, which may help in overall improvement of
treatment rendered. House‘s classification was designed to help clinicians
anticipate a variety of patient responses when faced with specific clinical
procedures. The classification system is relatively simple, which is its
strength and its weakness.

33
The literature on the dentist/patient relationship has focused directly on the
needs of the patient. Winkler discussed the need to fit oneself to the
personality of the patient.31 Koper characterized and typed patients who have
difficulty in adapting to complete dentures as problem patients, difficult
denture patients, or difficult denture birds.32 Jamieson truly stated that
―fitting the personality of the aged patient is often more difficult than fitting
the denture to the mouth.‖33

Among the reasons that the House classification requires reevaluation is that
some of the terminology is antiquated, falling out of use, or no longer carries
the same meaning within psychiatry. For instance, the word hysterical has
come to be regarded as derogatory and judgmental. Although the term has a
historical place within psychoanalysis (hysterics served as the original
psychoanalytic patients), given House‘s description of the type today one
might speak more of a narcissistic patient.34

Another more important reason for reevaluation is that the House

classification pertains to the patient in isolation. House provided little
attention to how the patient‘s reactions and behaviors are codetermined by
the treatment and behavior of the dentist.

Simon Gamer et.al in 2003 proposed another classification system

Intersection of particular patient types and particular dentist’s needs34
The proposed classification is based on 2 factors:
(1) the level and quality of the engagement or involvement of the patient
toward the dentist (including such issues as domination, submission,
and idealization and devaluation of the dentist) and
(2) the level of willingness to submit (trust) to the dentist.

The ideal patient stance, which is most likely to lead to the best treatment
outcome, is a reasonable amount (versus an excessive amount) of
engagement and willingness to submit (trust). The level of patient
engagement with the dentist and treatment process exists along a continuum
from completely overinvolved (++++) to disengaged (+). The level of the

34
 patient‘s willingness to submit (trust) also exists along a continuum from
willingness to submit to the dentist‘s recommendations without a second
thought (++++) to intense reluctance to do anything the dentist recommends
(+).

Behavioral profiles of patients:

 Ideal,
 Submitter,
 Reluctant,
 Indifferent, and
 Resistant

Ideal
The ideal patient, which corresponds to House‘s philosophical mind, is
reasonably engaged (+++) and reasonably willing to submit (trust) (+++) to
the dentist. This type of patient is not ranked (++++) in either category,
because these patients are considered mature with a healthy life balance.
They are not vulnerable to regression or excessive dependence on authority
figures. Therefore they are not prone to fixate on and be overly absorbed with
their particular dental treatment. They have worked through whatever
childhood conflicts and animosities they held for authority figures.
Furthermore, the ideal patient has a healthy level of distrust. Any reasonable
patient should have some skepticism; they should permit themselves to have
questions and doubts. Patients deserve explanations for professional dental
recommendations to understand the situation and arrive at a final decision
regarding treatment. Therefore the ideal patient tends to be neither overly
suspicious nor blindly accepting of the dentist‘s recommendations.

Submitter
The submitter patient rates (++++) on engagement and (++++) on willingness
to submit (trust). Such patients lack in discrimination and tend to idealize the
dentist, which results in a high degree of engagement and utter surrender.
This renders the submitter incapable of providing genuine informed consent
because he/she has surrendered the use of critical faculties and therefore
cannot be an active partner in the treatment.

35
Reluctant
The reluctant patient rates (++) on engagement and (++) on willingness to
submit (trust). He/she is often leery of the dentist and skeptical of the
treatment plan.

Indifferent
The indifferent patient, who corresponds to House‘s indifferent mind, rates +
on engagement and (+) on willingness to submit (trust). Usually forced into
seeing the dentist by a concerned family member or friend, the indifferent
patient is minimally engaged and indifferent to the dentist to the extent that
willingness to submit (trust) is not an issue.

Resistant
The resistant patient corresponds to House‘s exacting mind and Boucher‘s
critical patient. Resistant patients are skeptical of the dentist as a person and
of being helped by anyone under any circumstance. The resistant patient is,
paradoxically, very engaged with the dentist but in an adversarial way. Rather
than being dependent, they challenge the dentist. And, like the indifferent
patient, there is no trust.

36
 CLINICAL EXAMINATION

During the 18th century, Esthetic harmony and judgements were perceptual based on
common guidelines for all the people with no intellectual element and reflection of
any principles and causes.35 With the emerging modern societies as the people are
growing more esthetically conscious , the incorporation of facial beauty and harmony
during complete denture rehabilitation has become must. Current concepts in
diagnosis and treatment planning of dento-facial rehabilitation focus on the balance
and harmony of various facial features. The various extraoral facial features affecting
the treatment planning of prosthodontics rehabilitation are discussed in detail below.

1. Facial form

Facial form can be defined as the outline form of the face as viewed from
anterior/frontal aspect. The significance of facial form in complete denture
rehabilitation is mainly attributed to the proper selection of shape and size of the
artificial teeth so as to restore the optimal dentolabial relation in harmony with overall
facial appearance. During the ivory age, teeth were selected, mostly by dimensional
measurements, with minimal consideration given to face form or other facial
qualities.36 The first esthetic concept in dentistry was introduced by J W White in
1872, as theory of correspondence and harmony. His early concept highlighted some
facts like existence of tooth to face size proportion as well as harmonious relationship
between age, gender, and appearance.37, 38 Similarly correlation between tooth form
and face form was also affirmed by Hall in 1886. 39

“Berry’s Biometric Ratio Method,” was introduced by Berry in 1903

according to the outline form of the edentulous face.40 Later in 1914 Typal form
theory based on Law of harmony as proposed by Leon Williams had a wider
acceptance. He hypothesized the presence of harmony between frontal view of central
incisor and inverted image of face. In order to simplify the selection, he broadly
categorized all people of having three basic face forms : Oval, Square and Tapering.41
Later House & Loop in 1939 expanded William‘s work to include not only the pure
typal forms but also the combinations of typal forms and discovery of the relationship
of the width of the face and width of the central incisors. Thus the classification was

37
modified and the four face form types were proposed as: Square, Square tapering,
Tapering and Ovoid.

Square face form Ovoid face form Tapering face form

According to study done by L. Ibrahimagic et al in 2001, there were 11 different

facial form recognized in the population of Zenica, Bosnia and Herzegovina with 98%
of the population having three face forms : Oval face form – 83.3%, Square-tapered
face form – 9.2% and tapered face form – 7%.42 Sellen et al in 1998 and Shah et al in
2011 also found square, taper and ovoid as the most common face forms.43, 44

38
Methods of determining facial form and its significance in Prosthodontics

a. Visual perception matching:

Visual assessment of face form is based on perception of
visual matching of face form. The method is more subjective and depends
on personal interpretation rather than actual metric principles.

According to study done by Walter Wright (1942) in Pittsburgh

School of Dentistry, it was stated that face form-vary with visual
observation (only 13%-same, 39%similar, 66%dissimilar). Visual
perception is no longer used for face matching due to its subjectivity and
individual perception variation.

b. Drawing an imaginary line

An imaginary line is drawn 2.5 cm ahead of tragus joining

the three point at the frontal prominence (temple), zygoma & angle of
mandible perpendicular to the floor. The intersection of two lines drawn
from temple to zygoma and from zygoma to angle of mandible is
compared.45

i. If lines are parallel, it signifies square face form

ii. If lines are converging, it signifies tapering face form
iii. If lines are diverging, it signifies ovoid face form
iv. If upper lines are parallel & lower lines are converging, it signifies
square tapering face form

39
c. Trubyte face form template

The trubyte system is based on hypothesis of typal

form theory as proposed by John Leon Williams. The widely accepted
hypothesis of the Trubyte system is considered the most ideal method for
determining the form and size of artificial teeth for edentulous patients.
While determining the face form by trubyte template,
the indicator is placed on the patient‘s face, allowing the nose to come
through the central triangle. The pupils of the eye are centered in the eye
slots and the indicator is hold with its central line coinciding with the
median line of the face.45
 In Square form - the sides of the face will approximately follow the
vertical lines of the indicator.
 In square tapering, the upper third of the lower 2/3rds will taper inward.
 In tapering faces, the side of the face from the forehead to the angle of the
jaw will taper at an inward diagonal.
 Ovoid faces will be best determined by examination of the curved outline
of the face against the straight vertical of the indicator.

d. Computer generated

In this system, the photographs are taken, digitized and scanned.

The concept of apparent face used to trace the face following a standard of
points, serving to digitize linear and angular measurements.46

40
 Fig. 2 - Guide points for mapping the tooth.

Fig. 1 - Guide points for mapping the face

The faces were classified into three basic forms, according to pre-defined standards.
 Triangular face, with edges converging from the condylar point to the chin,
taking the zygomatic arch and the angle of the jaw as references
 Square face, with the sides almost parallel each other
 Ovoid face, in which the surfaces are rounded, presenting a double curvature
at the margin of the chin, and the most prominent point being below the
zygomatic arch.

The similarity between the face form points and Maxillary central
incisor shapes are verified by superimposing the exported tracings.

Size of the teeth

The width of the anterior teeth in accordance with the face can be calculated as
below.

 Mesiodistal width of the anterior six teeth =

1/3 of bizygomatic width of the face

 Mesiodistal width of the central incisor =

1/16 of bizygomatic width of the face

41
 The face bow can be used as a caliper to record the bizygomatic breadth. The
trubyte tooth indicator is useful in determining the size of the maxillary central
incisors. For the size, the side indicator bar is slided until it touches the face
and the width of the upper central tooth can be read in millimetres. The length
of the tooth can be determined by sliding the bottom indicator bar up to
position immediately underneath the chin with lips at rest and the length of the
upper central incisor in millimetres.47

There are many researches suggesting both for and against the Williams typal
theory for the selection of anterior teeth. Although majority of the Literature
reviews do not show highly defined correlation between the facial form and
form of the tooth but if they are matched in a conventional manner then it will
be harmonius and acceptable.

2. Facial Profile

Facial profile can be defined as the outline form of the face as viewed
from lateral aspect. The relative straightness or curvature of the outline of face
as viewed from side determines the facial profile. There are various methods
for determining the facial profile

a. Drawing an imaginary line

The facial profile is determined by taking reference of three points. The

forehead, the base of the nose and the prominent point of the chin.

 Straight—three points are in line

 Curved—points of the forehead or chin are recessive.

Based on these three points the profile can be straight, convex or concave.
Two imaginary lines are drawn joining bridge of nose to base of nose and
then base of nose to prominent part of chin.45

42
 Classified as:

Class I - Normognathic (straight)

If the lines joining the bridge of nose to base of nose and base of nose to
prominent part of chin are in same straight line, it is classified as normognathic
profile

Class II - Retrognathic (convex)

If the lines joining the bridge of nose to base of nose and base of nose to
prominent part of chin produces convexity, it is classified as retrognathic
profile

Class III - Prognathic (concave)

If the lines joining the bridge of nose to base of nose and base of nose to
prominent part of chin produces concavity, it is classified as prognathic
profile

Straight profile Convex profile Concave profile

43
b. Trubyte tooth indicator

Apart from face form, trubyte tooth indicator also helps in determining the
facial profile from lateral aspect.

c. Cephalometrical Analysis

The facial profile can be determined by calculating the

convexity angle as determined by the cephalometric
analysis. The convexity angle is defined as the angle
colligated by the lines N-A and A-Pg. The convexity
angle of facial bone structures ( N-A : A-Pg ) expresses
the sagittal protrusion of the maxillary part of the face
compared to facial profile (the convex or concave face).
This cephalometric method can be reliably used in
determining the facial profile.48

44
Significance of facial profile

i) Biomechanical Consideration

Facial profile helps in determining the relative relation of the

upper and lower jaw assessing the degree of jaw discrepancy. Thus it
tentatively indicates the favourable/unfavourable prognosis of the
rehabilitation beforehand along with its consequences so that the
treatment plan and motivation of the patient can be done accordingly.
For instance, in case of severe jaw discrepancy, preprosthetic surgery
may be required. If the patient is not willing for the surgery or surgery
is not indicated due to systemic health condition, the shortcomings of
the denture and its functional limitations should be explained earlier to
the patient before the treatment begins.

ii) Esthetic Consideration

The labial surface of the tooth viewed from mesial should
show a contour similar to that when viewed in profile which is
biologically and esthetically harmonious. (The labial surface of the
tooth when viewed from the incisal should show a convexity or
flatness similar to that seen when the face is viewed from under the
chin or from the top of the head.)

iii) Modification in teeth arrangement

Patient exhibiting convex or concave profile in an
increased degree may require modification (addition or omission) in
the arrangement of the teeth.

3. Facial Symmetry
Facial symmetry can be defined as the relative similarity between the right
and left half of the face when viewed in relation to a projected midsagittal line.
According to the theory of Sexual Selection, facial symmetry plays a large
role in male and female perceived attractiveness. Facial symmetry is

45
considered to be prime among many other characteristics related to health,
beauty and facial attractiveness.
Asymmetry refers to the variation in the configuration of one
side of the face from the other which may be due to
i. Pathological condition
ii. Physiological condition

Asymmetry caused due to pathological condition may be

due to significant injuries, untreated infections, certain rare genetic disorders,
neurological disorders as Bell‘s Palsy. The complete denture rehabilitation in
such case is preceded only after treating the etiology for the favorable
prognosis. On the other hand facial asymmetry may also be caused due to
physiological condition. Facial asymmetry is a valid marker of cognitive
aging. Progressive changes occurring throughout life in the soft tissues of the
face will cause more prominent facial asymmetry in older faces. Therefore,
symmetrical transformation of older faces generally increases their
attractiveness.

Significance of facial symmetry in Prosthodontics

Facial symmetry in completely edentulous patient is determined by

taking the reference of midline of face not the labial frenum. Thus facial
midline is of considerable importance than the dental midline for the
harmonious dentofacial appearance. Facial symmetry becomes important in
Prosthodontics in order to simulate the natural esthetic appearance of the
patient. Asymmetry due to aging, irreparable trauma, bells palsy may pose
difficulty during the various stages of fabrication of Complete Denture thereby
compromising the esthetics. Jaw relation and arrangement of teeth are the two
major steps to be relatively influenced by facial asymmetry.

Facial asymmetry to a moderate degree can be masked by

modifying the thickness of flange of the denture i.e., fullness can be increased
or decreased according to requirement during orientation jaw relation.
Asymmetry can also be masked by creating illusion during teeth arrangement
by incorporation of characteristic features as overlapping, distally tilted

46
 laterals etc. Additionally carving also plays a role in masking asymmetry to
some extent. These are features that aids in minimal to moderate facial
asymmetry.

In case of pathological facial asymmetry as Bells palsy where there

is facial paralysis of permanent nature causing asymmetry, maxillary complete
denture with extended buccal flange can be fabricated. This extension is used
to elevate the cheek musculature, vestibule and lips thereby improving the
fullness and support to the face on the affected side enhancing the symmetry
of the face and ultimately the esthetics.49

4. Facial Height
Facial height can be defined as the linear dimension in the
midline from the hairline to the menton. Previous studies have reported the
significance of vertical facial height on overall facial esthetics. Apart from
esthetics and harmony, the maintenance of facial height plays an important
role in the optimum health of the entire stomatognathic system. Ideally facial
height can be divided into three equal parts
 Upper facial height
 Mid- facial height
 Lower facial height

47
Upper facial height extends from hairline to bridge of nose (In absence of
hairline i.e., bald case, the reference line is identified by texture of skin)

Mid facial height extends from bridge of nose to base of nose

Lower facial height extends from base of nose to chin

The lower facial height is again divided into two parts

 Base of nose to lip : one-third

 Lip to chin : two-third50

Upper 1/3 of lower facial

Lower 2/3 of lower facial

According to Leonardo da Vinci’s 1490 male head profile with proportions,

lower facial third is divided into upper third (upper lip) and lower two-thirds.51
Nani F B et al in 2008 and Reyneke in 2012 also divided the lower facial
third into upper lip forming the upper third and the lower lip and chin forming
the lower two-thirds.52

48
Means of measuring facial height
i) Vertical jaw relation procedure (physiological rest
method/swallowing/speaking /esthetics)
ii) Willis guage

After the complete loss of teeth, due to absence of any vertical stop the
reduction in the lower facial height is conspicuous. It also serves to underscore
the resiliency of the masticatory system as it adapts to changes associated with
attendant teeth loss. Any dimensional changes in morphological face height
because of loss of teeth are inevitably transmitted to the TMJs. The process of
loss of vertical facial height in a long term thus involves the joint changes that
cause an imbalance in adaptation and a degeneration that results from
alterations in functional demands on or functional capacity of the joints. In
addition, the features exhibited due to decreased facial height are :

 Drooping of corners of mouth

 Angular chelitis
 Prominent nasolabial fold
 Depressed mentolabial sulcus
 Rolling or collapse of lip
 Decrease in horizontal labial angle

Comprehensive Prosthodontic Rehabilitation aims to focus on all these

consequences by the optimum restoration of the facial height.

49
Table: Described clinical technique for assessment of occlusal vertical dimension

5. Complexion
Despite the optimum functional requirement, esthetics is the prime
concern for patients seeking prosthodontic treatment. The selection of proper
shade of artificial teeth is critical esthetic component that has been shown to
truly influence patient esthetic perception and improved prosthesis acceptance.
Complexion of face, eye and hair are crucial reference for selection of tooth
shade during complete denture fabrication. The lack of this reference makes
shade selection procedure a challenging and subjective exercise. The tooth
shade selection will be more objective if another facial appearance feature is
used as a reliable guide. It will help the artificial dentures to harmonize better
with the facial appearance, and patient compliance will be improved

The eye colour as a guideline is disregarded by many due to its size and
distance away from teeth. The hair is not a reliable guide due to its rapid
change in colour compared to the teeth and frequent change of colour by the
patient, however, this reflects the esthetic concern of the patient.54 Most

50
 researchers consider the face skin colour as a more predictable reference for
artificial tooth selection during complete denture fabrication. The tooth colour
complimenting the skin colour is essential for the aesthetically successful
prosthesis. Majority of the dental researchers advocate the people with darker
skin complexions to have corresponding darker teeth while fair complexion
individuals with lighter teeth. According to the researchers, this correlation
makes the teeth colour harmonise with corresponding face skin tone in the
background. Few researchers have also shown the inverse relation of tooth
with skin colour.55 Some authors dismissed the existence of any correlation
between facial skin and tooth colour. General concession is to give significant
weight for patient's perception while selecting the teeth colour in edentulous
patients.

It is also suggested that the hue of artificial teeth should harmonize with the
patient‘s complexion.4, 54, 56 These authors also advocated the use of the colour
of the facial skin as one basic guide in selecting colour for artificial teeth in
Caucasians.In a study conducted by Satheesh B. Haralur, Ahmed
Mohammed Dibas, Nabil Abdullah Almelhi et al in 2014, a strong
correlation was found between the skin and tooth colour parameters; hence the
skin colour can be used as a guide for artificial tooth selection in edentulous
patients.57

6. Lip

According to Greenwal L in 2001 ― The beautiful smile is the one in which

size, colour, shape and position of teeth are in harmony, proportion and
relative symmetry to each other and with the elements that frame them.‖58
Apart from the tooth size, shape, color and position the esthetically pleasing
and harmonious smile depends on the components as well that frame them as
the type, contour, length and mobility of lips. All these components should
form a harmonic and symmetric entity.59 Thus lips have a greater role in the
esthetic value of the smile.

51
The upper and lower lips are referred to as the "Labium superius oris" and "Labium
inferius oris", respectively. The juncture where the lips meet the surrounding skin of
the mouth area is the vermilion border, and the typically reddish area within the
borders is called the vermilion zone. The vermilion border of the upper lip is known
as the cupid's bow. The fleshy protuberance located in the center of the upper lip is a
tubercle known by various terms including the procheilon (also spelled prochilon), the
"tuberculum labii superioris", and the "labial tubercle". The vertical groove extending
from the procheilon to the nasal septum is called the philtrum.

Based on religious, linguistic and ethnic variation, the morphology of the the lip vary
individually. These variations influences the treatment planning of prosthetic
rehabilitation. The morphology of lip can be described in four parameters.

 Types
 Contour
 Length
 Mobility

i) Lip type/thickness

Lip thickness can be measured as the height of vermilion border of upper lip to
lower border of upper lip. It basically determines the musculature/tonocity of
the lip. The lip can generally be of following types :

a) Thick lips b) Average lips c) Thin lips

52
 Most clinicians determine this feature subjectively or utilize the Likert scale of
Astley and Clarren [2000] The thickness of lip may vary among various ethnic
groups as negros most often have a thick type of lip.

Significance of type of lip in Prosthodontics

The lip type have significant influence in determining the thickness of flange
of denture and arrangement of teeth. Thick lips have more tonocity and need
lesser support from artificial teeth and labial flange. Thus there is freedom in
determining the thickness of labial flange and teeth arrangement in thick type
of lips. However, thick lips if encroached might affect the stability of denture.
On the other hand thin lips have less tonocity and thus rely on appropriate
labiolingual position of the teeth along with labial flange, for their fullness and
support. Thin lips if encroached esthetics will be compromised.

ii) Lip contour

Lip contour refers to the support of the lips. The contour and appearance
of the vermillion border usually are altered by tooth loss.60
Based on the amount of lip support, lip contour can be classified as
- Adequately supported
- Unsupported

Adequately supported Unsupported

In case of adequately supported contour of lips, the labial fullness should be

reduced during orientation jaw relation with a resultant decrease in the
thickness of labial flange or a flangeless denture can be given provided that all
other factors for retention and stability are adequate. In severe cases,
preprosthetic surgery should be advised to the patient. If the patient is not

53
 willing for the surgery, adequate counseling should be done regarding the
consequences in the esthetics. For the dentist, good with unsupported contour
of lip as esthetics can be enhanced by increasing thickness of labial flange of
denture. Restoration of lip support and vermillion border width must be
considered during placement of anterior teeth.

iii) Lip Length

Lip length can be measured from base of nose to vermilion border of the upper
lip. The significance of determining the lip length during the Prosthodontic
rehabilitation is the the visibility of the anterior teeth and denture base during
rest, speaking and smiling phase. Prosthodontic guidelines have generally
recommended placing the maxillary incisor teeth so that 2mm of teeth is
displayed at normal rest phase. Among all the significant factors affecting the
degree of teeth exposure, lip length is one of them.61

A study done by Ahmad in 2005 determined the length of lip to vary from 10
– 36 mm in different individuals.62 Similarly Naini F B in 2008 found the lip
length to be in the range of 18 – 22 mm.52 SK Maharjan in 2014 did a study
to measure the maxillary anterior teeth display in various face forms and lip
lengths in Nepalese context. The study determined the lip length to be 18-22
mm along with the correlation between face form and lip length. Long lip
were common in square face form and short lip in oval face form.50

54
 Based on the measured length of the lips, lips are classified as
i. Long lip:
The length of lip that is more than 22mm allowing the visibility of
anterior teeth in
minimal amount i.e., < 2mm.
ii. Average lip:
The length of lip ranging from 18-22mm allowing the 2mm visibility of
anterior teeth.
iii. Short lip:
The length of lip less than 18mm allowing the visibility of anterior teeth
more than
2mm along with the display of denture base. Short lips impedes the
freedom in teeth
arrangement so that the mold selection and denture characterization
becomes critical.

Short lip Average lip Long lip

In some individuals the upper lip is so short that full length of upper anterior
teeth is visible with resting upper lip, in others the upper lip may be so long that
no part of upper anterior teeth can be seen with resting upper lip. This study
determined the relation of upper lip length with various variables (free way space,
closest speaking, inter canine distance, inter molar distance and palatal depth) to
use them as guides and as a pre extraction records to aid for comfortable denture
construction with pleasing esthetic result

55
 .

Fig., Display of denture base in short lip

According to Journal of Contemporary Dental Practice JR Patel Feb 2011,

lips are classified into five types:63
Very short lip length: 10 – 15 mm
Short lip length: 16 – 20 mm
Average lip length: 21 -25 mm
Long lip length: 26 – 30 mm
Very long lip length: 31 – 36 mm

iv) Lip mobility

The degree or extent to which the lips can perform the physiologic
movement as smiling, poutting, sucking whistling determines the lip
mobility. Based on the mobility, lips are classified as having

• Normal mobility (class 1)

The ability of lips to perform the physiologic movement to an
optimum degree classifies it as Class I lip mobility. These patients are
capable of performing all required movements which facilitates border
molding and jaw relation procedure.

• Reduced mobility(class 2)
Lips with Class II mobility shows reduced degree of movement of
lips which might interfere the proper border molding and jaw relation
procedure. Extra effort might be required for accurate recording. In

56
 addition, the reduced mobility might show little of anterior teeth
influencing the esthetic perspective.

• Paralysis(class 3)
Lips with Class III mobility shows very limited movement. Such
condition generally occurs in patients suffering from stroke, Bells
palsy, Parkinson disease. The patient have half of the lip paralysis,
leading to unilateral drooping of mouth & facial asymmetry. The
prognosis is poor as the adequate recording of peripheral borders and
proper jaw relation record cannot be accomplished. Also the esthetics
is severely compromised due to relative disharmony in the anterior
teeth display by the reduced mobility of the lips.60

Nasolabial fold

The nasolabial folds, commonly known as "smile lines" or "laugh lines", are
facial features. They are the two skin folds that run from each side of the nose
to the corners of the mouth. It is defined by facial structures that support the
Buccal fat pad. They separate the cheeks from the upper lip. The term derives
from Latin nasus for "nose" and labium for "lip". (nasolabial angle male : 85-
90º , female : 95-105º )

Mentolabial sulcus

The indistinct line separating the

lower lip from the chin. Also known as sulcus
mentolabialis / mentolabial furrow.Deepening and
prominence of nasolabial fold and mentolabial
sulcus is the normal aging signs that occurs
physiologically. Further the loss of teeth leading
to reduced lower facial height causes the increase
in length and depth of folds. Though it cannot be
eliminated completely but can be minimized by
increasing the fullness of denture in those regions
to an acceptable degree.

57
 Note: Other measures to enhance the cosmetics

 Lip plumbs
 Botex (Botulinum toxin)
 Derma fillers
 Face lift surgery

7. Neuromuscular Evaluation

Neuromuscular control refers to the functional forces exerted by the

musculature of the patient that can affect the retention. It is of vital
importance for a successful denture, since the forces generated during
mastication are sufficient to destabilize dentures with optimum retention.4
Clinically it was observed that in real life, prosthodontists recognize the
ability of certain patients to wear their dentures and function without
complain despite the fact that they may be extremely ill fitting, unstable or
even broken.64 Hence neuromuscular control is a complementary factor.

a. Muscle of Mastication
In the dentulous patient mastication is a highly coordinated neuromuscular
function that involves effective movements of the jaw and continuous
modulation of force. It is an alternating rhythm of isotonic and isometric
contractions governed by central pattern generator, located in the brain
stem.65 Stimulation and feedback generated by sensory input from
proprioceptors in the oral cavity, muscles and joints may have an influence
on the governed pattern. In the elderly subjects these mechanisms act with
some marked differences. Reduced chewing efficiency due to loss of teeth
and elimination of periodontal afferent flow lead to changes in the neuro-
muscular pattern Moreover, some age related changes, such as
deterioration in the fast and slow fibres in the striated muscles, result in
impaired muscle force.66, 67
Edentulous persons are considered as oral

58
invalids with reduced capacity in various functions of the stomatognathic
system such as bite force, tactile thresholds and chewing ability.68

On account of its tissue resolution capacity, computed tomography (CT) is

an excellent method for the examination and quantitative analysis of the
masticatory muscles. A study was done by Raustia et al in 1996 to
evaluate the influence of the long edentulous period by CT on the structure
of the main masticatory muscles in 10 edentulous patients and to study
their functioning by electromyography (EMG) in connection with the
renewal of the dentures. CT scanning was performed before prosthodontic
treatment and EMG recordings of the masseter and temporal muscles
before treatment and 4 weeks and 6 months after insertion of the new
dentures. The results suggested, however, that a long edentulous period is
visible not only in the functioning of the masticatory muscles, in terms of
decreased EMG activity, but also as decreased density of the muscles
which implies muscle atrophy, as seen by CT in the masseter and medial
pterygoid muscles.69

In a study done by Iva Z. Alajbeg, Melita Valentic-Peruzovic, Ivan

Alajbeg et al ,considering muscle activity during chewing, higher values
of myoelectrical signals (in μV) were found in dentate subjects than in
complete denture wearers during five sequences of mastication. However,
the amounts of muscle activity in proportion to its maximal activity were
higher in edentulous subjects when compared to elderly dentates. This
indicates that the elevator and depressor muscles in the edentulous group
change a pattern compared to dentate group in order to perform optimal
mastication with the reduced absolute muscle activity due to denture
insertion and protective reflex mechanisms of neuromuscular control.70

According to Grasso et al., (1994) and Zarb et al., (2004) the buccal
flanges of the maxillary denture should slope up and out from the occlusal
surfaces of the teeth and the buccal flanges of the mandibular denture
slope down and out from the occlusal plane, the contraction of buccinators
will tend to seat both dentures on their basal seats. Lingual surface of

59
 lingual flanges should slope toward the center of the mouth so the tongue
can be seated against it and hence achieving a perfect border seal. The base
of the tongue is guided on top of the lingual flange by the distolingual end
of the flange which turns laterally towards the ramus. This part of the
denture also helps to ensure border seal at the end of the mandibular
denture.54
b. Speech
Speech is a very sophisticated, autonomous, and unconscious activity
which involves neural, muscular, mechanical, aerodynamic, acoustic, and
auditory factors. Speech is the unique ability of human being which is a
learned process formulated, perceived and decoded by making use of
anatomical structures designed primarily for respiration, mastication and
deglutition. A very complex neurophysiological mechanism governs the
production of speech. A large number of oral mechanosensitive receptors
(tactile and kinesthetic) are involved in its motor control. After the loss of
teeth due to the physiological changes in the dentoalveolar complex, one of
the component for proper articulation of speech is compromised. Absence of
teeth might affect the proper pronounciation of words and make the speech
unclear. Therefore Prosthodontic rehabilitation significantly influences the
speech performance.

Based on the ability of the patients to articulate & coordinate;

 Normal speech:
Patient can produce an articulated speech with their existing dentures &
can easily
accommodate to new one.
 Affected speech:
Impaired articulation/coordination require special attention during
anterior teeth arrangement.

Methods for Speech Analysis

There are basically two methods of speech analysis
i) Perceptual/acoustic analysis

60
 ii) Kinematic methods for movement analysis

In routine clinical practice, the speech analysis is generally done

by perceptual method; asking the patient to speak. In case of patient
with severe speech pathology problems, the clarity and pronounciation
should preferably be analyzed by speech pathologist before the
prosthodontic rehabilitation, in order to establish a basis for future
comparisons and, if possible, identify problems. An acoustic analysis is
based on a broad-band spectrogram recorded by a sonograph during
the uttering of different phrases containing key phrases. By doing this,
an objective opinion of the performance of certain sounds may be
achieved.

Kinematic analysis includes such methods as ultrasonics, x-ray

mapping, cineradiography, optoelectronic articulatory movement
tracking, and electropalatography (EPG). They also could be a useful
tool for assessment of tongue contact positions and movements. EPG is
used for registrations of tongue contact patterns during speech
production and a mapping of the contacts could be achieved.

Classification of patient according to Speech

1. Rapid, jerky speech is frequently characteristic of a hysterical patient.
2. The exacting patient often displays forcefulness and abrupt speech
qualities in placing his questions and in stating his demands.
3. In contrast to these patients, the speech of the philosophical or indifferent
patient frequently has a monotone quality in his speech, which may occur
as a result of his lack of interest and certainly reflects the absence of
enthusiasm.

61
Clinical significance of speech in Prosthodontics

Speech production is the interrelationships of the tongue, teeth, denture

base, and lips. Speech production can be used as a guide to position the
artificial teeth. Tooth positions are crucial to the production of certain sounds.
The major two steps that affect the speech production are :
 Positioning of teeth
 Thickness of palatal surface of denture base

Speech production made by patients at the try-in appointment can never be

as accurate as when they are too short the processed acrylic resin denture
base has been substituted for the trial bases, and the patient has become
accustomed to the new dentures. Patients who are capable of articulate
speech with existing dentures (or natural teeth) usually have no problem
producing articulate speech with new dentures. Patients with speech
impediments require special attention.

Speech difficulty as a sequelae of oral rehabilitation with complete denture

is generally a transient problem. Effort should be made to avoid them by
pretreatment records or assessment of speech and provision of information
to patients about likely initial deviations from normal speech, immediately
after the oral rehabilitation. Speech adaptation to new complete dentures
normally takes place within 2-4 wks after insertion. Particular attention
should be paid to patients with long experience of wearing complete
dentures. When new prosthesis have to be made for these patients, certain
difficulties in learning new motor acts may delay and obstruct the
adaptation. A frequent cause is impaired auditory feedback, and therefore a
simple auditory test might be useful in such patients to make a proper
diagnosis. It also is important to listen to and analyze patient‘s speech
sounds before the rehabilitation starts and even more important to inform
patients that temporary speech sound deterioration may result from the oral
rehabilitation treatment.

62
 When the vertical dimension is established during the maxillomandibular
registration, speech can be used for guidance to assess a correct Vertical
dimension of occlusion. During the pronounciation of the s sound, the
interincisal separation, vertical distance, should average 1-1.5mm. This is
also referred to as the closest speaking space. In a recent study, influence
of alterations of VDO and palatal configuration on three consonants, k, c,
and s was investigated. It was concluded that malformation of the palatal
parts of the denture influenced speech production more than differences in
VDO did.54

c. Facial muscle tone

According to House60 , muscle tone classified as
i. Class 1
The facial muscle tone of patient belonging to Class I have
normal tension, tone & placement of muscle of mastication and facial
expression. No degeneration of facial muscle has taken place.
Immediate denture patients are classified as having Class I facial
muscle tone. Class I type has a good prognosis as maximum muscle
activity can be utilized.

ii. Class 2
The facial muscle tone of patient belonging to Class II have
approximately normal function but slightly impaired muscle tone.
Maximum of the muscle function cannot be utilized.

iii. Class 3
The facial muscle tone of patient belonging to Class III have greatly
impaired muscle tone & function. The patient with a Class III type of
facial tone generally presents with a history of long term edentulism,
accompanied with ill-fitting dentures, decreased VD, decreased biting
force, wrinkles & drooping commissures. They are most often coupled
with poor health. The prognosis of such patient is poor.

63
Class I facial muscle tone Class II facial muscle tone Class III facial muscle tone

d. Co ordination
The facility for learning and coordination appears to diminish
with age. Advancing age tends to be accompanied by progressive atrophy
of elements in the cerebral cortex, and a consequent loss in the facility of
coordination occurs. Optimum muscular control and coordination are
essential to the effective movement to be carried out during the fabrication
of denture as border molding, jaw relation etc. A patient lacking the ability
of proper coordination reveals the potential for problems in making jaw
relation records before they are attempted. To make an observation of
neuromuscular coordination, the clinician should ask the patient to open
the mouth about halfway and move the lower jaw from left to right, then to
put the tongue into the right cheek and into the left cheek, to stick it out,
and put it up and back inside the mouth. The ability, or lack of ability, to
do this movements on demand will be apparent. If the clinician feels the
problems are significant, the patient can be asked to perform the
movements in front of mirror to visually coordinate the movements.
Classified as
 Class I:Excellent
Patient learn quickly to manipulate & readily adapt to new dentures
 Class II:Fair
 Class III:Poor
Patient may never adapt to a denture completely

64
8. Temporomandibular joint
The area where the mandible articulates with the cranium, the TMJ, is one of
the most complex joints in the body. It provides for hinging movement in one
plane and therefore can be considered a ginglymoid joint. However, at the
same time it also provides for gliding movements, which classifies it as an
arthrodial joint. Thus it has been technically considered a ginglymoarthrodial
joint.65

The etiology of TMD is multifactorial and these include trauma, genetics,

anatomical factors and occlusion. The most popular theories regarding TMD
etiology are based on the biopsychosocial model, which involves a
combination of biological, psychological and social factors. Among all the
vital factors edentulism is considered as one of the causative factor of TMD
symptoms.

When the teeth are lost completely due to absence of vertical stop the
mandible comes closer to the maxilla and also the posterior dislocation of the
mandible frequently occurs. Edentulous patient cannot control the mandibular
movements in the same manner as the dentulous patient can do. Such a change
of the position of the mandible against the maxilla disrupts the TMJ
biomechanics and may generate various temporomandibular disorders (TMD),
as a result of changes in the spatial relation of the articular disc, fossa and
mandibular condyle. If the organism fails to compensate for such
dysfunctions, the patient will feel persistent pain in the TMJs, but also the
masticatory muscles and various areas across the head.

65
The current consensus is that loss of teeth and lack of posterior occlusal
support seem to have little association with TMDs. However, some believe
that several oral and dental factors, including posterior tooth loss, edentulism,
and denture use, may be associated with TMD signs and symptoms. It has
been suggested that edentulism may alter several angles and pressure
relationships affecting TMJ mechanics.71

The effect of denture condition on TMDs is controversial. One study found no

statistically significant correlations between signs and symptoms of TMDs and
denture retention, stability, occlusal disturbances, freeway space, age of
present denture or the number of sets of dentures.72 However, some studies
have shown that denture wearers have a higher prevalence of TMD symptoms
compared to the normal population or to those who still have natural teeth, and
that the incidence and intensity of TMDs are higher in subjects with greater
tooth loss in the supporting zones.73-76

Few epidemiological investigations have reported the signs and symptoms of

TMDs in complete denture wearers. Some have found no correlation between
certain characteristics of dentures (retention, stability, occlusal errors, freeway
space, age of present denture, or number of sets of dentures) and the presence
or severity of TMD signs and symptoms. However, in a study by Lundeen et
al. the relationship between denture wearing and symptoms of TMDs was
assessed in 278 denture patients and denture wearers were found to have a
higher prevalence of TMD symptoms than the normal population.

The common signs and symptoms of TMDs are:

1. Pain or tenderness in the temporomandibular joint, muscles of mastication,
facial areas, ear region, shoulder and neck
2. A clicking, popping or grating sound when opening or closing the mouth
or while chewing
3. Catching or locking of the joint with deviations or deflections of the
mandible on opening or closing the mouth
4. Limitations in opening or closing the mouth77

66
Management of Temporomandibular Disorders in the Edentulous Patient
The prosthetic approach to TMD treatment in the edentulous patient has
traditionally consisted of optimizing the stability, retention, and occlusion of
the complete prosthesis.
However, management of TMDs should primarily be directed toward
palliation of the condition. Based on the evidence from clinical trial of TMDs
it is strongly recommended that, unless there are specific and justifiable
indication to the contrary, treatment be based on the use of conservative and
reversible therapeutic modalities. While no specific therapies have been
proven to be uniformly effective, many conservative modalities have provided
at least palliative relief from symptoms without producing harm.54

i) Reassurance and Self-Care Regimen

The patient should be reassured about the relative frequent occurrence
of TMDs in the population, the good prognosis of the condition, and the merits
of prudent management strategies. In addition, the patient should be instructed
to follow a home care program to promote tissue rest and self healing that
includes the following:
 Application of moist heat (10 to 20min, 4 times a day)
 Cold application (5 minutes each time)
 Soft diet
 Avoidance of muscle strain (e.g.,avoid gum chewing or clenching)
 Identification and avoidance of events that can trigger pain or
discomfort

According to Dworkin, Huggins, Wilson et al in 2002 the patient

under following the self care regimen showed the significant decrease
in pain of TMJ/masticatory muscles and reduce additional visits for
TMDs treatment as compared to patients who received the usual TMDs
treatment (e.g physiotherapy, patient education,medications,oral
splints)78

67
 ii) Pharmacotherapy
Pharmacotherapy may be required when the supportive treatment fails
to increase comfort level. For acute pain states, dentist most commonly
prescribe medications with analgesic properties, as well as muscle relaxants,
NSAIDs and selective cyclooxygenase - 2 (COX – 2) inhibitor. These
medications are particularly useful for the treatment of arthritic conditions
involving TMJs.

iii) Biobehavioral Modalities

The biobehavioral therapies include biofeedback, stress management,
relaxation, hypnosis, and education. As proposed by Dworkin in 1997, ―the
label biobehavioral refers to proven, safe methods that emphasize self
management and acquisition of self control over not only pain symptoms but
also their cognitive attributions or meanings and maintaining a productive
level of pychosocial function, even ifpain is not totally absent.‖

9. Lymph Node Examination

For each lymph node group

 Local inspection : Obvious lymphadenopathy, surgical scars, overlying
skin (erythema, rashes)
 Palpation : determine site, size (note<1cm is often normal), shape,
consistency(hard = cancer, rubbery = lymphoma), teethering to other
structures (cancer)

The major lymph nodes of the head and neck area should be palpated with the
patient in an upright position. Findings which should be noted in the patient
record include enlarged palpable nodes, fixed nodes, tender nodes and whether
the palpable nodes are suspicious for an submerged infectious roots and even
for malignancy. Groups of tender nodes usually occur in conjunction with
some type of acute infection. Occasionally nodes will remain enlarged and
palpable after an infection. This is a relatively common occurrence especially
within the submandibular group of lymph nodes. When examined, these

68
 nodes should be small (less than 1 cm), non-tender and mobile. Remember to
correlate findings from the medical history and general appraisal of the patient
to the observations made during the head and neck examination. For example,
a previous history of cancer should cause the clinician to be more suspicious
of newly appearing palpable nodes than if there is no history of cancer. If
suspicious nodes are discovered, the patient should be referred to a physician
for immediate evaluation.79

Digital palpation of the submental lymph Palpate the submandibular lymph Bilateral palpation of the supraclavicular
nodes nodes using a cupped hand lymph nodes.

Palpation of the anterior cervical nodes Palpation of the posterior cervical Bilateral palpation of the occipital
nodes nodes

Preauricular nodes Postauricular nodes

69
INTRAORAL EXAMINATION

Optimal outcome of complete denture treatment depends on the successful

integration of the prosthesis with the patient‘s oral functions plus
psychological acceptance of the dentures by the patient. These parameters
require that patients perceive their dentures as stationary or well retained
during function, and that the prostheses and their effects on the face meet the
esthetic and psychodynamic requirements of the patient. Goiato et al., in 2008
stated that Patient‘s requirements of complete denture are to restore the normal
contour, function, esthetics and speech. Satisfaction with CD wearing is based
on the interplay of psychological, biological, anatomical and fabricational
factors.80

Most of these goals are accomplished through achieving retention, stability

and support. A thorough knowledge of the anatomy of the denture bearing
surfaces is paramount to designing and fabricating functional dentures. The
functional anatomy of the denture foundation areas of the maxilla and
mandible and the relationship of these anatomic structures that impact the
retention, stabilty and support.Among all the factors influencing the prognosis
of CD, those related to patients' denture supporting tissues should be the first
to receive the attention of the treatment. Without recognizing the features of
the relevant and applied anatomical factor of the subjects' denture supporting
tissues, favourable prognosis of CD therapy is unlikely.

1. Arch Size
Arch Size is an anatomical factor that determines the amount of basal seat
available for denture foundation. The arch size can be compared with the
facial size and the built of the patient. A person with a wider face and
healthy built frequently have a large arch size whereas a person with thin
built have a small arch size. Among all the major factors involved in the
retention of denture, arch size is the most important anatomical factor
responsible for adding the retention, stability and support to the denture.

70
 The mean denture bearing area of
i. Maxilla: 22.96 cm2
ii. Mandible: 12.25 cm2
Depending on the size of an arch, they are classified as:
i) Class I (Large arch size)
ii) Class II (Medium arch size)
iii) Class III (Small arch size)

Large arch size Medium arch size Small arch size

There is no definite mechanism for comparison of arch size; it is analyzed by

the visual perception.

Significance of Arch Size

i) Retention
With the increase in size of an arch, the surface area of denture bearing
foundation increases. Thus there will be a large surface area for the
physical factors to act which ultimately increases the retention. On this
view, large arch size is an ideal for achieving the maximum retention
whereas small arch size has the least retention.

ii) Stability
Stability and Retention are interrelated to each other. With the
increased retention, there is optimum stability of the denture. Thus
large arch size offering ideal retention will ultimately enhance the
stability whereas small arch size offers the least stability.

71
iii) Support
Arch size enhances the support by accomplishing the principle of
Snow shoe effect. Greater the surface area, less the force exerted
within physiological limit. Thus the large arch size offer the greatest
support as compared to medium and small arch size. As compared to
mandible, maxilla has a large arch size. Therefore maxillary arch offer
the increased retention as compared to mandible.

iv) Selection of Tray

Larger arch size require the larger trays of size 3 or 4, medium arch
size require 1 or 2, small arch size require 0 or 1 for taking primary
impressions. In case of unavailability of the tray, customization of the
tray may be required even for the primary impression for recording the
proper extension of denture bearing area.

v) Selection of Teeth
Arch size helps in determining the selection of size of teeth. The large
arch size requires the larger teeth, medium for medium arch size and
small for small arch size. The anterior teeth is determined by
measuring distance between the canine prominence and the posterior
teeth is determined by the posterior limit of the teeth arrangement. For
maxillary, it is anterior to Maxillary tuberosity whereas for
mandibular, it should be at the beginning of sloping of retromolar pad.

vi) Discrepancy between maxillary and mandibular arch size

The cause of discrepancy between the maxillary & mandibular arch
sizes may be due to
 Developmental origin
 Trauma
 Early loss of teeth in one of the arches

This discrepancy in the arch size causes difficulty in jaw

relation procedure & teeth arrangement. It also causes the decrease in
the stability of denture resting in smaller one of the two arches

72
 2. Arch Form
Arch form can be defined as a curve formed by configuration of bony
ridge. The original configuration/form of edentulous arch remains fairly
constant in absence of surgical intervention even after the removal of
natural teeth. Knowledge of an arch form as an anatomical parameter is of
considerable reliance, especially regarding the positioning and selection of
anterior teeth for artificial prosthesis. Numerous facial and intraoral
measurements have been proposed as a guideline to assist clinician for
selection of artificial teeth, however, the issues regarding the reliability of
selection of teeth based on these guidelines arises due to individual
anatomical variations such as arch form.81
Based on the curve formed by bony ridge, House classified arch form as
 Class I (square arch form)
 Class II (ovoid arch form)
 Class III (tapering arch form)
Regarding the arch form the square arch form has an increased surface
area so that the retention, stability and support are ideal which is less in
ovoid arch form and even more less in tapered arch form. Tapered arch
form are usually associated with high arch palate that further compromises
retention and stability.

Fig. Square arch form Ovoid arch form Tapered arch form

Fig. Arrangement of teeth according to various arch form

73
Significance of Arch Form

i) Fabrication of occlusion rim

The curvatures of occlusion rims should simulate the arch form of the
edentulous ridge so that both the width of the occluding surfaces and the
contour of the arch form of the occlusion rims should be individually
established to simulate the desired arch form of the artificial teeth.

ii) Arrangement of artificial teeth for optimum stability, occlusion and

esthetics
The central incisors in the square arch form should assume a position
more nearly on a line with the canines. The distal end of the central
incisors rotate toward the edge. The edges of lateral incisors are
perpendicular to the midline. The distal end of canines rotate toward the
line of posterior arch form so that the distance between the canines are
wider. The four incisors have little rotation because the square arch is
wider than the tapering arch. This gives a broader effect to the teeth and
should harmonize with a broad, square face.
The central incisors in the tapering arch are a greater
distance forward from the canines than in any other arch. There usually is
considerable rotating and lapping of the teeth in the tapering arch because
of less space, so crowding results. . The distal ends of central incisors
should be rotated lingually. Lateral incisors follow to arch line. The distal
end of canine is set upto posterior ridge so that the distance between the
two canines is narrow/less. The rotated positions reduce the amount of
tooth surface showing, and the teeth do not appear as wide as in other set
ups. This narrowed effect is usually in harmony with a narrower tapering
face. In case of natural teeth, while moving in function, the frictional
movement wears contact areas. Artificial teeth need to be ground on these
corresponding contact areas to allow the necessary rotational positions and
give the desired effect of a tapering setup.
The central incisors in the ovoid arch are forward of
the canines in a position between that of the square and that of the tapering
arch. The edges of central incisor are perpendicular to midline. Lateral

74
incisor follows to the arch line. Distal end of canine follows towards the
line of posterior ridge so that the distance between the two canines is less
narrow than tapering. The teeth in this form of arch are seldom rotated,
and they therefore show a greater amount of labial surface than in tapering
set up and, as a result, have a broader effect that should harmonize with an
ovoid face.54

The arch form of the artificial anterior teeth should be similar in shape to
the arch form of the residual ridge. When the anterior teeth are arranged in
an arch form that corresponds to the form of residual ridge, natural
appearing irregularities that may have been presented in the patient‘s
mouth will often be reproduced.

Regarding the arch form, the very earlier study conducted by Nelson AA
in 1922 concluded the existence of definite relationship between maxillary
teeth and the alignment form of upper anterior teeth.82 In the recent studies
conducted by Rai R in 2010, Intercanine distance was correlated with
nasal width in various arch form and concluded that a significant
correlation exists between interalar and intercanine distance in case of
square and ovoid arch form but not significant in case of taper arch form.83

Changing the shape and position of the dental arch away from the form of
the natural arch causes a highly unsatisfactory loss of face form and
expression. A square arch form where the natural arch was more tapering
will cause a stretching of the lips, with elimination of the natural philtrum.
A tapering arch form where the natural dental arch was square will not
adequately support the corners of the mouth for proper facial expressions.
The shape of the dental arch determines the size of the buccal corridor.
When the arch form of the posterior teeth is too wide or the lips do not
move to their full extent during smiling because of improper support, the
size of the buccal corridor will be reduced or perhaps eliminated.

Apart from the esthetics, change in the position or form of their dental arch
may lead to unfavourable consequences such as loss of stability. Unless

75
 the teeth are aligned in a proper arch form in both the maxillary and
mandibular arches, the occlusion will not be normal. Angle described his
lines of occlusion in 1907, as one of the criteria for normal occlusion. He
described the line of occlusion as ―the line with which in form and
position, according to type, the teeth must be in harmony if in normal
occlusion‖.

iii) Waxing & carving

In tapering arch form due to the crowding of root, carving should be
such to enhance the prominence of the root.

3. Ridge Form/contour
The cross-sectional contour of the ridge is known as the ridge form. The
contour of the ridge is an anatomical factor which according to the ridge
height and width determines the favourable or unfavorable prognosis of
the prosthesis. Ridge form can be determined by visual perception or
palpation. According to DCNA the ridge form of maxillary arch are
classified as follows:

 Class –I:
Class I ridge form consist of parallel labial/buccal and palatal sides
giving the alveolar ridge square to gently round configuration.
Increased vertical height of the ridge with a flat crest and parallel or
nearly parallel sides provides the maximum resistance to the
lateral/horizontal forces which primarily enhance the stability of the
complete denture. The optimum stability of the denture, in turn,
secondarily enhance the retention of the denture. When the retention
and stability of the denture are in harmony the support of the denture is
ultimately improvised. Hence Class I type of ridge form is considered
an ideal for the most favorable prognosis of the denture.

76
  Class –II:
Class II ridge form consist of converging buccal and palatal ridge slope
giving the tapered or ―V‖ Shaped alveolar ridge configuration. Due to
the tapered contour of the ridge the occlusal forces acting over the
ridge causes an inclined plane effect. Thus the leverage forces act
which is unfavourable for both the stability and retention of the
denture.

 Class –III:
Class III ridge form consist of flat alveolar ridge configuration. Due to
the increased surface area though the retention is good primarily but
due to lack of vertical height, there is decreased resistance to lateral
forces so that the stability is compromised ultimately leading to the
loss of retention secondarily.

Fig. Class I ridge form Class II ridge form Class III ridge form

The mandibular arch can similarly be classified as follows:

 Class –I:
Class I mandibular ridge form consist of Inverted ―U‖ shaped ridge
configuration. The ridge consist of parallel walls from medium to tall with
broad crest. Unlike the maxillary arch, the mandibular arch has decrease
denture bearing area so that the physical factors do not act in mandibular arch
as effectively as in maxillary arch. Thus the maximum retention and stability
77
 in mandibular arch can be achieved via the increased vertical height of the
ridge with a flat crest and parallel or nearly parallel sides. Hence anatomical
factor as ridge form becomes critical for the optimum retention and stability in
lower denture.

 Class –II:
Class II mandibular ridge form consist of Inverted ―U‖ shaped ridge
configuration but the vertical height is short with flat crest. Thus in Class II
case, the stability and retention can be rated good but not an ideal as in Class I.

 Class –III: Unfavorable

Class III ridge form consist of various ridge contour such as
 Inverted ―W‖
 Short inverted ―V‖
 Tall thin inverted ―V‖
 Undercut
z

Such a condition of ridge is rated unfavourable for the retention and stability
of denture and offer a poor prognosis. Apart from the biomechanical factors,
they may pose difficulty during the impression procedure. Knife edge ridge
are incapable of withstanding much occlusal forces and can easily become
sore. Hence modification in spacer design may be required. In case of
undercuts and irregularities preprosthetic surgery as alveloplasty may be

78
required. Insufficient ridge height may require vestibuloplasty or ridge
augmentation procedure.

Among all the types, Class I maxillary and mandibular ridge form is though
considered ideal but it has certain drawbacks. Due to increased vertical height
of the ridge, there is often limited interarch space so that gothic arch tracing
cannot be performed and the teeth of less occlusogingival height should be
selected.

4. Ridge relation
According to GPT-8, ridge relation can be defined as ―the positional
relationship of the mandibular residual ridge to the maxillary residual
ridge.‖ Smith defined it as the anteroposterior position of mandibular
residual ridge relative to maxillary residual ridge when the jaws are in
centric relation and separated by the distance they will be separated by the
prosthesis. Differences in the method of ridge resorption in both arches
leads to many ridge relations which are abnormal and require a
modification in the teeth setting in order to obtain maximum efficiency of
dentures. The ridge relation can be classified as:

 Class-I: Normal/Orthognathic
The ridge relationship in which the position of mandibular ridge is at
same or slightly behind the maxillary ridge when seen in sagittal plane

 Class-II: Retrognathic
The ridge relationship in which the position of mandibular ridge is
behind the maxillary ridge when seen in sagittal plane. Class II
situation can result due to smaller mandible and normal maxilla or due
to normal mandible and larger maxilla, or due to larger maxilla and
smaller mandible. In this condition, the mandible is in distal relation to
the maxilla or in other words the overjet will be more than Class I
situation.

79
  Class-III: Prognathic
The ridge relationship in which the position of mandibular ridge is in
front of the maxillary ridge when seen in sagittal plane. Class III
situation can result due to larger mandible and normal maxilla, or due
to normal mandible and smaller maxilla or due to larger mandible and
smaller maxilla. In this situation, the mandible is infront compared to
Class I situation. In other words, the overjet will be 0mm edge to edge
bite) or at times the mandible will be infront of maxilla.

Fig. Class I ridge relation Class II ridge relation Class III ridge relation

Method of determining ridge relation

Ridge relationship is always viewed from the side and correlate with the
patient‘s profile. The patient should be asked to sit upright in a relaxed
position in the dental chair. Then the lips are carefully parted to see the ridge
relation. This clinical method for determining ridge relation is not accurate as
patient might move the jaw unconsciously while parting the lips. Hence to
avoid the error, mounted diagnostic cast is the most reliable method.

Significance of Ridge relation

The significance of ridge relation can be appreciated during the arrangement
of the teeth and managing the undesirable leverage forces that occur due to the
ridge discrepancy. During the fabrication of complete denture for all the three
situations the molar relation should be placed in Ideal Class I relation, that is
the mesiobuccal cusp of the upper first molar occludes with the buccal groove
of the lower first molar. This relation is known as ―Key of Occlusion‖ which
should be maintained for all artificial dentures from biomechanical point of
view. In class II ridge relation if teeth arrangement is done following Angle‘s

80
class II, then the upper first molar is placed one cuspal width infront compared
to normal Class I relation and subsequently the upper second molar also comes
one cuspal width infront of the normal situation. Naturally in lower arch the
distal half of the lower second molar goes out of occlusion (there is no
opposing part from the upper molar.) In class II ridge relation if teeth
arrangement is done following Angle‘s class II, the opposite of Class II
relation is encountered. That is the distal half of the upper second molar goes
out of occlusion and the masticatory efficiency is impaired and stability of the
denture will be less.

Class I ridge relation is an ideal for the jaw relation procedure and arranging
the artificial teeth. On the contrary, the compensation of ridge discrepancy of
Class II and Class III is done by the modification in the teeth arrangement. In
Class II ridge relation resulting due to smaller mandible and normal maxilla,
one premolar is removed from either side of the lower arch; if it is due to
larger maxilla then one extra premolar is added to both sides of the upper arch,
hence there will be three premolars on each side of the upper arch. Naturally
the upper molars goes distally and occluding lower molars also goes distally
creating space for two premolars on each side of lower arch. But it should be
remembered that the distal end of the posterior teeth should be infront of the
tuberosity and retromolar pad. In Class III ridge relation resulting due to larger
mandible, then one extra premolar is added on each side of the lower arch; if it
is due to smaller maxilla one premolar is removed from the upper arch from
both the sides.

Anteriorly the compensation of excessive overjet in Class II is done by straight

or decreased proclination of upper anterior teeth followed by increased
proclination of lower anteriors. Similarly the compensation of lack of space or
no overjet in Class III is done by increased proclination of upper anterior teeth
followed by decreased proclination of lower anterior teeth. In many of the
Class III situations, the anterior teeth will be placed in ―edge to edge‖ relation
for esthetic purpose.

81
 5. Ridge parallelism
The relative parallelism of the maxillary and mandibular ridge in relation
to the occlusal plane is known as the ridge parallelism. The relative ridge
parallelism determines the direction of occlusal forces acting over the
ridge which has a significant effect on the stability of denture. Ridges that
are not parallel- cause movement of the bases when teeth occlude because
of unfavorable direction of forces.

Ridge parallelism can be classified into following types:

 Class I: The maxillary and mandibular ridge are parallel to occlusal plane.
Class I ridge parallelism offer the ideal stability of the denture because the
applied occlusal forces act vertically and uniformly over the ridge, occlusal
contacts are evenly distributed and bilateral thereby providing occlusal
balance and harmony.
 Class-II:
The mandibular ridge is divergent from the occlusal plane anteriorly. Because
of the divergent mandibular ridge, the occlusal forces act at an angle causing
an inclined plane effect so that uneven distribution of occlusal forces occurs
leading to the instability of the denture.
 Class-III:
The maxillary ridge is divergent from occlusal plane anteriorly or both the
maxillary and mandibular ridges are divergent anteriorly. As the occlusal
contacts are immediately above the incline of the posterior part of the residual
ridges which will cause a complete denture to slide forward causing tipping
effect. This will lead to instability of the denture with compromised
masticatory efficiency and trauma to the residual ridge.

Class I ridge parallelism Class II ridge parallelism Class III ridge parallelism

82
 6. Interarch space
According to GPT-8, interarch space/ridge can be defined as ―the vertical
distance between the maxillary and mandibular dentate or edentate arches
under specified conditions.‖ Interridge distance signifies the difficulty in
teeth arrangement procedure.

 Class-I:
The interridge distance between the maxillary and mandibular ridge is
adequate enough to accommodate the artificial teeth. The interridge distance is
around 15-20 mm. Class I interridge distance is an ideal for the
occlusogingival height of the teeth which enhances the esthetics.
Thickness of upper and lower denture base = 2 + 2mm = 4mm
Occusogingival height of upper & lower premolar = 6 + 6mm = 12mm
Freeway space = 2-4 mm
Thus, ideal interarch space : 4 + 12 + 2/4mm =18-20mm

 Class-II:
The interridge distance between maxillary and mandibular ridge is excessive
in Class II interarch space. The interridge distance is around 20 mm. Thus the
increased interarch space may though facilitate the artificial teeth arrangement
without compromising the occlusogingival height of the teeth but the
excessive interridge distance results in a large restorative space between the
maxillary and mandibular ridge leading to a fabrication of a heavy maxillary
prosthesis which influences the retention and stability of the denture.

 Class-III:
The interridge distance between maxillary and mandibular is insufficient to
accommodate the artificial teeth. The distance is less than 15mm. Small
amount of inter ridge distance leads to difficulty in setting teeth and
maintaining a proper freeway space. Thus the trimming of artificial teeth is
required which is time consuming. In addition, if excessive trimming is done
the morphology of the teeth might be changed that compromises the esthetics
along with the strength of the teeth.

83
Class I interarch space Class II interarch space Class III interarch space

Method of measuring interridge distance

Clinically the patient is asked to sit upright in a relaxed state in dental chair.
Then the lips are carefully parted and the interridge distance is measured at premolar
region. This clinical method of measuring interridge distance is not reliable. Precise
measurement is not possible in dynamic stage clinically, hence Mounted diagnostic
cast is the most effective method for determining interridge distance. The reference
point for measurement is taken premolar because there is overlapping in the anterior
region whereas among the posterior teeth the first premolar is the most accessible one.
Measurement is done with Boley‘s guage.

7. Bony defects/prominences/irregularities
Bony defects are any outgrowth or irregularities on the surface of denture
bearing foundation that might interfere in the complete denture
rehabilitation. The most commonly encountered bony defects in the
common clinical practice are tori, exostosis, osteomas, bony spicules.
Although all are bony outgrowth but the basic difference among them are:

84
 Tori : The tori are the bony outgrowth which are site specific in its
occurrence. The torus is considered to be a developmental anomaly,
although it does not present until adult life and often will continue to
grow slowly throughout life. In the maxillary arch, the tori occurs on
the palate known as torus palatinus whereas in mandibular arch, the
tori occurs lingually below the premolars above the location of the
mylohyoid muscle's attachment to the mandible known as torus
mandibularis. 90% of the mandibular tori have a bilateral occurrence.
The prevalence of palatal tori ranges from 9% - 60% of the population
and are more common than bony growths occurring on the mandible
(lower jaw), known as torus mandibularis (ranges from 5% - 40%).
They are hard round swellings anatomically and the common problem
resulting from these structures relates to the generally thin mucosal
covering, relative to the overall denture supporting tissues. The
underlying mucosa will not tolerate normal occlusal loads on a
denture. Extremely thin mucosa that can be easily pressurized during
procedures and difficulty in achieving border seal.
.
Large mandibular tori can prevent complete seating of impression trays
and denture. This can cause discomfort, rocking or instability of a denture
unless adequate and accurate relief is provided in the denture. The relief
area must be no deeper or extensive than required, or loss of retention of
the denture may result. If the extent of the bony prominence is ill-defined,
the assistance of a disclosing paste will be required to outline the area to be
relieved. Depending on the size and its effect on the denture, tori can be
classified as follows:

Class –I:
Tori are absent or minimal in size. The size of the existing tori do not
interfere with denture fabrication. Only slight relief can manage the
condition.

85
 Class-II:
Tori of moderate size. The condition may though pose mild difficulties in
denture fabricaton procedure but preprosthetic surgery is not required.
Adequate relief is required, with a precaution not to compromise the
retention. Alternatively complete denture incorporating a combination of
soft acrylic flanges and liners can also be fabricated

Class-III: Large tori are present. These tori compromise the fabrication
and function of the denture, requiring surgical recountouring. , an
exostosis or torus may be so large and/or undercut as to prevent denture
insertion, or cause the baseplate to excessively encroach on the available
space in the oral cavity. The class III condition posing absolute indication
for preprosthetic surgery are:
That prevent the formation of an adequately extended and stable denture.

Maxillary torus: If this extends onto the post dam area (junction of the
hard palate and soft palates) and peripheral seal is significantly reduced,
surgery will be required.

Mandibular tori: If these are large enough to significantly reduce the

width of the tongue space anteriorly, surgery will be required.84

 That traps the food debris , causing a chronic inflammatory condition

Fig. Mandibular tori Buccal exostoses Bulbous tuberosities

86
 Based on their appearance Tori can be categorized as

 Arising as a broad base and a smooth surface, flat tori are located on the
midline of the palate and extend symmetrically to either side.

 Spindle tori have a ridge located at their midline.

 Nodular tori have multiple bony growths that each have their own base.

 Lobular tori have multiple bony growths with a common base.

Exostoses

Superficial bony masses / lumps found in any portion of the denture bearing
foundation,not site specific are named as exostosis or osteoma. A buccal exostosis
is the formation of an exostosis (bone mass) on the outer, cheek-facing side of the
maxilla (upper jaw) or the cheek-facing side of the mandible (lower jaw). They
are less common on the lower jaw. They begin to develop in early adulthood and
may very slowly enlarge over years. They are painless and self-limiting but may
contribute to periodontal disease (gum disease / pyorrhoea) if they become too
large. Buccal exostoses have no malignant potential. Similar to tori, the size of the
exostoses determines its management. That is, for the minimal to moderate size of
exostoses, adequate relief is sufficient whereas for the larger size of exostosis
interfering with border seal and functioning, the treatment plan has to be directed
towards surgical intervention.

The torus may be bosselated or multi-lobulated but the exostosis is typically a

single, broad-based, smooth-surfaced mass, perhaps with a central sharp, pointed
projection of bone producing tenderness immediately beneath the surface mucosa.
Though the exact etiology of exostoses and tori is not known but the literatures
have speculated that the Tori / buccal exostoses may be the outcome of mild,
chronic peri-osteal ischemia secondary to mild nasal septum pressures (palatal
torus) or the torquing action of the arch of the mandible (mandibular torus) or
lateral pressures from the roots of the underlying teeth (buccal exostosis). The
condition is also considered to have hereditary origin to some extent.
(www.exodontia.com)

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 Osteomas

Osteoma is a benign often asymptomatic neoplasm, consisting of well-differentiated

matured bone. It is characterized by proliferation of either compact or cancellous bone
in an endosteal or periosteal location forming a large amount of osteoid which
become calcified showing typical characteristic X ray changes, such as focal
rarefaction and reactive bone, which appeared some distance from the lesion. They
are frequently found in lingual surface of the mandible.

They are considered to be trauma-provoked inflammatory responses or true (benign)

neoplasms. Unless such a bony prominence is specifically located, is stalked or is
associated with an osteoma-producing syndrome such as the Gardner syndrome, there
may be no means by which to differentiate an exostosis from an osteoma, even under
the microscope.( Maxillofacial osteoma associated with cutaneous sebaceous cysts,
multiple supernumerary teeth and colorectal polyposis is known as Gardener‘s
syndrome.)

Histologically osteomas consists of mature, lamellar bone or cancellous bone with

abundant fibrofatty marrow between bony trabeculae. Histologically there is no
evidence of differentiation between osteoma and tori, they can only be differentiated
clinically and radiographically. Radiographically osteoma show as well
circumscribed, densely sclerotic and radiopaque mass. Osteomas are diagnosed and
treated by local excision so as to avoid interferences during the fabrication process.
Recurrence of peripheral osteoma after surgical excision is extremely rare.

8. Palatal Vault

According to GPT 8, the palatal vault can be defined as the deepest and most superior
part of the palate or the curvature of the palate determines the palatal vault. The shape
of the palatal vault contributes to stability as limited by the length and angulation of
the palatal ridge slopes. The depth and anatomy of palatal vault is significant for the
stability of the denture based on angulation of the forces to be applied on the slope of
palate and retention of the denture based on amount of coverage of more surface area.
The shape of palatal vault can be categorised into following three shapes:

88
i) “U” shaped vault:
the U shape of palatal vault provides a greater area of contact and the application
of occlusal forces are perpendicular to the palate. Thus U shaped palatal vault is an
ideal for the favorable retention and stability. Class I ridge form is usually associated
with this shpae of palatal vault.

ii) “V” shaped vault:

the V shape of palatal vault though provide a greater surface area of contact but
due to the palatal sloping the occlusal force act at an inclined plane causing leverage
force. This would compromise the denture stability and secondarily the retention of the
denture.

iii) Flat palatal vault:

Due to the broader surface area coverage, the retention is satisfactory initially.
But due to the absence of vertical height, the resistance to lateral forces is less leading
to compromised stability and ultimately the loss of retention too.

a)

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a)Incisive Papilla

The incisive papilla otherwise known as palatine papilla is a small pear or oval shaped
mucosal prominence situated at the midline of the palate, posterior to the palatal
surface of the central incisors. Histologically it consists of firmly interwoven fibers of
dense connective tissue lined by simple or pseudostratified columnar epithelium
which is frequently keratinized. The incisive papilla is generally situated over the
incisive foramen through which emerge the nasopalatine nerves and palatine vessels.
Watt and Likeman found that the papilla moved forward about 1.6 mm as a result of
maxillary alveolar bone resorption and the incisive fossa lies slightly posterior to the
papilla.85

 Several investigators have studied the horizontal relationship between incisive

papilla and maxillary central incisor and measured the papilla incisor distance in
dentate subjects to extrapolate this distance as a guide to place maxillary central
incisors in complete dentures. As early as 1948 Harper stated ―When artificial
teeth are set in proper position, which may be determined by the incisive papilla,
the foundation is correctly laid for natural speech, pleasing appearance and
normal function‖.(86) Based on this premise, incisive papilla is recognized as an
important landmark in complete denture fabrication. The center/middle or the
base/posterior border of the papilla are mostly used as reference for papilla-
incisor measurements. Anterior border and center of incisive papilla are likely to
change after extraction of incisor teeth, while the posterior border is relatively
stable. Papilla becomes round after extraction of incisor teeth due to changes in
the anterior border. During edentulous transformation as the papilla changes to
round form, its center also changes. There is a shift in the center of the papilla
from the dentulous to edentulous state. In dentulous subjects incisive papilla is
seen in various shapes and this change will be more in a long papilla compared to
a short papilla. The anterior border of the papilla is not a reliable landmark
particularly when the papilla is continuous with the interdental papilla, since post
extraction changes occur at the anterior border. The base/posterior border is a
reliable landmark as it is definable and subject to least change in the edentulous
state. Labial surface of the maxillary incisors should be 12 to 13 mm from the
posterior border of the incisive papilla.87 Another clinical significance of incisive

90
 papilla is in case of prominent incisive papilla. Pressure on papilla by the
maxillary denture can result in pain or burning sensation and also the tingling
sensation requiring adequate relief

Fig. Incisive papilla requires

relief in denture

Fig. Incisive papilla Fig. Papilla as a guide to select anterior teeth

Classification of Incisive Papilla88

Nine different types of incisive papilla were recognized and they are classified
according to the order of their occurrence.
Type I: Large pear
Type 2: Small pear
Type 3: Inverted pear
Type 4: Tapering/flame
Type 5: Cylindrical/spindle
Type 6: Round/oval/football
Type 7: Dumb-bell/bowling pin
Type 8: Double papilla
Type 9: Rudimentary and difficult to recognize.

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b)Rugae

According to GPT 8 rugae can be defined as “the irregular fibrous connective

tissue ridges located in the anterior third of the hard palate”. The palatine
rugae are ridges situated in the anterior part of the palatal mucosa on each side
of the medial palatal raphae and behind the incisive papilla (IP). Lysell’s
classification in 1955 is the most important, and it has been used widely in
research involving rugae.89 It is comprehensive and includes the IP. Rugae are
measured in a straight line between the origin and termination and are grouped
into three categories:
 Primary: 5 millimeters or more;
 Secondary: 3 to 5 mm;
 Fragmentary: 2 to 3 mm

Clinical significance of palatine rugae

i) Secondary stress bearing area

The palatine rugae is considered as secondary stress bearing area as the bone
in palatine rugae is though compact but the occlusal forces act at an angle

ii) Palatine rugae in speech and palatal prostheses:

For patients who experience difficulty with their speech patterns when
acclimating to a new prosthesis, the texture of the rugae in the palatal region
of the denture may prove helpful. Palatography has been used to determine the
optimum thickness and shape of the palatal surfaces. This approach was
developed in a study of phonetics to determine the contact position of the
tongue relative to the palate in the production of specific sound. Essentially,
application of these techniques ensured contact between the tongue and palate
during articulation of these sounds. The ―s‖ and ―sh‖ phonemes have received
particular attention. Thus the lack of texture on the palatal portion of a
complete denture can impede proper articulation one solution is to add
palatine rugae.90, 91

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 iii) Taste sensation
The tip of the tongue when touches the irregular surface of the palatine rugae
causes the stimulation of glands on the dorsum of tongue that stimulate the
taste sensation.

iv) Forensic Identification

It is a well-established fact that the rugae pattern is as unique to a human as
are his or her fingerprints, and it retains its shape throughout life. The
anatomical position of the rugae inside the mouth surrounded by cheeks, lips,
tongue, buccal pad of fat, teeth and bone keeps them well-protected from
trauma and high temperatures. Thus, they can be used reliably as a reference
landmark during forensic identification.(92-94)

c)Mid palatal raphae

A median longitudinal rather narrow, low elevation in the center of the hard
palate that extends from the incisive papilla posteriorly over the entire length
of the mucosa of the hard palate. The mid palatal raphae is either rigid or
compressible that is detected by the blunt end of the probe.in the region of the
medial palatal suture, the submucosa is extremely thin, with the result that the
mucosal layer is practically in contact with the underlying bone. For this
reason, the soft tissue covering the median palatal suture is non resilient and
may need to be relieved to avoid trauma from the denture base. The prominent
midpalatal raphe, if not relieved adequately, can act as fulcrum point causing
the rocking of the denture.
Raphae is any seam like union (line or ridge) between two similar parts or
halves of an organ. In case of rigid midpalatal raphae, more relief in required
in midpalatal region as compared to compressible midpalatal raphae.

Fig. Palatine rugae Fig. Midpalatal raphae

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d)Soft Palate/Palatal throat form

The soft palate is a movable muscular fold, suspended from the posterior
border of the hard palate. The soft palate makes up approximately one third of
the posterior portion of the palate its oral mucosal lining is covered with
mucous secreting salivary glands. It separates nasopharynx from oropharynx.
It has no bony frame and is made up entirely of various muscle fibers. The
musculature is comprised of five main structures including the musculus
uvulae, the tensor veli palatini, the levator veli palatini, the palatopharyngeus
muscle and the palatoglossus muscle.

The significance of soft palate in

edentulous patient is multifunctional.
The anatomy of soft palate has a
significance in the placement of
posterior seal of the denture. Soft palate
aids in speech and the pronunciation of
velar consonants along with the dorsum
of the tongue. When swallowing, it
rises to close the nasal passages and
prevent any food or liquid from entering into the nasal cavity. It does the same
thing for the larynx when sneezing. The uvula helps produce the gag reflex
when touched.

The soft palate can be classified in two ways:

Based on the area covered across the distal edge of tuberosities

(M.M.House classification)

 Class-I: Large and normal in form, with a relatively immovable band

of resilient tissue 5-12 mm distal to the line drawn across the distal
edge of the tuberosities

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  Class-II: Medium size and normal in form, with a relatively
immovable resilient band of tissue 3-5 mm distal to a line drawn across
the distal edge of the tuberosities
 Class-III: Usually accompanies small maxilla. The curtain of soft
tissue turn down abruptly 3-5 mm anterior to a line drawn across the
palate at the distal edge of the tuberosities. Thus it is the curtain drop
appearance of soft palate.

Based on the angle the soft palate makes with hard palate (Winkler
classification)

The more acute angle in relation to hard palate, more muscle activity
necessary for velopharyngeal closure. So the more soft palate is
markedly displaced in function, the less area can be covered by denture
base. Determined when the patient is in upright position with the head
held erect.

 Class I: Soft palate is horizontal as it extend posteriorly with minimal

muscular activities; most favorable as it allows more tissue coverage
for PPS.
 Class II: Soft tissue turn down at about 45 degree angle to the hard
palate with muscular activity more than class I but less than class III
 Class III: Soft tissue turn down sharply at about 70 degree angle just
posterior to hard palate; least favorable as space for PPS is minimum.

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Significance of soft palate
The most important clinical significance of soft palate is in the precise
recording of posterior palatal seal area. In class I, the soft palate is horizontal
as it extends posteriorly, requiring minimal muscular activity for
velopharyngeal closure allowing more than 5mm of seal area. Thus there is
more area to play or for the placement of PPS in class I soft palate. In class III,
the soft palate is more acute in relation to hard palate, necessitating marked
elevation of musculature for velopharyngeal closure permitting a narrow seal
of less than 1mm. Class II type of soft palatal contour lies between class I and
class III classes allowing 1 to 5 mm of seal area depending on muscular
activity of soft palate.

The depth of the PPS depends on the anatomy of the soft palate
 Class I palate - shallow PPS
 Class II palate - medium PPS
 Class III palate - deep PPS

96
 According to Levin95 , the thickness of denture base also depends on the type
of soft palate. He advices
 Use of thin denture base for class I soft palate ( PPS is not deep but wide).
 Thicker denture bases for class III soft palate ( PPS is deep but not wide).
 Medium thickness for class II soft palate .

Methods of determining soft palate

The ideal method for determining the soft palate is cephalometric analysis.
Clinically the soft palate can be determined by the visual perception or by
asking the patient to say ah in short vigorous burst.

e)Palatal sensitivity
The degree of sensitivity of palate can be classified as
 Class-I: Normal
 Class-II: Subnormal (hyposensitive)
 Class-III: Supernormal (hypersensitive)
The palatal sensitivity is a sensory reflex that can be checked by a wisp of
cotton or blunt end of instrument on the palate especially on posterior region.
The significance of determining the palatal sensitivity is that it gives an idea of
gag reflex and thereby take the preventive measure for its management.

f) Gag reflex

Gag reflex is a normal healthy body defense mechanism that prevents the
entry of foreign particles to the trachea. It is a motor reflex that activates for
the protection, however the condition in an exaggerated form can interfere
with the normal clinical procedure during the fabrication of the denture along
with post insertion adaptation. The causes of gag reflex could be

i) Iatrogenic
The iatrogenic causes of gag reflex could be the visual stimuli, odours,
sound, mouth mirror, saliva ejector, placement of impression tray, record base,

97
trial denture. Means et al in 1970 suggested that majority of patients show a
history of precipitating cause.96

ii) Systemic problems

Gastrointestinal disturbances, inflammation of the pharynx, diaphragmatic
hernia, sinusitis are the common systemic condition causing gag reflex.
Murphy et al in 1975 surveyed gagging and analyzed medical histories.
iii) Anatomical anomalies like deviated nasal septum, nasal polyps etc
iv) Psychological factors
v) Current medication
vi) Faulty existing prosthesis
-overextended borders (especially posterior border)
-inadequate posterior palatal seal
-poor occlusion
-poor retention
-smooth shiny denture surface
-inadequate freeway space

An exaggerated gag reflex can be problematic during various clinical steps of

fabrication of complete denture. While making primary impression, gag reflex
on one side may be uncomfortable to the patient while on the other side
prevents the proper recording/extension of the impression. Severe gag reflex
pose difficulty during final impression, jaw relation procedures. Thus the
management of gag reflex becomes essential during the fabrication of
complete denture.

Management of gag reflex varies depending on the severity

a. Prosthodontic management (Reduction of amount and duration of

stimuli)
- no overextension of the tray
-avoid excessive loading of impession material on the tray
-patient should be seated upright leaning forward while making impression
-use of fast setting impression material

98
-saliva ejector to remove excess saliva
- Flamer and Connely in 1984 suggested a technique for construction of a
palateless denture (not covering palatal vault) but they noted that it is only
satisfactory if maxillary ridge is well formed so that minimizes horizontal
movement).

b. Distraction Maneuvers
-Talking and reassuring the patient constantly or engaging him in some topic
of special interest
-raising the foot alternately
-counting the digits (1 to 10)
-asking the patient to breathe deeply through the nose

c. Progressive desensitization (if pathologic or severe gaggers)

-weak stimuli is given first and then slowly increased
-Marble technique : Patient is asked to practice with marbles in the mouth
and then the number of marbles are slowly increased. Singer et al in 1973
tried to place glass marbles in mouth prior to the treatment of denture
patients.97
-acrylic base plate can be given to practice at home prior to treatment.
Murphy et al in 1975 attributed the problem to complete or partial maxillary
denture and thus treated gagging patients by construction of clear acrylic
training plate combined with relaxation therapy.
- Appleby and Bay’s technique of finger massaging the soft palate can
exhaust the gag reflex thereby allowing for graduated exposure to the dental
prosthesis or procedure.

d. Pharmacological management
In severe cases where other measures are inadequate to control the gag
reflex, administration of gels or medications are indicated as follows:
-local anaesthetic gels
-antihistamines
-sedatives
-tranquilizers
-CNS depressant

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Gagging may cause difficulty at the time of denture insertion. In such cases
the posterior border of maxillary denture should be carefully observed. A thick
square edge irritates the pharyngeal aspect of tongue constantly when it is in
its rest position and initiates gagging. A thin posterior edge, properly sealed
and sinking into the compressible tissues of the palate, will not irritate the
tongue. Proper counseling of the patient should be done to solve the problem.
In sensitive patients, the gag reflex is easily released after placement of new
dentures, but it usually disappears in a few days after adaptation to the
dentures. However, other causes such as faulty occlusion, overextended
borders (posterior part of maxillary denture and distolingual part of
mandibular denture), poor retention of maxillary denture must be checked if
the problem persists. Patients can be advised to suck sweets or candies which
increases the flow of saliva and keeps the tongue occupied preventing it from
resting against the posterior border of denture before it has learned to tolerate
it thus preventing gagging with new dentures.

Evaluation of Soft tissue/Mucosa condition

The prime objective of complete denture rehabilitation is to achieve good

stability and optimum support from the denture bearing area. Complete
dentures are entirely dependent for support on soft tissue (mucoperiosteum)
and underlying hard tissue (bone). The health and quality of these tissues are
therefore very important determinants of success in the wearing of complete
dentures. The edentulous ridge is surrounded by the cheeks, lips and the floor
of the mouth which are covered by lining mucosa that is relatively thin and
easily traumatized. It is also the site of variety of pathoses. The term
masticatory mucosa has been applied to the mucosa covering the residual
alveolar ridges and palate. It is usually attached to underlying periosteum and
if not attached, instability of a denture and trauma to underling mucosa may
result. The latter one is specialized mucosa covering the surface of the tongue.
A comprehensive clinical examination of all these tissues should be done
carefully for any abnormalities, irregularities and pathoses. Abnormalities,
whether they are local, mechanical, or systemic in origin, must receive proper
diagnosis and treatment.

100
Diagnosis of abnormalities of the mucosa requires the recall of the normal
appearance. Shape, color, and texture are significant characteristics. The color
of the mucosa will reveal much about its health. The differences in the
appearances between a healthy, pink mucosa and red, inflamed tissue will be
apparent. The cause of any inflammation must be determined. Is the
inflammation the result of trauma caused by ill fitting dentures or a
manifestation of infection must be determined. Concomitant inflammation of
the corners of mouth may raise a suspicions of Candida albicans. A cytosmear
may be made easily and examined for pseudohyphae. Some variations occur
frequently with no significance and are therefore accepted as normal. These
include Fordyce‘s granules in the buccal fat pads and varicosities in the floor
of mouth of elderly patients.

101
• Successful complete denture rehabilitation is relatively advantageous to the
epithelium as they can simulate rather than irritate the underlying mucosa.
However ill fitting/faulty prosthesis can alter the character, condition and form
of the underlying oral tissues. Soft tissue pathologies like papillary
hyperplasia, candidiasis, flabby ridge, traumatic ulcers are most commonly
associated with prolonged use of ill fitting dentures. The pathological changes
must be carefully examined and resolved, prior to the beginning of the new
prosthetic rehabilitation.
In case of irritated mucosal condition, the denture is left out of the
mouth for several days so that the edema will subside, and the remaining
lesion will become considerably smaller. If the condition is not long standing
and rather limited in extent, simply adjusting the denture flange area in the
affected area will bring about a resolution of the lesion. The use of tissue
conditioners will also help to subside the lesion. When this does not resolve
the lesion surgical excision becomes imperative and this is followed by
fabrication of a new set of adequately fitting dentures. The pathological
condition such as leukoplakia, white lesions, ulceration on lateral borders of
the tongue should be carefully examined, diagnosed and treated before the
rehabilitation begins.

The mucosal thickness is another important factor to be considered for the

support of the denture. The thickness of the alveolar mucosa influences the
probability of the occurrence of denture-induced irritations. Thick denture-
supporting tissues offer relief from mucosal tenderness and ulcers whereas
thin denture supporting tissues undergoes ulceration. According to M.M
House, the mucosal thickness can be classified into following three types:
 Class I: normal uniform density of mucosal tissue (approximately
1mm). Investing membrane is firm but not tense and forms an ideal
cushion for the basal seat of a denture
 Class II:
a. soft tissues have thin investing membranes and are highly
susceptible to irritation under pressure

102
 b. Soft tissues have mucous membranes twice the normal
thickness (2mm)
 Class III: soft tissues have excessively thick investing membranes
filled with redundant tissues. This may require tissue treatment.

The significance of mucosal thickness is in predicting the retention, stability

and support of the denture. Class I type of mucosal thickness forms an ideal
denture bearing mucosa whereas class IIa mucosal thickness is easily
traumatised, hence it determines the need of relief in certain areas. Class III
mucosal condition may necessitate the surgical correction for the favorable
prognosis, hence the patient should be counselled accordingly. It also helps in
determining the length of edentulous span.

Variation in the mucosal thickness limits the equalization of pressure all over
denture bearing tissue causing soreness in the areas to be relieved. According
to study done by Dong J, Zhang FY, Wu GH et al in 2015, the mucosal
thickness in denture-bearing area of edentulous mandible was not uniform;
thus concluded that the tissue surface of the denture base or custom tray
should be selectively relieved, which may reduce the risk of denture-induced
irritations.98
Similarly the thickness of palatal masticatory mucosa is also important. It can
be used in alveolar ridge augmentation procedure in case of moderate to
severe ridge resorption.. Clinically the thickness of mucosa can be measured
by “bone sounding with periodontal probe, with a rubber stopper”. The
probe with the rubber stopper, securely in place, is then lined up to a 0.5 mm
sterile stainless steel ruler. On the rugae area, the measurement point is taken
the base of the rugae, but not the hill. Alternatively, it can also be determined
by syringe needle/endofile with stopper under LA. These direct clinical
measurement methods are invasive that used needles and periodontal probes
after local anesthetic administration. Ultrasonic devices were non-invasive and
easy to use; however, this method lacked consistency. Thus the accurate
assessment of the mucosal/ palatal thickness can be done by CBCT.98, 99

103
 Determining mucosal thickness Determining tissue compressibility

Tissue compressibility
The compressibility of the tissue is det ermined by the amount of
displaceability of the denture bearing tissue. The denture bearing foundation is
covered by the mucous membrane which serves as a cushion between the base
and supporting tissues. The mucosa is composed of mucosa and submucosa.
The submucosa is formed by connective tissue that varies in character from
dense to loose areolar tissue and varies considerably in thickness. A cross
section of hard palate shows that palate is covered by soft tissue of varying
thickness, even though the epithelium is keratinized throughout. Thus the
thickness and consistency of the submucosa is largely responsible for the
compressibility of the tissue.

The amount of displaceability of the tissue is ascertained by pressing the ball

portion of the T burnisher into the tissue of the mouth lightly and ascertaining
the depth to which the ball buries itself in the tissue. At the midline of the
palate, there may be little tendency of the tissue to yield, then again there may
be considerable tissue yielding. As a rule, the tissues lying laterally to the
median line will show more resiliency. Anterolaterally the submucosa contains
adipose tissue which exhibits resiliency and posterolaterally it contains
glandular tissue and hence the tissues through the hamular notch will generally
be readily displaceable.100 Absence of compressibility of the tissue may
signify the condition such as Oral submucous fibrosis.

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Tongue

Tongue, a well developed muscular organ with a rich nerve supply in the
floor of mouth, poses a strong challenge to the success of the fabricated
prosthesis. It plays an important role in the retention and stability of complete
dentures. Functionally, it is associated with mastication and speech with
complete dentures. It is important for a prosthodontist to understand the role
played by this organ in various phases of complete denture therapy. This helps
in careful designing of the prosthesis by the prosthodontist which aids in
acclimatization of tongue to the prosthesis, making it a success.101

Tongue position and posture are important considerations in this respect.

Proper examination of this organ at the diagnostic appointment helps in
formulation of a scrupulous treatment plan as it influences all the further
treatment phases starting from the impression making to adjustment phase of
the complete denture therapy. After the loss of teeth, tongue expands into the
space created by loss of teeth, known as Proptosis Lingualis. The enlarged
tongue creates problem during impression making, contributes to mandibular
denture instability, is crowded by denture base resulting in difficulty in
swallowing. The crowded tongue always presses on the front part of palate
causing soreness and tenderness. It also causes excessive pressure on the
mandibular denture which pushes it forward and outward everytime the mouth
is opened.

The influence of tongue during various phases of denture therapy may be

discussed as follows

The Diagnostic Appointment

At the diagnostic appointment the size, position and activity of tongue are the
main points of concern.

Tongue Type
Class-I: Normal in size, development and function. Sufficient teeth are present
to maintain normal form and function

105
Class-II: Teeth have been absent long enough to permit a change in the form
and function of tongue
Class-III: Excessively large tongue
The enlargement of the tongue caused by intrinsic muscles and that could be
physiological or pathological.

Tongue Position
The position of tongue strongly influences the prognosis of mandibular
denture. Wright has classified the tongue position as:
Class 1 – Tongue lies in the floor of mouth with the tip forward and slightly
below the incisal edges of mandibular anterior teeth. It has the most
favourable prognosis as adequate border seal can be achieved because floor of
the mouth will be high enough to cover the lingual flange.
Class 2 – The tip is in a normal position but the tongue is broadened and
flattened. It is not a favourable position.
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 tongue.
Its very unfavourable position as an adequate border seal can‘t be achieved.
An attempt to extend the flange to gain border seal results in overextension
during tongue movements that would dislodge the denture.

Clinical Evaluation of Tongue Position

Clinically, tongue position can be evaluated by asking the patient to open just
wide enough for a small portion of food and observing different positions of
the tongue. In the normal position the tongue appears relaxed and completely
fills the lower arch with its apex lightly contacting the linguals of the
mandibular teeth. The retruded position is found in 25% of the general
population according to Levin. In this position, the tongue is retracted and
depressed into the floor of the mouth. It allows an easier ingress of food and
air under the lingual borders with the loss of peripheral seal. It is accompanied
by higher floor of mouth due to more tension in all the associated lingual
muscles.

106
Tongue Movements And Muscular Coordination

These should be carefully examined to determine the denture prognosis as

these are important in controlling the dentures during normal physiological
activities. Proper tongue movements are also important for border molding.

Lingual Frenum Attachment

It should be examined for favourable and unfavourable position in relation to
the ridge crest. There should be adequate relief in the denture for lingual
frenum so that the patient is able to touch the upper lip with the tip of tongue
without dislodging the mandibular denture. In case of close attachment to the
ridge, surgical intervention may be required. Denture should be made before
surgery and it acts as a stent after surgery preventing future relapse.

The mucosa of the tongue should be evaluated for any chronic ulceration in
the lateral borders of the tongue. The ulceration may signify the underlying
pathology

107
Impression Making

Adequate retention in mandibular denture can be achieved if lingual surface is so

designed that the denture maintains contact seal with tongue and floor of mouth not
only at rest, but also in function. Tongue position at the time of impression making
has a profound effect on the ultimate shape and success of denture. While speaking
the tongue is normally in contact with the palate, but on wide opening it assumes a
guarded position by reflex retraction. In this position, there is a deep lingual pouch.
Tongue and floor of mouth should be in average movement during impression
making. Following tongue movements help in correct shaping of the lingual flange of
mandibular denture

Sublingual crescent area/Anterior lingual sulcus

It is molded by asking the patient to protrude the tongue and then push the tongue
against the front part of palate. Protruding the tongue determines the length of anterior
lingual flange, whereas pushing the tongue against the anterior part of the palate
causes the base of the tongue to spread out and develop the thickness of anterior
lingual flange.

Middle region of alveolingual sulcus

In this region the lingual flange must slope towards tongue more or less parallel to
direction of mylohyoid muscle so that the tongue rests on top of the flange and aids in
stabilizing the mandibular denture. This slope of the lingual flange provides space for
the floor of the mouth to be raised during function without displacing the lower
denture maintaining the border seal. In this area the flange rests on soft tissues and not
in contact with bone. This region can be molded by asking the patient to protrude the
tongue which activates the mylohyoid and raises the floor of mouth. This will
determine the length and slope of lingual flange in molar region. It is important to
remove the border molded material built up on the inside of the lingual flange as it
interferes with mylohyoid muscle action.

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Posterior region of alveolingual sulcus
It is molded by asking the patient to protrude the tongue moderately. The patient is
asked to wipe the upper lip with tongue while recording this area which will activate
the superior constrictor muscle that supports the retromylohyoid curtain.54

Jaw Relation Record Stage

The occlusal plane is strongly related to the stability of the mandibular denture. The
level of the occlusal plane should be kept low so that lateral borders of the tongue can
rest upon the occlusal surfaces of teeth when the mouth is opened wide to receive
food and thus prevent the mandibular denture from lifting.
However, if the requirements of occlusal balance make it necessary to have a steep
compensating curve or large angle of plane of orientation, the tongue cannot easily
overlap the lower molars to stabilize the mandibular denture. In such cases, it is
necessary to leave off the second molar, so that an adequate posterior shelf is
provided distal to the first molar. This shelf should be at least 1cm in length from the
distal surface of first molar to the posterior border of denture. This provides space for
thick posterior part of tongue to rest upon and stabilize the denture.

Teeth Setting Stage

The teeth must be placed in a position near to that occupied by natural teeth (neutral
zone). The teeth must never be set inside the alveolar ridge as it cramps the tongue
space causing denture movement and irritation to the patient.

Try-In Stage
At the time of try-in, the tongue acts as a guide in evaluating the height of occlusal
plane. At rest, after swallowing, with its tip gently touching the lingual surfaces of
mandibular anterior teeth , the tongue assumes a position in which its lateral border, is
at the level of the lingual contour of mandibular posterior teeth. The dorsal surface of
the tongue is nearly level with the occlusal surface of the posterior teeth. Speech
evaluation at the try-in stage helps in determining the correct position of teeth as well
as contouring of the polished denture.

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Post-Insertion Problems Related To Tongue Displacement of mandibular
denture
The most common complaint of complete denture patients concerns the ―looseness‖
of mandibular denture. Patient should be made aware of the importance of tongue
position in maintaining denture retention and stability. Proper tongue position should
be demonstrated to the patient while he looks in a mirror. Patient should be made to
practice opening and closing while tongue assumes a normal position. Once practiced,
the enhancement of mandibular denture stability reinforces the normal position.

Trouble in speaking and eating

Some patients have trouble in stabilizing the mandibular denture while speaking and
eating. This is because tongue muscles act on denture, dislodging the same. Once the
tongue muscles are trained to hold the denture, the problem is solved. Proper
counselling of the patient should be done. The tongue should touch the inner surface
of the mandibular denture and never be pulled away from it while eating or speaking.
He should be explained that problem of speech with dentures would be solved within
7-10 days. In case of old denture wearers, this problem is solved when the muscles get
adapted to the new prosthesis.

Remedy for Retruded Tongue

1. Tongue exercises and counselling can be of help to these patients

2. A small training groove of about 2mm width and 2mm depth can be made just
below the anterior central incisors on mandibular denture (lingual side). The patient is
instructed to keep the tongue on groove at all times except while eating and speaking.
Most patients can learn to keep the tongue in correct position with this remedy.

Designing of the lingual flange (polished surface) in patients with macroglossia

In case of patients with large sluggish tongue, proper designing of the lingual flange
at the wax up stage helps increase the stability of mandibular denture providing
adequate room for the tongue to perform its function of distributing the food during
mastication and to relax when the mouth is at rest without disturbing the mandibular
denture. This can be achieved by adding as little as wax possible, behind the incisors
in the anterior region while behind the premolars, a flat or slightly concave surface

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should be established forming the anterior lingual plane and it disappears in the
molar region. In the molar and retromolar region, the polished surface is designed to
be slightly concave facing inwards, upwards and forwards. In patients with large
sluggish tongue, posterior corner of the lingual flange can be designed to go down and
back far enough at the point of equilibrium between mylohyoid and superior
constrictor on one part and tongue on the other forming a posterior lingual rest or
lingual shelf for the tongue. The heavy immobile base of the tongue rests on this
extension, whereas if it was not there, the tongue by shear bulk would push the
denture forward and dislodge it. Narrow posterior teeth should be selected for patients
with macroglossia to provide as much as space possible for the tongue higher up at
the level of occlusal plane where the tongue is the widest.101

Microglossia

Though impression making is easy microglossia jeopardizes the lingual seal. In such
cases, the mandibular denture should be planned to be made with thick lingual flanges
with wider posterior teeth while retaining its characteristic shape.

Surgically Resected Tongue

Patients with surgically resected tongue should be made aware of difficulties
(mastication and speech) of wearing a mandibular complete denture without normal
range of tongue movements. These patients get accommodated to the altered tongue
function by overclosure of the mandible. Insertion of complete dentures in these
patients restoring the vertical dimension of occlusion requires an augmentation
prosthesis for normal tongue function. The area of loss of tongue bulk should be
correspondingly augmented on the palate with baseplate wax. Additions should
include evaluation with pressure indicator paste, looking for uniform tongue contact.
Placing a tissue conditioner on the palatal surface of the denture can be used to create
a functional impression of residual tongue during swallowing. This technique helps to
achieve improvement in both mastication and articulation. The augmentation can be
added at the try-in-stage. A processed maxillary base is suggested because the bulk of
acrylic resin needed in the palate could cause considerable distortion if the base and
augmentation are processed together. Patients undergoing glossectomy may not be

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able to curl the tongue or approximate the palate in the midline during speech. Placing
a groove in the anterior palate may create the necessary air channel during speech.

Lateral Throat Form

The lateral throat form can be defined as ―An area beyond the attachment of posterior
border of mylohyoid muscle where the distolingual border of mandibular denture can
be extended to aid in its retention.‖ Lateral throat form (retromylohyoid fossa/LTF) is
the area situated at the distal end of the alveololingual sulcus. Its synonyms are
distolingual vestibule and retromylohyoid fossa. It is bounded anteriorly by the
mylohyoid muscle, laterally by the pear-shaped pad, posterolaterally by the superior
constrictor muscle, posteromedially by the palatoglossus muscle, and medially by the
tongue.102

Neil divided lateral throat form into 3 classes. Neil has classified retromylohyoid
space as deep, moderate and shallow.104 Tallgren classified as class I being large,
class II between I and III and class III being shallow and unfavorable.105 Sharry in
1974 wrote that the distal extension of the alveolingual area is formed by the
palatoglossal arch, the superior constrictor of the pharynx, the mandibuloglossus
muscle fibers, and the styloglossus muscle. W.R. Laney in 1983 elaborated Neil‘s
lateral throat form. With the index finger passively contacting the curved wall of
mucosa in the retromolar fossa with the tongue at rest, the patient is instructed to
protrude the tongue. If the lateral throat form changes configuration so as to place
heavy pressure on the finger, it is known as Class III; if the pressure is minimal or if
no pressure is exerted, the lateral throat form is Class I; any position of the tissues
between these extremes is a Class II lateral throat form.
According to Neil, the lateral throat form can be classified as
Class-I: Mild / No displacement of finger on protruding the tongue
Class-II: Moderate displacement
Class-III: Severe displacement

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 Class III
Class II
Class I

The lateral throat form greatly influences the fabrication of mandibular complete
dentures. The extension of the denture into this area can resist horizontal forces,
increases border seal, prevents tongue from returning to denture‘s polished surface,
act as a dis-placing lever on the denture border and contribute in the neuro-muscular
control mechanism.103The lateral throat form determines the length and thickness of
distolingual flange which ultimately influences the retention and stability of the
denture. The overextended distolingual border causes the loss of border seal leading
to displacement of denture and soreness of the underlying mucosa.

Determination of lateral throat form intraorally

Subject was made to sit straight in dental chair with head rested against the rest. The
first simple method of determining lateral throat form is the visualization with mouth
mirror.the other method include the use of little finger or small head of mouth mirror.
As described by Neil; the patient is instructed to set the tongue into a relaxed position.
The examiner should put his relaxed gloved index finger or small head of mouth
mirror, lightly adapted to the patient‘s lingual vestibule, toward the lateral throat
form. The patient is told to protrude the tongue 1/4th of an inch beyond the edge of
the lower lip. If the finger felt no appreciable movement, the throat form is classified
as Class I. If the finger is entirely displaced, the throat form is Class III. The throat
form is Class II when the finger feels intermediate functional movement of the tissue.
This classification is determined and in the same manner for both sides i.e., left and
right.

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According to study done by Huang PS, Chou TM, Chang HP, et al in 2007 the
proportion of lateral throat form Neil's Class I lateral throat form was 70%, the
proportion of Class II was 25%, and the proportion of Class III was 5%.(103) Ajay
Gupta in 2010 stated that even in poorest of poor conditions lateral throat form has to
be recorded very critically for stability and retention of mandibular denture. As it
constitutes the most important bracing potential in the mandibular foundation. The
lateral throat form needs to be measured, to select proper stock tray for primary
impression. The custom tray has to be adjusted and extended properly to record the
lateral throat form.106

Frenum Attachments
The frenal attachments should be examined for favourable or unfavorable position in
relation to the crest of the ridge. They are classified as
 Class-I: High in maxilla / low in mandibular
 Class-II: Medium
 Class-III: Freni encroach on the crest of the
ridge and may interfere with denture seal. In
addition, it will create deep labial notch in
the denture, with the frequent chance of
midline fracture. Thus it may require
preprosthetic surgical correction.

Floor of the mouth

The floor of the mouth presents a wide variety in anatomy and functional relation to
the ridge crest. If the floor of the mouth is near the ridge crest at rest or the magnitude
of movement is great, retention and stability of the denture will be poor. The floor of
the mouth in the sublingual gland and mylohyoid areas can be very high and close to
the ridge crest and at times may spill over the ridge and eliminate the alvelolingual
sulcus altogether. If these tissues cannot be selectively placed by the denture flange,
the prognosis of the mandibular denture is very poor. In such case, the success of
denture will largely depend on the utilization of the retromylohyoid space which is
critical for lingual seal and lateral stability.4

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Saliva
"Saliva is a clear, tasteless, odourless slightly acidic viscous fluid, consisting of
secretions from the parotid, sublingual, submandibular salivary glands and mucous
glands of oral cavity". Salivary fluid is an exocrine secretion consisting of
approximately 99.6% of water and 0.5% of solids. Cellular components constitute
yeast cells, bacteria, protozoa, polymorphonuclear leucocytes, desquamated epithelial
cells etc. Inorganic salts constitute about 0.2% of solids and consists of sodium
chloride, potassium chloride, acid and alkaline phosphatase, calcium carbonate,
calcium phosphate, potassium thiocyanate (smokers‘ saliva is rich in
thiocyanate).Organic components: constitute 0.3% of solids and contain enzymes like
ptyalin (salivary amylase), lipase, carbonic anhydrase, bacteriolytic enzyme and
lysozome. It also contains immunoglobulins and other antimicrobial factors.

A healthy person‘s mean daily saliva production ranges from 1 to 1.5 L,( the average
daily secretion of saliva normally ranges from 500-1500 ml.)107 a large proportion of
this volume is secreted at meal time when the secretory rate is highest. The salivary
flow (SF) index is a parameter allowing stimulated and unstimulated saliva flow to be
classified as normal, low, or very low (hyposalivation). It is slightly cloudy because of
the presence of cells and mucin. It is usually acidic in pH (6.02 - 7.05),

Saliva is produced in, and secreted from, primarily a set of three paired exocrine
glands namely the Parotid, Submandibular and Sublingual glands. In addition to these,
there are numerous minor salivary glands scattered throughout the oral cavity, such as
the labial, lingual, palatal, buccal, glossopalantine, retromolar glands etc. These minor
glands are typically located in the submucosa and have short ducts opening directly
onto the mucosal surface.

At rest, a small, continuous salivary flow, termed as basal unstimulated secretion,

covers, moisturizes, and lubricates the oral tissues. Resting saliva plays a very
important role in maintenance of oral health and contributes to the bulk of salivary
secretion in the diurnal cycle. Different glands contribute differently to unstimulated
salivary flow, with the submandibular gland contributing approximately 65–70% of
the total volume, and the parotid and sublingual glands contributing 20% and 8%

115
 respectively. The numerous minor salivary glands contribute to less than 10% of
unstimulated salivary secretion.107, 108

Stimulated saliva, which is secreted upon smell, taste, mechanical or pharmacological

stimulus is produced primarily by the parotid glands and contributes to most of the
daily salivary production. Such reflex salivation is controlled by the autonomous
nervous system and aids in chewing, formation and swallowing of the food bolus and
digestion of starch and lipids.109

Role of saliva in complete dentures

The role of saliva in maintaining the overall wellbeing of the oral cavity in dentate
individuals is well documented. In edentulous subjects, who have lost all their teeth
and are dependent upon artificial prosthesis to carry out the basic oral functions of
mastication, the presence of appropriate quantity and quality of saliva becomes even
more critical.
Optimal salivary flow and consistency plays an important role not only in the denture
fabrication process but also in the maintenance of integrity of the prosthesis. The role
of saliva as a lubricant and a buffer is central to the comfort and health of the oral
cavity. It is imperative for the prosthodontist to give due attention to these salivary
characteristics before, during and after denture fabrication. Any alteration in salivary
flow or characteristics may have a detrimental effect on denture stability and
retention.
In patients who present with an excessive secretion of saliva, proper impression
making becomes difficult. Also, the minor palatal glands are known to secrete saliva
rich in mucins. The presence of such highly mucous saliva may distort the impression
material and prevent the ideal reproduction of posterior portion of the palate in the
impression.
Saliva also plays a very important role in preserving denture integrity by keeping the
denture surfaces clean and in maintaining proper oral hygiene by physically washing
away food and other debris from the soft tissues and from the polished surface of the
prosthesis. The lubrication provided by saliva in dentate subjects is equally important
in the edentulous as this makes the surface of the dentures more compatible with the

116
movements of the lips, cheek and tongue. Salivary glycoproteins facilitate the
movement of soft tissues during speech, mastication and swallowing of food.

Successful rehabilitation of edentulous patients with complete dentures is largely

contributed to by satisfactory denture retention. An optimal flow, consistency and
volume of saliva is considered to be a major factor in enabling these physical factors
to act in unison and aid in denture retention.110, 111 The adhesive action of the thin film
of saliva between the denture base and the underlying soft tissues is considered to be
one of the principal factors that aids in denture retention. Such adhesive action of
saliva is achieved through ionic forces between charged salivary glycoproteins and
surface epithelium on one side and denture base acrylic resin on the other. This thin
film of saliva also acts as a lubricant and cushion between the denture base and oral
tissues and tends to reduce friction. Also, the cohesive forces within the layers of
saliva present between the denture base and mucosa aid in maintaining the integrity of
interposed fluids and aids in retention.

Not just the quantity, but also the flow rate, quality & consistency of saliva influence
denture stability and tolerance. The presence of thick ropy saliva may compromise
maxillary denture retention by creating a negative hydrostatic pressure in the area
anterior to the posterior palatal seal leading to downward dislodgement of the denture.
The normal salivary flow rate is about 1ml/min. Optimum quantity of saliva of
medium viscosity at this rate lubricates the mucosa and assists in denture retention.
An inadequate salivary flow may have a profound effect on denture retention and
stability and also tends to make mastication and deglutition difficult. Loss of the
mechanical protective influence of saliva on the denture supporting tissues would
predispose them to irritation. Also, the antibacterial action provided by saliva would
be proportionally reduced making the denture bearing oral tissues more susceptible to
infection.

Hypo-salivation and associated xerostomia is a common finding in the elderly. The

effect of age on salivary secretion and flow has been a matter of great debate.
However, it is now believed that aging does not directly reduce salivary flow per se; a
number of factors associated with aging may however do so. Drugs such as sedatives,
anti-hypertensives, anti-depressants and anti-histaminics. Any systemic factors such
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as alcoholism, depression and the presence of diseases such as uncontrolled diabetes,
pernicious anaemia, rheumatoid arthritis, Vitamin A & Vitamin-B deficiency and
Sjogren‘s syndrome are also known to have a profoundly negative influence on
salivary secretion. Patients who have undergone radiotherapy in the head and neck
region also present with xerostomia due to the associated destruction of salivary
glands.

In patients with xerostomia in whom some residual salivary capacity remains,

stimulation of salivary glands may be induced by the by the frequent snacking and by
the use of lemonades, lozenges and sugar free gums like xylitol.112 Sialogogues such
as pilocarpine may also be prescribed in an attempt to stimulate salivary secretion.113
In severe cases where the salivary glands cannot be stimulated to produce sufficient
saliva, salivary substitutes may be used. These substitutes range from readily
available compounds such as milk to the commercially available substitutes such as
artificial saliva (which may be mucin or carboxymethyl cellulose based), Salinum
(containing Linseed oil), Luborant (based on lactose peroxidase) and others.
Glandosane is a salivary substitute with an acid pH indicated specifically in denture
wearers.

―ARTIFICIAL SALIVA‖ product contains

Carboxymethyl cellulose - 10 gm/L
Sorbitol - 30.0 gm/L
Potassium chloride - 1.200gm/L
Sodium chloride - 0.843gm/L Magnesium chloride - 0.051gm/L
Calcium chloride - 0.146gm/L
Dipotassium hydrogen phosphate - 0.342gm/L

Another approach to providing optimal lubrication in complete denture patients is the

use of saliva delivery systems in the form of oral lubricating devices or reservoir
dentures. The clinician may either fabricate new reservoir dentures for the patient or
may add reservoirs to the existing dentures. An important concern is the size, shape
and location of the reservoir. The commonly preferred sites for adding reservoir is the
palate in the maxillary denture and interior of the mandibular complete denture. The
prosthodontist‘s role does not end just at denture fabrication and delivery. An

118
important concern for prosthodontic patients who have recently received new dentures
is the discomfort associated with a significant increase in salivary secretion. The
prosthodontist should explain to the patient that the new dentures are perceived as
foreign objects, stimulating the salivary glands to produce excessive saliva, which
necessitates frequent deglutition. Such an increase in salivary flow is however a
transient natural response of the oral tissues and tends to diminish over time. During
this period, the patient should also be advised to avoid compulsive rinsing & spitting
as it is unsettles the denture. Also, following the delivery of complete dentures in
patients with xerostomia, it is important to advise the patient to use the dentures for
shorter periods of time and to consume soft and moist foods which would be tolerated
better by the oral mucosa. Such patients should also be advised to have frequent sips
of water and should be followed up regularly to assess and suitably treat any form of
mucosal ulceration or denture stomatitis.112

Table: Description of unfavourable (score1) and favourable (score2) features of

the various anatomical structures/aspects of the maxillary DSTs.114

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Conclusion
Successful rehabilitation of complete edentulism in aging society is complex and challenging
process. Every edentulous state has its own complexity. Prior to any procedure, it is
imperative that the dentist thoroughly evaluate all the aspects of patients regarding the
psychosocial and anatomical factor and then only plan for definitive treatment. The treatment
plan followed by correct diagnosis is the key to the successful management of edentulous
patient. A thorough diagnosis and treatment plan thus becomes an essential parameter to
ensure a predictable result in the complete denture rehabilitation.

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