Continuous loading beyond the adaptive capacity of the joint can
lead to degenerative joint disease. In the absence of prosthetic
rehabilitation, a complete edentulous patient is susceptible to
Importance of patient motivation and
The success of complete denture prosthesis is determined not only by
proper diagnosis and treatment planning but also by communicating
with the patient. Patient motivation and education are one of the most
important factors which influence the success of the complete denture.
There has to be a good communication between the patient and the
dentist in order to build a mutual trust and a good rapport.
Patient motivation and education
Patients should be informed about their oral condition after complete
digital and visual examination and radiographic investigation. It is
best to dictate the observation made during examination to the
• Firstly, it informs the patients about the conditions existing in their
mouth. It educates the patients about their oral condition and the
need for a specific treatment.
• Secondly, it informs the patients in a formal and dignified manner
Most of the time, it is quite possible that the patients may not know
the significance of the observations dictated to the assistant. Any
query from the patients should be addressed with proper knowledge
about the existing condition, e.g. knife-edged lower ridge with the
anterior redundant tissues. Patients are educated about the existing
condition and the problems that may be encountered during the
treatment. Additional time may be required to treat some patients
than others depending on the conditions.
It is always best to avoid discussions about the existing dentures.
Even if the patients insist a discussion on the existing dentures, they
should be told that a new diagnosis is to be made after making clinical
observations. Patients’ reactions to this will give a good indication
Patients should be clearly informed about the proposed treatment
in details in the language which they understand so as to avoid any
misunderstanding. Patients are educated about the procedures
necessary to do mouth preparation before impression making. The
number of appointments expected and the time required to handle the
case in the best way should be considered.
Construction procedures such as the impression material, jaw
relation records, teeth and denture base material should be dictated to
the assistant in the presence of the patient. Any procedure requiring
extra time should be specified during the treatment planning itself.
Some decisions are based on the choice of the patient such as the type
of denture base (acrylic or metal) or the shade of the teeth or choice of
Patients are motivated and educated to make the best choices,
suiting their conditions. A summary of the proposed treatment plan is
explained to the patients and the possibilities and limitations of the
treatment are underlined. Patients are educated about the proposed
treatment plan, so that the patients do not have unrealistic
expectations. The instructions and suggestions are given to the patient
preferably in the patient’s own language.
Patients should be informed about the estimated cost of the
treatment and the payment process. Fees of the treatment should be
based on the existing conditions, time required to treat and on the
aesthetic demands and mental attitude of the patient. Uniform fee for
all the patients is unjustified.
Patients are educated and motivated to maintain oral hygiene and
to use the oral hygiene aids. They are advised and motivated to follow
proper nutritional programmes. They should be educated on the
importance of having a balanced diet. Instructions on maintaining oral
hygiene should be given right from the first appointment. It is
important to understand the value of patient education and
motivation in the success of complete denture prosthetics.
Physiological rest position and its importance
Physiological rest position is defined as ‘the postural position of the
mandible when an individual is resting comfortably in an upright position
and the associated muscles are in the state of minimal contractual activity’.
The physiological rest position is the position of the passive
equilibrium governed by gravity and the elasticity of the tissues and
muscles attached to the mandible.
J.A. McNamara (1974) believed that this position is maintained by
the tonic activity of the elevator muscles opposing the gravitational
forces. The neurological basis of this position is influenced by the
muscle spindles in the elevator muscles which when stretched result
in the monosynaptic jaw closure or development of myotatic (stretch)
The gamma efferent system influences the firing threshold of the
muscle spindles and can alter the sensitivity of the feedback system
through myotatic reflex. When the mandible tends to depress due to
the gravitational force, the myotatic reflex activates a number of motor
units in the elevating muscles resulting in the elevation of the
mandibular position in the original position. This unconscious activity
maintains the mandible in the physiological rest position.
The response threshold of the muscle spindle is influenced by the
activity of the gamma efferent system. Gamma efferent system is
excited by the reticular formation in the central nervous system, thus
establishing the connection between the brain, brainstem activity,
muscle spindle and the muscle tonus or contraction. This connection
explains the clinical observation that muscle tonus increases with the
emotional stress or psychic tension.
Increase in the tonus of the mandibular elevators decreases the
vertical dimension at rest and also the interocclusal distance or
freeway space. Thus, emotional or psychological state of the patient
has a positive influence on the physiological rest position.
Some researchers believe that tongue–palate relationship acts as a
sensory mechanism to determine the postural rest position. Factors
influencing the postural rest position are age, physical and mental
health, history of bruxism, sequence and duration of the tooth loss,
alveolar ridge height, respiratory and postural changes.
Head and body postures have strong influence on the rest position
of the mandible. Therefore, during recording of the jaw relation, the
patient is asked to sit or stand in the upright position and gazing
Morphological changes associated with
Loss of teeth adversely affects the normal appearance of the patient to
a large extent. It is important to understand the morphological
changes occurring in an edentulous patient and identify the means to
rectify them during the treatment.
The following morphological changes are associated with
• Loss of the labiodental angle
• Deepening of the nasolabial groove
• Decrease in the horizontal labial angle
• Prognathic appearance of the patient
• Increase in the columella–philtral angle
Soft tissue changes in denture patients
It is common to observe changes under the complete denture in both
hard and soft tissues. These begin as soon as the dentures are inserted
in the patient’s mouth. Oral mucosa shows low tolerance to injury or
irritation and is normally not suited to the load-bearing role of the
complete dentures. It shows little or no response to this altered
function. Continuous wearing of denture shows soft tissues changes
such as the papillary hyperplasia and pseudoepitheliomatous
SOFT TISSUE CHANGES IN DENTURE PATIENTS
FIGURE 1-7 Papillary hyperplasia developed in palatal vault.
FIGURE 1-8 Epulis fissuratum developed due to chronic
irritation of ill-fitting maxillary denture border.
• Complete denture prosthodontics deals with replacement of all the
natural teeth with artificial substitutes.
• Somatoprosthetics is the art and science of prosthetic replacement
of the external parts of the body that are missing or deformed.
• Myotatic reflex is the mechanism that mediates the jaw-closing
reflex and the jaw-jerk reflex.
• Chewing cycle in a dentulous patient when viewed in the frontal
plane demonstrates the jaw motion in the shape of tear drop.
• Cyclic jaw movements are controlled by the chewing centre in the
• Direction of resorption of the maxillary ridge is upwards and
• Direction of resorption of the mandibular ridge is downwards and
• Translatory movements of the condyle and the disc are controlled
by the capsular ligament and the superior head of the lateral
planning for edentulous patients
Mental Attitude of the Patient, 15
Neuromuscular Coordination, 19
Lateral Throat Form (Postmylohyoid Space), 27
Pavlovian Conditioned Reflex, 29
Pre-extraction Records and Their Importance, 31
Nutritional Requirement of Edentulous Patients, 32
Role of Nutrition in Prosthodontics, 34
Success of complete denture treatment depends on thorough
diagnosis and proper treatment planning, which will satisfy the need
Diagnosis is defined as ‘determination of the nature of the disease’.
Treatment planning is defined as ‘the sequence of procedures planned
for the treatment of a patient after diagnosis’. (GPT 8th Ed)
Factors necessary to be evaluated for proper diagnosis and
treatment planning prior to fabrication of dentures are as follows:
(i) General information about the patient:
• Name, age, sex, occupation, address
(ii) Medical and dental history:
(iii) Observation of the patient:
• Temporomandibular joint (TMJ) examination
(vi) Examination of existing prosthesis
• Tissue conditioning: Prescription of medication, finger massage, type
• Preprosthetic surgery: List of any preprosthetic procedures required
(ii) Control settings on the articulator
• Tooth selection: Shade, mould, material of the anterior and posterior
• Denture base material: Type of material to be used
• Characterization: Type of stains, location, etc.
• List of changes to improve the new denture
Mental attitude of the patient
Mental attitude of the patients largely determines their ability to
adjust and accept the new prosthesis.
The mental attitude of the patient can be classified as follows:
Class 1: Patients are in good health, well adjusted to life and in need
• Have no experience with dentures and do not anticipate special
difficulties with new prosthesis
• If denture wearer, then worn the dentures satisfactorily
Class 2: Such patients are exacting and concerned with appearance
and efficiency of complete dentures.
• Reluctant to accept complete dentures
• Doubts whether anybody can satisfy their needs and may insist a
Class 3: Hysterical and nervous patient with long, neglected oral
• Will accept complete dentures as the last resort
• Have met failures during previous attempts to wear dentures
Dr Milus House proposed the following classification of patient’s
mental attitudes on the basis of extensive clinical experiences:
• Cooperate with the dentist and learn to adjust
• Rational, sensible, calm and composed even in difficult situations
• Have ideal attitude for successful treatment and have excellent
• Have little concern for their teeth or oral health
• They are apathetic, unmotivated and not interested in the treatment
• Have little appreciation for the efforts of their dentists
• Require more time for their instruction on the value and use of
• Their attitude can be very discouraging to the dentist
• Have questionable and unfavourable prognosis
• Find faults with everything that is done for them
• Never happy with their previous dentist because the previous
dentist did not follow their instruction
• Firm control of these patients is essential
• They are methodical, precise and very demanding
• Can be traumatic in a dental practice, if not controlled properly
• Medical consultation is always advisable for such patients
• Often they will have a recent series of personal tragedies such as
loss of a spouse, business problems or other things not directly
related to their denture problems
• Doubt the ability of anyone to help them
• They need kind and sympathetic approach
• Usually require more time to build confidence in the dentist
• Can be excellent patients, if handled carefully
Extraoral examination of the patient starts as soon as the patient enters
It is based on visualization and palpatory methods.
• Patient’s head and neck region should be first examined in general
for the presence of any pathological conditions relating to a
nondental or systemic condition.
• Nodules, naevi or ulcerations are noted.
It includes the evaluation of facial form and facial profile. There
should always be harmony between the facial form, facial profile and
the artificial teeth selected.
M M House and Loop, JP Frush and RD Fisher, and Leon Williams
classified facial form on the basis of the outline of the face (Fig. 2-1) as
FIGURE 2-1 Facial form: (A) square; (B) tapering; (C) square
• Examination of the facial profile is very important because it helps
in determining the jaw relation and occlusion.
• The profile is obtained by joining two reference lines. One line joins
the forehead and deepest point in curvature of the upper lip and the
second line joins the deepest curvature of the upper lip and the
most prominent portion of the chin.
• E. Angle classified facial profile as follows (Fig. 2-2):
FIGURE 2-2 Facial profile: (A) straight; (B) convex; (C)
Class I: Normal or straight profile.
Class II: Retrognathic profile or convex profile —occlusion has class II
disharmony in the centric position.
Class III: Prognathic profile or concave profile —occlusion has class III
disharmony in the centric position.
• This can be evaluated by examining the face when the patient bites
on the existing dentures. If the face appears collapsed with wrinkles
around the face, then it suggests a decreased vertical dimension.
Lesions such as angular cheilitis may also be present in these
• If the face appears strained and taut, then it suggests an increased
• Colour of the skin, eyes and hair along with patient’s age helps in
shade selection for the anterior and posterior teeth.
• Skin colour, texture and lesions may also indicate the systemic
condition of the patient, e.g. bronzed skin occurs in Addison disease
and lemon yellow complexion may indicate jaundice.
• Such patients may require prolonged adjustment with the dentures.
Lip should be examined for the following characteristics:
• Lack of adequate lip support results in a collapsed appearance
• Adequate lip support is important for the success of complete denture
• Wrinkles around the mouth can be corrected to some extent with proper lip support;
however, excessive wrinkles due to age or medical condition cannot be corrected even with
thickness in faciolingual position of the tooth can alter its fullness and support
• Thick lip gives the dentist more flexibility in positioning the anterior teeth
• Length of the lip will affect the exposure of the tooth while in function
• Short lips may show more of the teeth and even the denture base when the patient smiles or
• Long lips would hide the denture base and most of the teeth during facial expression
• The amount of lip fullness is proportional to the support it gets from the mucosa or the
• Thickened labial flange of the denture makes the lip appear too full
• Arrangement of teeth in the anterior region is very crucial as it directly determines the
Digital examination of the joint area is made by placing the middle
fingers bilaterally just anterior to the auricular tragi and asking the
patient to open and close the jaws slowly.
Auricular palpation indicates any clicking in the joints or
asynchronous movements in the joints.
• The TMJ should be evaluated for the following symptoms:
• Pain and tenderness in the muscles of mastication
• If the joint indicates excessive increase or decrease
in the vertical dimension of occlusion
• Crepitus or clicking sounds during condylar
• Limitations of mandibular movements
• A patient suffering from one or more of the above symptoms is
considered to be suffering from a TMJ disorder.
• For patients associated with TMJ disorder, the following treatment
• Control or reduction of contributory factors
• Treatment of pathological sequelae
• Due to difficulty in opening and closing of mouth,
recording of the jaw relation is difficult
• Postinsertion occlusal discrepancies and vertical dimension should
• Health of the TMJ is a key factor in the assessment of the ability of
patients to cooperate with the dentist when jaw relation records are
Speech of a patient can be classified on the basis of his/her ability to
Class I (normal): Such patients can produce articulated speech with
their existing dentures. They usually learn to articulate distinctly with
Class II (af ected): Such patients have impaired speech articulation
with existing dentures. They require special attention during teeth
arrangement, palatal designs, etc.
• Physical abilities and motor skills of the patients should be observed
as soon as they enter the clinic.
• The gait, level of coordination and steadiness of the patients reflect
on their neuromuscular coordination.
• Recording of jaw relations becomes difficult in patients with poor
neuromuscular coordination. These patients usually face problems
• Coordinated mandibular movements are essential for stable
• Jaw movements are observed as the patients open or close their
mouth. Any deviation to particular side should be noted.
• Some patients can make lateral movements and protrusive
movements with ease, whereas others are comfortable in
performing hinge movements only.
• Bilateral balanced occlusion is indicated in patients who can
perform all eccentric movements with ease, whereas prosthetic
approach should be altered in patients with limited or excessive
Class I: Tissues are normal in tone and function. Completely
edentulous patients mostly do not have class I musculature as some
amount of degenerative changes occur in all such patients except in
patients with immediate dentures.
Class II: Patients wearing efficient dentures with correct vertical
height present with almost normal tone and function of the muscles.
Class III: Subnormal muscle tone and function because of wearing illfitting dentures.
Systemic intraoral examination and proper interpretation determine
the correct procedures for the mechanical phase of complete denture
• Colour of the mucosa reveals about its health.
• Normal mucosa is coral pink coloured.
• Redness of the mucosa refers to inflammation of the tissues to
• Treatment will vary because of differences in the causes of
inflammation and the length of time the tissues have been irritated.
• The inflammation caused by irritation can be:
• Common prosthetic causes of irritation are as follows:
(i) Overextension of the denture borders
(ii) Ill-fitting dentures, etc.
• Some tissues recover with simple rest (i.e. keeping the denture out
of the mouth). Some require relieving overextended borders or sore
spots and use of tissue conditioning resins inside existing or
repairing of denture; others will require surgery to make them as
• Oral tissue must be healthy before impression for new dentures is
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