DENTAL CLINICS OF NORTH AMERICAVOLUME 40 - NUMBER I - JANUARY 1996

From the University of Texas Dental Branch, Houston (RLE); and

University of Texas Health Science Center, San Antonio (RDP), Texas

PATIENT EVALUATION AND

TREATMENT PLANNING FOR
COMPLETE-DENTURE THERAPY
Robert L. Engelmeier, BS, DMD, MS,
and Rodney D. Phoenix, BA, DDS, MS

Evaluation of patients for complete-denture therapy should be thorough and well

documented. A logical method to accomplish this is to use a checklist. Over the
years, many clinicians have developed classification systems for anatomic and
psychological characteristics of complete denture patients. Most of these systems,
however, have concentrated on the classification of just one or only a few features.
This article offers a thorough checklist to be used during patient evaluation.
References are given for all classifications drawn from the prosthodontic literature.
This evaluation form is confined to a single sheet of paper. The checklist format
makes the form quick and convenient to use. Once completed, this form can be added
to the patient's dental record for future reference. Use of this checklist provides a
greater level of understanding of the patient's problems, anatomy, and treatment goals.
We believe that through greater understanding a clinician should be able to deliver
improved care to the edentulous patient.
INSTRUCTIONS FOR COMPLETING THE DIAGNOSTIC RECORD FOR
COMPLETE DENTURES
I.

PERSONAL DATA
-Name
-SSN:
A Social Security number or Patient number is required.
-Age: Age is an indicator of the patient's ability to wear and to use dentures.
Through the fourth decade of life tissues heal rapidly and are relatively resilient,
Individuals adapt to new conditions more readily and esthetics are of paramount
importance. Beyond the fifth decade, however, tissues do not heal as rapidly. The
body does not adapt readily to new situations. Women facing the physiologic and
psychological problems of menopause often present as exacting or hysterical
patients who are very concerned with esthetics. Men at this age often are
preoccupied with their careers. It is not unusual for them to present as indifferent
patients who are concerned only with comfort or function.

Facial form (profile): Classify according to Angle:

Class 1

Normal

Class 2

Retrognathic

Class 3

Prognathic

b. Muscle Tone: Classify according to House:

Class 1: The patient exhibits normal tension, tone, and placement of the
muscles of mastication and facial expression. No degenerative changes are apparent.
The majority of edentulous patients have experienced some degree of degeneration.
Usually, only immediate-denture patients have normal musculature.
Class 2: The patient displays approximately normal function but slightly impaired muscle
tone. Maximum muscle function cannot be used following the loss of all natural teeth.
Class 3: The patient exhibits greatly impaired muscle tone and function. This impairment
usually is coupled with poor health, inefficient dentures, and loss of vertical dimension,
wrinkles, decreased biting force, and drooping commissures.
c. Muscle Development: Classify according to House:
Class 1: Heavy
Class 2: Medium
Class 3: Light
d. Complexion: Hair, eye, and skin color provide useful guides in shade selection. Skin
color also can reveal underlying disease and pathology. Patients with significant sun
damage warrant referral to a dermatologist. Pale, anemic-looking patients may have
underlying systemic diseases and may require longer adjustment periods. Heavy
wrinkles at the commissures and nasolabial fold usually suggest decreased Vertical
Dimension of Occlusion (VDO) or poor support of facial musculature by the denture.
e. Lip: The contour and appearance of the vermillion border usually are altered by tooth
loss. Restoration of lip support and vermillion border width must be considered during
placement of anterior teeth. Classify the lip contour as "adequately supported" or
"unsupported." Also, comment on the amount of vermillion border visible. Lip
mobility should be noted. Patients with minimal lip mobility show very little of the
anterior teeth. Some stroke victims may have paralysis of half the lip, leading to
unilateral mouth droop and facial asymmetry. Patients must be counseled regarding
treatment limitations when dealing with such physical challenges. Otherwise, patients

may have unrealistic expectations regarding functional and esthetic results. Classify lip
mobility as normal (class 1), reduced mobility (class 2), or paralysis, (class 3).
Comment on any unilateral reduction of mobility. Lip length also plays an important
role in esthetics. A long lip reveals little of the anterior teeth, whereas a very short lip
allows the display of the denture base. Mold selection and denture characterization can
be critical factors in these cases. Classify lip lengths as long, normal or medium, and
short.
f. Temporomandibular joint (TMJ): Note any crepitus or clicking. Report any
history of TMJ discomfort or locking. Comment on the smoothness of mandibular
movements. Note any deviation of the mandible. Severe joint pain can indicate a severe
discrepancy in the VDO.
g. Neuromuscular Evaluation:
- Speech: 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 or those who cannot articulate optimally
with their existing dentures require special attention when the dentist places the
anterior teeth and forms the palatal portions of the denture base. If normal muscle
activity is altered by -significant changes in tooth placement and denture-base
contour, a longer and more difficult period of adjustment may be anticipated.
Classify speech as "normal" or "affected" (comment on any impediments).
- Coordination: Patients with good neuromuscular coordination can be expected to learn
to manipulate dentures relatively quickly and likewise adapt readily to new dentures.
Patients with poor coordination or a neurologic deficit (such as from a stroke) may
never adapt to a denture completely. Classify neuromuscular coordination as follows:
Class 1: Excellent
Class 2: Fair
Class 3: Poor
h. Oral Cavity:
- Arch Size: Classify arch size as follows:
Class 1: Large (best for retention and stability)
Class 2: Medium (good retention and stability but not ideal)
Class 3: Small (difficult to achieve good retention and stability)
- Arch Form: Classify according to House:
Class 1: Square
Class 2: Tapering
Class 3: Ovoid

Many arches are combinations of the aforementioned categories (e.g., square-tapering).

-Sex: Generally, appearance is a higher priority for women than for men. Though younger
men often are concerned with esthetics, males often grow indifferent to their own
appearances as they age. During this process, men shift their concerns to the comfort
and function of dentures.
-Race: Race can be a critical factor in the characterization of dentures (i.e., choice of
denture base shade, placement of denture base stains, etc.).
-Occupation: A patient's job and social standing often determine the value he or she
places on oral health, as well as the esthetics and other qualities desired in a denture.
-Cosmetic Index: Classify the patient from class 1 (high cosmetic index) to class 3 (low
cosmetic index). Patients with high cosmetic indices, though often exacting, usually are
appreciative and cooperative. Conversely, patients with low cosmetic indices often are
indifferent, uncooperative, and place little value on the efforts of the prosthodontist.
-Personality: Classify the patient according to House:
- Philosophic: Those patients are easygoing, congenial, mentally well-adjusted,
cooperative, and confident in the dentist. Prognosis is excellent.
- Exacting: These patients are precise, above average in intelligence, immaculate in
dress and appearance, often dissatisfied with past treatment, doubt the ability of the
practitioner to satisfy him or her, and often want written guarantees or remakes at
no additional charge. Once satisfied, an exacting patient may become the
practitioner's greatest supporter.
- Hysterical: These patients submit to treatment as a last resort, have a negative
attitude, are often in poor health, are poorly adjusted, often appear "exacting" but
with unfounded complaints, have failed at past attempts to wear dentures, and have
unrealistic expectations (hysterical patients often demand esthetics and function
equal to or greater than natural teeth). Prognosis is poor.
- Indifferent: These patients are not concerned with appearance, often go without
dentures for years (or wear poor or worn-out dentures far beyond serviceability),
do not persevere, and do not adapt well. Such patients have no desire to wear
dentures and do not value the efforts or skills of the dentist.
11. MEDICAL HISTORY
- General Health: A thorough and accurate medical history must be obtained during the
diagnostic phase of complete-denture therapy and must be updated as necessary. The
medical history provides important insights regarding the patient's dental prognosis.
Not surprisingly, patients who exhibit good health generally are better prosthetic risks
than those in poor health. Hence, the practitioner must be aware of local and systemic
factors and must consider them during treatment planning. Systemic factors that may
affect complete-denture therapy include: anemia; arthritis; Bell's palsy; carcinomas;
diabetes; lupus erythematosus; nicotinic stomatitis; Paget's disease; Parkinson's
disease; pemphigus vulgaris; Plummer-Vinson syndrome; scleroderma; tuberculosis;
and diseases, conditions, or therapies leading to xerostomia. Localized lesions, defects,
and abnormalities provide a wide array of clinical situations that are not addressed

here. It should be recognized that any of the aforementioned conditions may

necessitate alteration of the treatment plan to serve the patient better.
- Pathology: A thorough head and neck examination should be performed. All pathologic
processes should be recorded. Appropriate diagnostic tests and surgical procedures
should be performed or arranged.
111. DENTURE HISTORY
- Chief Complaint: According to DeVan,3 "The dentist should meet the mind of the
patient before he meets the mouth of the patient." Hence, the dentist must determine the
reason the patient is seeking prosthodontic treatment. The patient should be questioned
regarding his or her chief complaint. There are several reasons for seeking this
information. First, if this is not done, the chief complaint may be overlooked during
therapy. Second, the response allows the practitioner to assess whether the patient's
expectations are "realistic" or "attainable." And finally, the response provides information
regarding the patient's psychological classification (for House's personality classification
scheme).
- Expectations: The reason the patient seeks prosthetic treatment is of critical importance.
His or her expectations must be determined. These expectations then must be evaluated to
determine if they are realistic and attainable. The practitioner must be cognizant of the
patient's personality classification and should not make unrealistic promises regarding
treatment outcomes.
- Years Edentulous, Max/Man: Responses to this question provide information about
bone resorption patterns and progression, as well as the timing of tooth loss. The patient
should be questioned regarding the reasons for tooth loss (e.g., periodontal disease, gross
caries, trauma, etc.).
- Previous Dentures, Max/Man: The patient should be questioned regarding the number
and types of previous dentures. Patients should be asked to comment on the reasons for
replacement. Patients displaying consistent patterns of remarks should be educated
regarding the realities of denture service. A patient with a history of several dentures over
a short period of time is a poor prosthodontic risk.
- Existing or Current Dentures: The patient should be questioned about the length of time
he or she has worn the current dentures. Responses should be compared with clinical
observations. Careful observation may provide valuable information about denture
experience, denture care, dental knowledge, parafunctional habits, etc.
- Denture Success: The patient should be asked about the esthetics and function of
existing maxillary and mandibular dentures. Responses may indicate the patient's ability
to wear or adjust to complete dentures. Denture success for each arch should be rated
"favorable" or "unfavorable."

- Pre-Extraction Records: Pre-extraction photographs, radiographs, casts, and facial

measurements may prove helpful in denture therapy. These adjuncts may be used to
recreate anterior esthetics and facial support, as well as to aid in the evaluation of vertical
dimension of occlusion.
IV. CLINICAL EVALUATION
a. Facial Form (frontal): Classify according to House and Loop, Frush and Fisher and
Williams:

Square
Tapering Square- Tapering
Ovoid
Ridge Form: Maxillary ridge and vault form should be classified as follows:
Class 1: Square to gently rounded

Class 2: Tapering or "V" shaped

Class'3: Flat

Mandibular Ridge Form: Mandibular ridge form is classified as follows:

Class 1: Inverted "U" shaped

(parallel walls from medium to
tall with broad crest)

Class 2: Inverted "U" shaped

(short with flat crest)

Class 3: Unfavorable:

Inverted "W"

Short inverted "V" Tall

Thin inverted "V"

Undercut (results from all teeth in labial or lingual version)

Defects: Note ridge defects, such as exostoses or divots, that may pose problems for
complete-denture patients or may warrant preprosthetic surgery.
Tori: Classify maxillary and mandibular exostoses as follows:
Class 1: Tori are absent or minimal in size. Existing tori do not interfere with denture
construction.
Class 2: Clinical examination reveals tori of moderate size. Such tori offer mild
difficulties in denture construction and use. Surgery is not required.
Class 3: Large tori are present. These tori compromise the fabrication and function of
dentures. Such tori usually require surgical recontouring or removal.

Interach Space: Classify interach space as follows:

Class 1: Ideal interach space to accommodate the artificial teeth.

Class 2- Excessive interarch space.

Class 3: Insufficient interarch

space to accommodate the
artificial teeth.

Ridge Parallelism: Classify ridge parallelism as follows: Class 1: Both ridges are parallel
to the occlusal plane.

Class 2: The mandibular ridge is divergent from the occlusal plane anteriorly.

Class 3: The maxillary ridge is divergent from the occlusal pladne anteriorly or both
ridges are divergent anteriorly,

Ridge Relationship: Classify according to Angle:

Class 1: Normal

Class 2: Retrognathic

Class 3: Prognathic

Bone Quantity: Classify according to Branemark et al (as viewed on radiographic

examination):
Class A: Maxillae
Mandibles

Class B:

Maxillae

Class C:

Maxillae

Mandibles

Mandibles

Class D:

Maxillae

Mandibles

Class E:

Maxillae

Mandibles

Bone Quality: Classify according to Branemark et al. (as seen on radiographic

examination),
Class 1:

Class 2:

Class 3:

Class 4:

Lateral Throat Form: Classify according to Neil:

Class 1:

Class 2:

Class 3:

Palatal Throat Form: Classify according -House:

Class 1: Large and normal in form, with a relatively immovable band of resilient tissue 5
to 12 mm distal to a line drawn across the distal edge of the tuberosities.
Class I

Class 2: Medium size and normal in form, with a relatively immovable resilient band of
tissue 3 to 5 mm distal to a line drawn across the distal edge of the tuberosities.
Class II

Class 3: Usually accompanies a small maxilla. The curtain of soft tissue turns down
abruptly 3 to 5 mm anterior to a line drawn across the palate at the distal edge of the
tuberosities.
Class III

Palatal Sensitivity: Classify sensitivity according to House:

Class 1: Normal
Class 2: Subnormal (hyposensitive)
Class 3: Supernormal (hypersensitive)
Mucosa Thickness: Classify thickness according to House:
Class 1: Normal uniform density of mucosal tissue (approximately 1-mm thick).
Investing membrane is firm but not tense and forms an ideal cushion for the basal
seat of a denture.
Class 2:
(a) Soft tissues have thin investing membranes and are highly susceptible to
irritation under pressure
(b) Soft tissues have mucous membranes twice the normal thickness.
Class 3: Soft tissues have excessively thick investing membranes filled with redundant
tissues. At the very least, this requires tissue treatment. Such conditions may
require surgical correction.
The quality of the mucoperiosteum may vary within each arch. Tissues may be extremely thin in one area
where teeth have been missing for a long time and normal where teeth were removed recently. Other areas
may be excessively thick with localized regions of redundant tissue. When tissue thickness varies, special
problems are created. Such variations make it difficult to equalize pressure under the denture and to avoid
soreness.

Mucosa Condition: Classified according to House:

Class 1: Healthy
Class 2: Irritated
Class 3:'Patliologic
Border Attachments: Attachments should be classified according to House:
Class 1: Attachments are high in maxilla or low in mandible with relation to ridge crest
(0.5 inches or more between level of attachment and crest of ridge).
Class 2: Attachment height in relation to the crest of the ridge is between 0.25 and 0.50
inches.
Class 3: Attachment height is less than 0.25 inches from the ridge crest.
Frenum Attachments: Classify according to House (classified in same manner as border
attachments):
Class 1: High in the maxilla or low in the mandible with respect to the crest of the ridge.
Class 2: Medium
Class 3: Freni encroach on the crest of the ridge and may interfere with tile denture seal.
Surgical correction may be required. All lingual tissues of the mandible are
classified as muscle attachments.
Saliva: Classify saliva as follows:
Class 1: Normal quality and quantity of saliva. Cohesive and adhesive properties of saliva
are ideal.
Class 2: Excessive saliva; contains much mucus.
Class 3: Xerostomia; remaining saliva is mucinous.
Tongue: Classify tongue according to House:
Class 1: Normal in size, development, and function. Sufficient teeth are present to
maintain normal form and function.
Class 2: Teeth have been absent long enough to permit a change in the form and function
of the tongue.
Class 3: Excessively large tongue. All teeth have been absent for an extended period of
time, allowing for abnormal development of the size of the tongue. Inefficient
dentures sometimes can lead to the development of a class 3 tongue.
Tongue Position: Classify according to Wright:
Normal: The tongue fills the floor of the mouth and is confined by the mandibular teeth.
The lateral borders rest on the occlusal surfaces of the posterior teeth and the apex
rests on the incisal edges of the anterior teeth. There is, no aberration in tongue
size or activity.
Class 1: Retracted: The tongue is retracted. The floor of the mouth pulled downward is
exposed back to the molar area. The lateral borders are raised above the occlusal
plane and the apex is pulled down into the floor of the mouth.
Class 2: Retracted: The tongue is very tense and pulled backward and upward. The apex
is pulled back into the body of the tongue and almost disappears. The lateral

borders rest above the mandibular occlusal plane. The floor of the mouth is raised
and tense.
V. EXISTING DENTURES
- Anterior Tooth Shade, Mold, and Material
- Posterior Tooth Shade, Mold, and Material: Existing dentures should be evaluated to
determine physical, esthetic, and anatomic characteristics. Shade, mold, and
material should be recorded for both anterior and posterior teeth. If the mold
cannot be determined, the general shape of the teeth should be recorded (e.g.,
square, square-tapering, tapering, ovoid, etc.).
- Esthetics, phonetics, retention, stability, extensions, and contours: Existing esthetics,
phonetics, retention,, stability, extensions, and contours should be evaluated.
These attributes should be rated (1) good, (2) fair, and (3) poor.
- Centric Relation and Vertical Dimension of Occlusion: Centric relation and vertical
dimension of occlusion should be assessed and rated "acceptable" or
"unacceptable," If unacceptable, it should be noted whether the existing VDO is
"inadequate" or "excessive."
- Occlusal Plane Orientation: The orientation of the occlusal plane should be noted.
Improper orientation as a result of tooth setting or changes in bony architecture
often creates a "reverse smile line." This condition is characterized by teeth that
slope downward as one progresses posteriorly. Consequently, the anterior teeth
assume a curvature that does not follow the arc of the lower lip.

REVERSE SMILE LINE

DESIRED SMILE LINE

- Palate: The palate of the existing maxillary denture should be examined. The denture
base material and thickness should be noted. Anatomic features should be
assessed. The practitioner should note the presence or absence of rugae on the
cameo surface of the denture base. Denture wearers may have become
accustomed to a particular palatal form, and may resist change. The practitioner
should listen to speech patterns, and determine whether appropriate "valving" is
taking place. Placement of rugae or a change in thickness may affect
pronunciation.

- Post dam: The posterior border of the maxillary denture should be examined. Likewise,
soft tissues in the vicinity of the "vibrating line" should be observed. The seal of
the existing maxillary denture should be evaluated clinically. Often, deficiencies
in retention of the maxillary denture may be traced to improper post-damming.
The post dam should be rated "acceptable" or "unacceptable."
- Base Adaptation: The fit of maxillary and mandibular bases should be assessed using
an appropriate disclosing medium, Adaptation should be rated "acceptable" or
"unacceptable."
- Midline: Maxillary and mandibular midlines should be observed. Although
discrepancies between maxillary and mandibular midlines, may be present, it is
critical that the maxillary midline coincide with the facial midline. Discrepancies
in midline placement create noticeable facial disharmonies. The existing
maxillary midline should be evaluated using intraoral (e.g., incisive papilla) and
extraoral landmarks (e.g., nasion, filtrum, middle of the chin). The midline should
be rated "acceptable" or "unacceptable.' Deviations of the maxillary midline
should be recorded by direction and amount (e.g., maxillary midline 2 mm to the
right of the facial midline).
- Buccal Vestibule: The buccal vestibule is an important esthetic and functional
component in complete denture service. Consequently, this space should be
assessed carefully. The buccal vestibule should be judged "acceptable" or
"unacceptable." Corrective actions should be proposed.
- Crossbite: The presence of a unilateral or bilateral crossbite often presents a
challenging situation. Crossbites should be noted and their effects on tooth
placement anticipated. This information may be entered into the diagnostic record
using the categories "none , unilateral," or "bilateral."
- Characterization: Characterization or staining of existing denture bases should be
evaluated and recorded. Existing denture bases may be classified as
"characterized" or ' 'uncharacterized."
- Comfort: The patient should be questioned regarding the comfort of maxillary and
mandibular dentures. Comfort for the respective arches should be classified as
"acceptable" or "unacceptable." Patients who experience discomfort should be
questioned to determine the nature and source of the discomfort.
- Hygiene: The patient's ability and motivation to clean the dentures should be assessed
during the clinical evaluation. The patient also should be questioned about his or
her denture cleansing regimen. These factors may affect denture-base contouring
(e.g, closed interdental contours versus open interdental contours) and tooth
arrangement (e.g., presence or absence of diastemata). Hygiene should be
classified as (1) good, (2) fair, or (3) poor.

- Wear: Wear often is an indicator of parafunctional habits or an abrasive diet. The wear
process must be assessed with respect to time. With these factors in mind, wear
should be classified as (1) minimal, (2) moderate, or (3) severe.
- Attachments and Hardware: Attachments and hardware usually are limited to
overdenture situations. When working under these constraints, it is important to
know the specific system in use and the availability of components.
VI. TREATMENT PLANNING
- Tissue conditioning: List proposed therapy as finger massage, prescribed medications,
type of tissue treatment material to be used and frequency of soft reline changes,
etc.
- Preprosthetic surgery: List any proposed preprosthetic procedures along with the staging
of these procedures.
Articulator:
- Instrument Number and Manufacturer
- Control Settings:
Horizontal condylar guidance (right and left);
lateral condylar guidance (right and left);
incisal guide anterior angle (right and left);
and incisal guide lateral angle (right and left).
-Tooth Selection: The shade, mold, and material of the maxillary anterior,
mandibular anterior, maxillary posterior, and mandibular Posterior should
be selected.
- Denture Base Material: Available materials include microwave resin, gold,
heat-cured resin, soft base, etc.
- Denture Base Shade: Base shade depends on the brand of acrylic.
- Anatomic Palate: Yes or no.
- Characterization: Establish the stains to be used; draw a "map" of the proposed stain
placement.
- List items to improve on in the new dentures, such as inadequacies of the existing
dentures (e.g., items from Section V).
- List items not to be changed in the new dentures, such as good features of the existing
dentures (e.g., items from Section V).
VII. PROGNOSIS:

Give the prognosis and list the reasons for the prognosis.

SUMMARY
A checklist is presented for use in evaluating and planning the treatment of patients for
complete-denture therapy. A thorough explanation of each item and classification
included in the checklist list also is presented. Classifications from the classic
prosthodontic literature are used wherever possible and their sources are referenced
appropriately.