The mental attitude of patients towards complete dentures plays a significant role in the success of their treatment. Understanding these attitudes can help dental professionals tailor their approach to meet the needs and expectations of their patients. Here are the four primary mental attitudes that patients may exhibit:

1. Philosophical (Ideal Attitude)

• Characteristics:
  • Accepts the dentist's judgment without question.
  • Exhibits a rational, sensible, calm, and composed disposition.
  • Open to discussing treatment options and understands the importance of oral health.
• Implications for Treatment:
  • This type of patient is likely to follow the dentist's recommendations and cooperate throughout the treatment process.
  • They are more likely to have realistic expectations and be satisfied with the outcomes.

2. Indifferent

• Characteristics:
  • Shows little concern for their oral health.
  • Seeks treatment primarily due to pressure from family or friends.
  • Requires additional time and education to understand the importance of dental care.
  • Their attitude can be discouraging to dentists, as they may not fully engage in the treatment process.
• Implications for Treatment:
  • Dentists may need to invest extra effort in educating these patients about the benefits of complete dentures and the importance of oral health.
  • Building rapport and trust is essential to encourage a more proactive attitude towards treatment.

3. Critical/Exacting

• Characteristics:
  • Has previously had multiple sets of complete dentures and tends to find fault with everything.
  • Often has high expectations and may be overly critical of the treatment process.
  • May require medical consultation due to previous experiences or health concerns.
• Implications for Treatment:
  • Dentists should be prepared to address specific concerns and provide detailed explanations about the treatment plan.
  • It is important to manage expectations and ensure that the patient understands the limitations and possibilities of denture treatment.

4. Skeptical/Hysterical

• Characteristics:
  • Has had negative experiences with previous treatments, leading to doubt and skepticism about the current treatment.
  • Often presents with poor oral health, resorbed ridges, and other unfavorable conditions.
  • May exhibit anxiety or hysteria regarding dental procedures.
• Implications for Treatment:
  • Building trust and confidence is crucial for these patients. Dentists should take the time to listen to their concerns and provide reassurance.
  • A gentle and empathetic approach is necessary to help alleviate fears and encourage cooperation.
  • It may be beneficial to involve them in the decision-making process to empower them and reduce anxiety.

LIMITING STRUCTURES

A) Labial, lingual & buccal frenum

- It is fibrous band extending from the labial aspect of the residual alveolar ridge to the lip containing a band of the fibrous connective tissue the that helps in attachment of the orbicularis oris muscle.
- It is quite sensitive hence the denture should have an appropriate labial notch.
- The fibers of buccinator are attached to the buccal frenum.
- Should be relieved to prevent displacement of the denture during function.
- The lingual frenum relief should be provided in the anterior portion of the lingual flange. 
- This anterior portion of the lingual flange called sub-lingual crescent area.
- The lingual notch of the denture should be well adapted otherwise it will affect the denture stability.
 
B) Labial & buccal vestibule
 
-     The labial sulcus runs from the labial frenum to the buccal frenum on each side.
-     Mentalis muscle is quite active in this region.
-     The buccal sulcus extends posteriorly from the buccal frenum to outside back corner of the retromolar region.
-     Area maximization can be safely done here as because the fibers of the buccinator runs parallel to the border and hence displacing action due to buccinator during its contraction is slight.

-     The impression is the widest in this region.
 
C) Alveololingual sulcus

-     Between lingual frenum to retromylohyoid curtain.
-     Overextension causes soreness and instability.

It can be divided into three parts:
i) Anterior part :
-     From lingual frenum to mylohyoid ridge
-     The shallowest portion(least height) of the lingual flange
ii) Middle region :
-     From the premylohyoid fossa to the the distal end of the mylohyoid region
iii) Posterior portion :
-     From the end of the mylohyoid ridge end to the retromylohyoid curtain
-     Provides for a valuable undercut area so important retention
-     Overextension causes soreness and instability
-     Proper recording gives typical S –form of the lingual flange
 
D) Retromolar pad
-     Pear-shaped triangular soft pad of tissue at the distal end of the lower ridge is referred to as the retromolar pad.
-     It is an important structure, which forms the posterior seal of the mandibular denture.
-     The denture base should extend up to 2/3rd of the retromolar pad triangle.

E) Pterygomandibular raphe
 
 SUPPORTING STRUCTURES

A) Primary stress bearing area / Supporting area
 
1.    Buccal shelf area
-     Extends from buccal frenum to retromolar pad.
-     Between external oblique ridge and crest of alveolar ridge.

Its boundaries are:
1.    Medially the crest of the ridge
2.    Laterally the external oblique ridge
3.    Distally the retromolar pad
4.    Mesially the buccal frenum
The width of this area increases as the alveolar resorption continues.
 
B) Secondary stress bearing area / Supporting area
 
1.    Residual alveolar ridge
-     Buccal and lingual slopes are secondary stress bearing areas.
 
RELIEF AREAS
A) Mylohyoid ridge
 
-     Attachment for the mylohyoid muscle.
-     Running along the lingual surface of the mandible.
-     Anteriorly: the ridge lies close to the inferior border of the mandible.
-     Posteriorly it lies close to the residual ridge.
-     Covered by the thin mucosa which may be traumatized by denture base hence it should be relieved.
-     The extension of the lingual flange is to be beyond the palpable position of the mylohyoid ridge but not in the undercut.
 
B) Mental foramen
-     Lies on the external surface of the mandible in between the 1st and the 2nd premolar region.
-     It should be relieved specially in case it lies close to the residual alveolar ridge due to ridge resorption to prevent parasthesia.
 
C) Genial tubercle
-     Area of muscle attachment (Genioglossus and Geniohyoid).
-     Lies away from the crest of the ridge.
-     Prominent in resorbed ridges therefore adequate relief to be provided.
 
D) Torus mandibularis
-     Abnormal bony prominence.
-     Bilaterally on the lingual side near the premolar area.
-     Covered by thin mucosa so it should be relieved

Concepts Proposed to Attain Balanced Occlusion

Balanced occlusion is a critical aspect of complete denture design, ensuring stability and function during mastication and speech. Various concepts have been proposed over the years to achieve balanced occlusion, each contributing unique insights into the arrangement of artificial teeth. Below are the key concepts:

I. Concepts for Achieving Balanced Occlusion

1. Gysi's Concept (1914)

• Overview: Gysi suggested that arranging 33° anatomic teeth could enhance the stability of dentures.
• Key Features:
  • The use of anatomic teeth allows for better adaptation to various movements of the articulator.
  • This arrangement aims to provide stability during functional movements.

2. French's Concept (1954)

• Overview: French proposed lowering the lower occlusal plane to increase the stability of dentures while achieving balanced occlusion.
• Key Features:
  • Suggested inclinations for upper teeth:
    • Upper first premolars: 5° inclination
    • Upper second premolars: 10° inclination
    • Upper molars: 15° inclination
  • This arrangement aims to enhance the occlusal relationship and stability of the denture.

3. Sear's Concept

• Overview: Sears proposed balanced occlusion for non-anatomical teeth.
• Key Features:
  • Utilized posterior balancing ramps or an occlusal plane that curves anteroposteriorly and laterally.
  • This design helps maintain occlusal balance during functional movements.

4. Pleasure's Concept

• Overview: Pleasure introduced the concept of the "Pleasure Curve" or the posterior reverse lateral curve.
• Key Features:
  • This curve aids in achieving balanced occlusion by allowing for better distribution of occlusal forces.
  • It enhances the functional relationship between the upper and lower dentures.

5. Frush's Concept

• Overview: Frush advised arranging teeth in a one-dimensional contact relationship.
• Key Features:
  • This arrangement should be reshaped during the try-in phase to obtain balanced occlusion.
  • Emphasizes the importance of adjusting the occlusal surfaces for optimal contact.

6. Hanau's Quint

• Overview: Rudolph L. Hanau proposed nine factors that govern the articulation of artificial teeth, known as the laws of balanced articulation.
• Nine Factors:
  • Horizontal condylar inclination
  • Protrusive incisal guidance
  • Relative cusp height
  • Compensating curve
  • Plane of orientation
  • Buccolingual inclination of tooth axis
  • Sagittal condylar pathway
  • Sagittal incisal guidance
  • Tooth alignment
• Condensation: Hanau later condensed these nine factors into five key principles for practical application.

7. Trapozzano's Concept of Occlusion

• Overview: Trapozzano reviewed and simplified Hanau's quint and proposed his triad of occlusion.
• Key Features:
  • Focuses on the essential elements of occlusion to streamline the process of achieving balanced occlusion.

II. Monoplane or Non-Balanced Occlusion

Monoplane occlusion is characterized by an arrangement of teeth that serves a specific purpose. It includes the following concepts:

• Spherical Theory: Proposes that the occlusal surfaces should be arranged in a spherical configuration to facilitate movement.
• Organic Occlusion: Focuses on the natural relationships and movements of the jaw.
• Occlusal Balancing Ramps for Protrusive Balance: Utilizes ramps to maintain balance during protrusive movements.
• Transographics: A method of analyzing occlusal relationships and movements.

Sears' Occlusal Pivot Theory

• Overview: Sears also proposed the occlusal pivot theory for monoplane or balanced occlusion, emphasizing the importance of a pivot point for functional movements.

III. Lingualized Occlusion

• Overview: Proposed by Gysi, lingualized occlusion involves positioning the maxillary posterior teeth to occlude with the mandibular posterior teeth, enhancing stability and function.
• Key Features:
  • The maxillary teeth are positioned more centrally, while the mandibular teeth are positioned buccally.
  • This arrangement allows for better functional balance and esthetics.

Kennedy's Classification is a system used in dentistry to categorize the edentulous spaces (areas without teeth) in the mouth of a patient who is fully or partially edentulous. This classification system helps in planning the treatment, designing the dentures, and predicting the outcomes of denture therapy. It was developed by Dr. Edward Kennedy in 1925 and is widely used by dental professionals.

The classification is based on the relationship between the remaining teeth, the residual alveolar ridge, and the movable tissues of the oral cavity. It is particularly useful for patients who are wearing or will be wearing complete or partial dentures.

There are four main classes of Kennedy's Classification:

1. Class I: In this class, the patient has a bilateral edentulous area with no remaining teeth on either side of the arch. This means that the patient has a full denture on the upper and lower jaws with no natural tooth support.

2. Class II: The patient has a unilateral edentulous area with natural teeth remaining only on one side of the arch. This could be either the upper or lower jaw. The edentulous side has a complete denture that is supported by the teeth on the opposite side and the buccal (cheek) and lingual (tongue) tissues.

3. Class III: There is a unilateral edentulous area with natural teeth remaining on both sides of the arch, but the edentulous area does not include the anterior (front) teeth. This means the patient has a partial denture on one side of the arch, with the rest of the teeth acting as support for the denture.

4. Class IV: The patient has a unilateral edentulous area with natural teeth remaining only on the anterior region of the edentulous side. The posterior (back) section of the same side is missing, and there may or may not be teeth on the opposite side. This situation requires careful consideration for the design of the partial denture to ensure stability and retention.

Each class is further divided into subcategories (A, B, and C) to account for variations in the amount of remaining bone support and the presence or absence of undercuts, which are areas where the bone curves inward and can affect the stability of the denture.

- Class I (A, B, C): Variations in the amount of bone support and presence of undercuts in the fully edentulous arches.
- Class II (A, B, C): Variations in the amount of bone support and presence of undercuts in the edentulous area with natural teeth on the opposite side.
- Class III (A, B, C): Variations in the amount of bone support and presence of undercuts in the edentulous area with natural teeth on the same side, but not in the anterior region.
- Class IV (A, B, C): Variations in the amount of bone support and presence of undercuts in the edentulous area with natural teeth remaining only in the anterior region of the edentulous side.

Understanding a patient's Kennedy's Classification helps dentists and dental technicians to create well-fitting and functional dentures, which are crucial for the patient's comfort, speech, chewing ability, and overall oral health.

Impression making is a critical step in prosthodontics and orthodontics, as it captures the details of the oral cavity for the fabrication of dental prostheses. There are several techniques for making impressions, each with its own principles and applications. Here, we will discuss three primary impression-making techniques: Mucostatic, Mucocompressive, and Selective Pressure Impression Techniques.

1. Mucostatic or Passive Impression Technique

• Proposed by: Richardson and Henry Page
• Materials Used: Plaster of Paris and Alginate
• Key Features:
  • Relaxed Condition: Records the oral mucous membrane and jaws in a normal, relaxed condition.
  • Tray Design: Utilizes an oversized tray to accommodate the relaxed tissues.
  • Tissue Contact: Achieves intimate contact of the tissues with the denture base, which enhances stability.
  • Peripheral Seal: This technique has a poor peripheral seal, which can affect retention.
  • Outcome: The resulting denture will have good stability but poor retention due to the lack of a proper seal.

2. Mucocompressive Impression Technique

• Proposed by: Carole Jones
• Materials Used: Impression compound and Zinc Oxide Eugenol (ZoE)
• Key Features:
  • Functional Recording: Records the oral tissues in a functional and displaced form, capturing the active state of the tissues.
  • Retention: Provides good retention due to the compression of the tissues during the impression process.
  • Displacement Issues: Dentures made using this technique may tend to get displaced due to tissue rebound when the tissues return to their resting state after the impression is taken.

3. Selective Pressure Impression Technique

• Proposed by: Boucher
• Materials Used: Special tray with Zinc Oxide Eugenol (ZoE) wash impression
• Key Features:
  • Stress Distribution: Loads acting on the denture are transmitted to the stress-bearing areas of the oral tissues.
  • Tray Design: A special tray is designed such that the tissues contacted by the tray are recorded under pressure, while the tissues not contacted by the tray are recorded in a state of rest.
  • Balanced Recording: This technique allows for a more balanced impression, capturing both the functional and relaxed states of the oral tissues.

Applegate's Classification is a system used to categorize edentulous (toothless) arches in preparation for denture construction. The classification is based on the amount and quality of the remaining alveolar ridge, the relationship of the ridge to the residual ridges, and the presence of undercuts. The system is primarily used in the context of complete denture prosthodontics to determine the best approach for achieving retention, stability, and support for the dentures.

Applegate's Classification for edentulous arches:

1. Class I: The alveolar ridge has a favorable arch form and sufficient height and width to provide adequate support for a complete denture without the need for extensive modifications. This is the ideal scenario for denture construction.

2. Class II: The alveolar ridge has a favorable arch form but lacks the necessary height or width to provide adequate support. This may require the use of denture modifications such as flanges to enhance retention and support.

3. Class III: The ridge lacks both height and width, and there may be undercuts or excessive resorption. In this case, additional procedures such as ridge augmentation or the use of implants might be necessary to improve the foundation for the denture.

4. Class IV: The ridge has an unfavorable arch form, often with significant resorption, and may require extensive surgical procedures or adjuncts like implants to achieve a functional and stable denture.

5. Class V: This is the most severe classification where the patient has no residual alveolar ridge, possibly due to severe resorption, trauma, or surgical removal. In such cases, the creation of a functional and stable denture may be highly challenging and might necessitate advanced surgical procedures and/or the use of alternative prosthetic options like over-dentures with implant support.

It's important to note that this classification is a guide, and individual patient cases may present with a combination of features from different classes or may require customized treatment plans based on unique anatomical and functional requirements.