9

Managing problems and complications I

Khalid Mortaja & Baraa'h Alsalamt

Khaled alHamad

The lecture will be about

managing problems and complications.

The lecture will discuss how to diagnose problems and how to manage it, for a finished set of complete dentures. Esthetics, function and occlusion related topics will be gone through. In order to understand this lecture, you have to have good understanding for the complete denture topic. --To start with, why would you replace teeth? It could be due to appearance, function, speech, comfort or for psychological reasons.

Its a good way of thinking to relate the problems of the complete denture to one of these points, as a denture might have a problem in any of them. ---

If a problem in the appearance is noticed, there must have been an error during the third (JRR) of fourth (Try-in) visit. As we start the third visit, you build the esthetics of the denture using a wax rim. Establishing the lip support, the incisal show, the occlusal plane orientation, the midline, the canine lines. You also choose the shape and the mold. In the fourth visit, you double check everything you did with teeth in wax. If there was no good communication between you and your patient, a problem with the esthetics will arise in the insertion visit. Usually, the patients dont concentrate on the esthetics during the try-in visit. Retention is what matters inthe most for them! The patient will notice every tiny esthetical problem in the insertion! And thus you have to be very careful, and take the patients agreement on what you think is good.

There are things that you can change or adjust after the delivery. For example if the patient is complaining that the incisal show is too much, you can take up to 1mm from the incisal surface.

On the contrary, if there was a midline shift, and the patient was concerned about it, you have to remove all the teeth and start over. Even at the try-in, if you noticed a midline shift, you have to remove all the teeth and re-set them again. The try-in stage is your last chance to correct things, as teeth are still in wax.

In your private practice, relatives might escort your patients. If the patient is shy and cant give you his opinion about your work, the relatives will do so and give you their opinions.

So to summarize, you can just adjust minimal errors such as incisal show at the insertion visit. ---

Moving to the biggest topic in todays lecture: Dentures are used for many reasons. Usually lower dentures are implants-retained. In the maxilla usually there is no problem with retention, while in the mandible you will be struggling with retention. The patient will express this in different ways; rocking, going up, too big and so. Too big might mean the occlusion is too big or the teeth are too big. You have to be very careful and address the patients complaint correctly, especially if you werent the one who did the denture.

Most of the problems with the retention are lack of stability. We understand that the complete denture depends on the peripheral seal. The heights and widths of the flanges must cover the entire outline of the denture and the post dam area for the posterior palatal seal. If its short in width or height, it will end with jeopardized retention.

The upper teeth should be slightly buccal to the ridge, as the maxilla tends to become smaller upon bone resorption.

How do you check retention in dentures? In the upper, you try to pull the anterior teeth down. To check the post dam area retention, you push the palatal surfaces of the anterior teeth. You check the retention around the disto-buccal area and the tuberosity by pulling the contralateral area down.

In the lower, you pick up a probe and try to lift the denture between the two central incisors. Dentures wont function probably if they are loose, and that would be because losing retentive forces. One of the most important problems in retention is the lack of peripheral seal. It could happen at the delivery clinic, when patient is speaking, eating, opening wide or after adjustment. How to check the peripheral seal? By direct vision you look at the flanges and compare them with the sulcus to see if there is any problems in height, or by adding tracing compounds (green stick) to area of concern then you border mold it, after that you check the results, if retention is improved, thats good and you can send it to the technician and he/she will replace the tracing compound with permanent acrylic material, by casting the denture as the impression, then a cast with the area of green stick covered is copied, green stick is removed and acrylic is added (heat cure acrylic or self-cure acrylic if the area is small). Important note here, when you add tracing compound (green stick) to the post-dam area, you might alter the special position of the denture thus affecting occlusion, so after placing tracing compound you have to check occlusion. Scenario: you placed tracing compound to the posy-dam area, retention improved, you checked occlusion by putting the lower denture against the upper and asked the patient to bite, 7s are only in contact (because the denture dropped posteriorly), what would you do? Now, if everything is ok apart from this problem and the changes are in the upper denture only, you have to cut the posterior teeth and no need to do anything to the anterior teeth because they will guide us to the vertical dimension, place wax and register new RCP, take a copy of the lower denture then send them to the lab. The technician will cast this impression which is the denture and the copy lower denture, mount them on the articulator, re-set teeth on the upper denture then give you a try-in. if the try-in is ok, continue to delivery stage. If the drop is minimal (less than the height of the cusp), you can selectively grind the posterior teeth and avoid going back to the registration step, and if the gap is too big then you have to do what is written above. Whenever you change anything you have to check occlusion.

How to overcome this problem? Proper impression techniques and border molding, so you wont have deficient borders. Locate the area (PPS) probably. Sometimes you might have torus close to post-dam area; you have to mark it probably on the cast, ask your technician to relief that area, then you maximize the retentive forces in order to compensate for the lack of a good (PPS). Now the resorbtion of the residual ridge is of major problem to retention, so you have to probably extend you dentures height and width, and if you have a good ridge, even if your ridge is under extended, you can get away with it because the denture will be acceptably retained.

Inelasticity
Patient

of cheeks can cause (aging, scleroderma, submucous fibrosis)

Recognizing and be sure about :

medical history
Observation Palpation

of mobility of tissues

Management
Adjust

of displaceability of lips and cheeks

borders by adding tracing compound and then replacing it with acrylic. to maximize the peripheral seal , and then send it to the lab to replace it with acrylic.

Avoiding
Proper

border moulding have to be achieved , you could use self cure acrylic but it is considered a temporary solution due to the causes we spoke about the last time that the chair side acrylic will be full of pours and halls so it will be weak and stained easily and the patient will be irritated and burned because of the chemical reaction of acrylic curing.

Air beneath the impression surface

Trapped air expands as denture moves away from supporting structure until air bubble reaches the borders and seal broken.
Poor

Deficient impression Damaged cast Warped dentures by using irritating materials to disinfect the denture. Over adjustment of dentures Changes in tissue fluid Resorption of residual ridge Excessive relief
Recognizing

fit may be due to :

Denture may rock under pressure Visual inspection: gaps may be seen around flanges , between the flange and the mucosa. Through deterioration of occlusion if denture has warped Through the application of thin layer of low viscosity disclosing agent. like PIP (pressure indication paste)
Management

If polished surface acceptable, teeth in neutral zone, free way space not more than 6mm, and occlusion satisfactory, then reline denture, Before taking the impression, relieve heavy contacts.

, it is an indication for reline :

Avoiding
1- When making the 2nd impression ensure: Uniform thickness of impression material achieved No pressure from tray Impression poured before distortion occurs. Borders are adequately supported 2- Cast must not be over trimmed or damaged 3- Optimum curing cycle used. 4- Denture must not be heated when trimmed and not be cleaned through boiling. 5- if the patient has resorbed ridges , you should follow him and do continuous reline

Changes in tissue fluid

dentures cant seat properly ,but when we place cotton rolls and ask the patient to bite over them , it gets the retention and esthetic. Lack of recovery from old denture(90 min gap) Medications (diuretics) Heart failure management If prolonged seating pressure by cotton pellets restore retention, reline/rebase using minimum pressure technique. consult with the physician Ensure old denture not worn for 90 minutes before the impression, if not the mucosal tissue would be missy and compressed.

Undercut residual ridge

it depend on the displaceability if it :
High:

you check if after addition of tracing compound the denture can be painlessly inserted and removed. if it is inserted painless you can just send it to the technician to replace it with acrylic.
Low

: if the displaceability is low check if angles path would help by changing them. If yes add tracing compound and replace it with acrylic. If not : you should find other ways to solve the problem , for ex. providing relief on that area or send the patient to do surgical treatment to minimize the undercut.

Avoiding:
With

high displaceabilityrequest the lab to process acrylic into undercuts.

Low displaceability- assess if angled path will help. If yes, process acrylic into undercut. If no, request

lab to block out undercut and accept compromised retention

Excessive relief over areas of reduced displaceability

Recognizing
Palpate Use

area and compare it with amount of relief provided

disclosing material.

Management
Reline/rebase:

outline area to be relived on the casts or on the impression and indicate amount of relief.

Avoidance
outline

area to be relived on the casts or on the impression and indicate amount of relief.

XEROSTOMIA
this will reduce the ability of retention of the denture , it is Lack of saliva due to : or disease of salivary gland Medications Irradiation of the head and neck Reduce ability to form seal Management Consider prescribing
Sugar

along borders.

free acidic sweets, chewing gums, artificial saliva.

Consult with the physician. Design denture to maximize retentive forces and minimize displacing forces.

Neuromuscular control
you should build the Basic shape of denturein a good way to stabilize the dentureif it is incorrect it would make the denture unstable. cross section of the posterior region should be triangular. Occlusal surface sited within confines of borders , of the upper teeth the max. teeth are slightly buccal to the crest of the upper ridge. which makes the lower teeth exactly over the crest of the lower ridge. this position will help the muscles to retain the upper denture. and the lower denture will take a triangular shape over the crest to be sta ble. and polished surfaces being slightly concave , for the muscles to set on it and seat it.
Recognizing

, if you find that there is a problem how to know the reason:

if Lower molar too lingually placed. clinching on the tongue : if it is mild you could try to cut the lingual part or make the lingual flange more concave. but if the error is too much you have to remake.

Lingual polished surface convex , Upper buccal flange insufficiently wide.

Management

Narrow lower teeth lingually Adjust lingual polished surface Add tracing compound to adjust buccal flange

Other causes
Motor neuron disorder
Presentation:

On delivery On eating On speaking After adjustment

Change in shape to the old dentures

Try

to adjust dentures to be similar to the old ones. template techniques or copy denture

Consider

High Occlusal plane on lower denture , ** normally the tongue have to be seated on the lingual cusps of the lower teeth , if it is higher you suspect increased VD and do the changes on the lower denture. more explanation: High Occlusal plane
Recognizing Usually associated with high VD if the upper incisal level is correct Management If upper occlusal plane correct hen:
If

If increased VD is under 1.5 mm: mount on the articulator and adjust lower using selective grinding

more than 1.5mm : reset t the correct VD

Patient does not appreciate the need for active control.

Patient does not appreciate the need for active control. we can teach them that by knowing that the dorsum of the tongue should support the back of the upper denture and the tip of the tongue should be resting against the lower anterior teeth. this will be learned by the patient over time. but if he is a new wearer you can teach him that by placing small pieces of acrylic on the posterior polished surface of the

upper denture and on the lingual part of the teeth and ask the patient to bite on something and place the tongue on these areas. to stabilize the denture.
Recognizing Ask patient to close on your finger by the anterior teeth and observe position of the tongue. Ideally should take the position shown on the figure. Management Train the patient to use his tongue to retain the denture by placing small beading of resin on the posterior border of the upper and lingual to the anteriosr. When patient has been without posterior

teeth, tongue adapts to increased available space.

Consider Use of small occlusal table Remove most distal posterior teeth Consider using special impression techniques: neutral zone technique.

Increased Displacing Forces

1- Overextension
it will not have a good retention may be in length or in width: Overextension (in length) : Recognition
Direct Look

vision and gentle manipulation of cheeks and lips, and movement of the tongue.

Overextension (in width): Buccal to tuberosities (encroachment on coronoid)

for sign of inflammation t the reflection of the sulcus.

Lingual & labial flanges: if thick could be lifted by the tongue and mentalis Management Reduce bulk- use disclosing agent if needed- and repolish Avoidance: Proper border moulding and impressioning

2- Deep post dam

Recoil of tissues pushes denture downwards

Recognizing
Pt Deep

complain of pain in region of the post dam. groove in palatal tissues with inflammation ranging from hyperemia to ulceration.

Management
Reduce

depth-use disclosing agent if needed- be aware of over reduction as the tissues may heal and lack of seal may develop

3- Poor

Recoil of displaced tissues lifts denture. Recognizing

Denture

fit to supporting structures

falls when teeth not in contact.( not to be confused with overextension or denture not sited in optimal space)

Management
If

polished surface acceptable, teeth in neutral zone, free way space not more than 6mm, and occlusion satisfac tory, then reline denture-using minimal pressure technique. Before taking the impression, relieve heavy contacts and ensure old dentures not worn for 90 minutes before making the impression

4-Occlusal

problems "From the

slides! :(" **It has been discussed in the first part of the next lec. (lec.10).
Done By : Khalid Mortaja Baraa'h Alsalamat I am Sorry :( , Good luck in the Exam :D Dentistry is Great, Love it OR Leave it. (Y)