Managing Problems and Complications Last time we talked about occlusal problems.

This lecture summarizes pinpoints of problems that could arise. There isnt much explanation about the problems because they are related to your understanding of the occlusal schemes for the complete denture.

Problems in Occlusion Uneven Initial Contact It causes dentures to tilt on supporting tissues, thus disrupting retentive seal. Also prevents even seating of loosening dentures on supporting tissues when teeth occlude. Recognizing: You ask the patient to close slowly into RCP until teeth just touch. Management: Aim is to adjust occlusion until even contact in RCP is achieved. Minor errors: use chair side techniques- difficult as dentures move on supporting tissues producing errors in markings. Major errors: use laboratory techniques. Remount the maxillary denture on a semi adjustable articulator using a face bow and the Mandibular denture with Pre-tooth contact registration. Then adjust the occlusion on the articulator using articulating paper. Gaps more than 1.5mm (vertically) or errors in anterio-posterior relation more than half a cusp cannot be adjusted by selective grinding and requires re-setting. We said in the occlusal scheme lecture that for the complete dentures to be stable in the patients mouth we must have balanced articulation; balanced contacts on both sides which differs from natural teeth. In natural teeth there are teeth and bone, so there is canine guidance or group function on one side (working side) and all teeth are out of occlusion on the other side. You stick to that rule when you do a crown, a bridge or a partial denture. But as for the complete denture, it is not anchored in the patients mouth, its just setting there. So if theres group contact on one side, the denture will flip because there will be displacement forces on the denture. So if there is uneven contact that will lead to displacement. How do you manage that? Usually on the insertion visit -or if it wasnt your work and the patient wants to review his dentures- you can check the contacts by using articulating papers. You hold the dentures in place and ask the patient to close on the articulating paper. If there is uneven contact, it will be 1 Managing Problems & Immediate Dentures| Prosthodontics

apparent. Adjust these contacts if the error is minor. In major errors you have to do a remount procedure. The remount procedure is simply making a facebow transfer in the upper denture, you make a precentric (just before centric) wax record, you put wax between the teeth and ask the patient to close until teeth just meet, you must stop the patient from forceful closure, we dont want the patient to close forcefully so that the dentures move and the teeth set into intercuspal position, because if the dentures are not stable and he closes his mouth forcefully, the dentures will be stabilized, but we actually have an error in occlusion. After that the technician pours the upper and the lower dentures now he has a cast with the registration. He mounts it on the articulator, and then he adjusts the occlusion. The technician might have to reset the posterior teeth. So he removes them and he puts a new wax rim with another bite record, occlusal registration, try-in and another insertion. This is very common in the clinic. One of the errors done by a dentist is that he holds the mandible in the registration closed. Now if the baseplate wasnt stable, especially if there is uneven pressure on the wax rim, the baseplates will not be seated properly so it will seem that the registration wax is even and you will see that the lower denture is raised a bit (the lower is raised mostly), so when the patient closes it flips. The try-in also doesnt work, you put them on each other and you think that the contact is even and excellent, but on the insertion visit you will notice a gap, because on insertion the denture will be more stable or it will look like that so you have to check the occlusion. On insertion or registration you have to hold the baseplate in place then ask the patient to close slowly until the teeth just meet, it will show if theres an error in occlusion or not. When the teeth meet forcefully it might cause flipping or they may get into nice occlusion so it will give you the false impression. A very common mistake in the registration stage is that you didnt hold the denture. You should use adhesive to make sure that the baseplate is fully seated on the ridge. When I do it myself I usually support the upper and the lower dentures, keep them in place and ask the patient to close while holding the baseplate, the lower on the lower ridge and the upper on the upper ridge. This is my technique I hold the baseplate forcefully seating it properly in its place to avoid this problem, because if I leave it as it is, the wax rims will never meet evenly, and it will flip.

Lack of freedom between RCP & ICP Patient with inaccurate control of Mandibular movement may not adapt to exact cusp-fossa relationship causing dentures to move and disrupt the peripheral seal. Recognizing: Age/ medical history: the patient has difficulty in achieving reproducible occlusal relationship. The patient is able to eat using old dentures with flattened, worn teeth. Management: Remount dentures and adjust teeth to produce area of freedom. If adjustment will result in loss of occlusal balance, reset/remake using cuspless teeth. Avoidance: Always allow 1-1.5mm of easy anterior movement of mandible from RCP. Consider use of cuspless teeth (non-anatomic) teeth, set in occlusal balance during lateral and protrusive movement (this produces no vertical overlap- possible effect on aesthetics)

Managing Problems & Immediate Dentures| Prosthodontics

You use cuspless teeth with a patient that has difficulty adapting into RCP, because of muscular problems or because he has been using a denture for a long time. You have to give those patients freedom between the RCP and ICP. If you give your patient one RCP locked into that position, he cannot afford that. You have to adjust that and give him a little bit of freedom. If you cant do it chairside, you must do a remount procedure. You can avoid that by careful assessment of the medical problem and by using non anatomical teeth.

Lack of occlusal balance in excursive movements It causes dentures to shift on supporting tissues and disrupt retentive seal. Many patients wear dentures successfully without occlusal balance, however, as retentive forces decrease, displacing forces generated by lack of balance assume greater significance. Recognizing: Hold the dentures in place on the supporting tissues. Request the patient to close until his teeth just touch, then to rub from side to side and forwards. By observation, note teeth slide easily without causing dentures to move over supporting tissues. Lack of balance is commonly associated with excessive vertical overlap of anterior teeth. Management: Adjust teeth until balanced contacts are achieved. Could be done chair side, but remount procedure is preferred. If achievement of balancing contacts would necessitate mutilation of teeth (excessive shortening of lower incisors), then reset teeth or remake dentures. If theres lack in occlusal balance (not just in centric, left and right, theres no balanced occlusion) you could adjust that chairside or in the laboratory. You recognize that problem by holding the denture in place and asking the patient to close until his teeth just meet, and then rubbing the teeth left and right, then you can visualize any major errors and you can use the articulating papers to mark these areas and adjust them chairside or in the lab. Excessive vertical overlap of anterior teeth Recognizing: Detection of interferences during speech: request the patient to produce the S sound. Upper and lower teeth should not touch. Management: Shorten the lower anterior teeth; this may result in an aesthetic problem. If up to 1.5mm of free way space is required, remount and selectively alter occlusal contacts to reduce vertical dimension at occlusion. If the extra freeway space required exceeds 1.5mm, remove the posterior teeth from the denture with incorrect occlusal plane, re-register, and then reset or remake the dentures. We talked about the anterior guidance last time and we said that the anterior guidance in the end is almost zero and theres no vertical overlap between anterior teeth, if this is the case then excessive force on the dentures will cause displacement. You could shorten the lower teeth to decrease this overlap between anterior teeth while reserving the aesthetics.

Managing Problems & Immediate Dentures| Prosthodontics

 Last lower tooth is too posteriorly placed Teeth overlie crest of the residual ridge as it rises towards the retromolar pad. Pressure on these teeth causes denture to slip up. Recognizing: Apply finger pressure on the last tooth and observe if denture moves. Management: Remove most posterior teeth from dentures. Sometimes the last tooth is placed high up on the ascending ramus of the mandible. You should place the 6 on the most concave part of the mandible, and then you can see if theres space behind the 6 to place the 7. If the 7 is raised on the ascending ramus of the mandible, whenever the patient talks the denture will tip forward. If thats the case, you have to remove the most posterior part of the denture and stop up to the 6.

Orientation of the occlusal plane is not parallel to the ridge Mastication produces forces that tend to move the dentures over supporting tissues. Problems can occur with large tuberosities, as these can depress the occlusal plane posteriorly and this may place the lower denture at a forward force. Management: Reset the teeth or remake the dentures. We need the occlusal orientation to be parallel to the ridges. If its not, this will cause the dentures to be unstable. It is very common in the clinics to be caused by large tuberosities. Here you are forced to make an occlusal orientation that is not parallel to the ridges. There will be contact in the posterior part and a big gap anteriorly, if there are large tuberosities posteriorly. You can manage that by either adjusting the wax posteriorly and lifting the occlusal orientation upwards, or lowering the lower rims, giving more free way space just to avoid the heavy contact posteriorly, and to provide space for teeth posteriorly. You could also shorten the upper teeth, or if its too excessive you could surgically adjust the tuberosity. If no surgery is indicated you could do the previous techniques without compromising the aesthetics.

Support Problems Lack of Ridge Little resistance to forces in lateral and anterio-posterior directions; the denture is liable to move, and thus disrupts the retentive seal. 4 Managing Problems & Immediate Dentures| Prosthodontics

Recognizing: By observation of the ridge. It may be associated with a shallow palate. Denture may move easily with finger pressure. It is very common with class five. Management: Minimize displacing forces and maximize retentive forces. Fibrous displaceable ridge Forces of mastication cause the denture to sink into and tilt on supporting tissues, thus disrupting retentive seal. Recognizing: By palpation of the residual ridge to determine displaceability. Denture may sink into tissues under finger pressure. History of presence of natural teeth (usually lower anteriors). Teeth may appear to meet evenly under forceful occlusion, but when the teeth just meet, incorrect occlusion often appears. Management: Reline/rebase. Precautions: - Remove acrylic from impression surface until no contact is evident. (You could check with disclosing material) - Add vent holes in the labial /buccal flange of the dentures. - Use a low viscosity material. - Provide best possible posterior teeth. The non-resilient soft tissue does not adapt to impression surface, may be associated with Endocrine/Nutritional deficiencies. Management is similar to fibrous displaceable ridge. You can recognize that problem by applying proper examination. If you missed it, you can use pressure indicating paste in order to see the area, adjust it, relief it and remake the denture. You have to use a technique we talked about in the impression lecture that will selectively provide a light body, so when the denture sets in place it doesnt apply pressure on that area. Bony prominence covered by thin mucosa The same technique could be used when theres a bony prominence covered by thin mucosa. You must selectively avoid excessive pressure on that area. (e.g., prominent maxillary midline suture, denture rocks about fulcrum produced by area of reduced tissue displaceability and thus disrupting the seal.) Recognizing: Denture rocks on finger pressure, inflammation of thin mucosa and palpation to determine degree of displaceability Management: Remove acrylic from impression surface (indicated by disclosing agent). Precautions: - Beware of excessive creation of space beneath the denture. - Beware of over thinning of the denture base which causes possible fracture. - Provide optimal occlusal contacts.

Managing Problems & Immediate Dentures| Prosthodontics

This is just a picture that shows how to avoid pain that is related to many different things. It is relieved by putting cotton inside the denture. Many reasons cause pain associated to dentures and you have to carefully identify them.

Causes of Discomfort Discomfort could be related to the impression surface, polished or occlusal surface. Related to impression surface: - Pressure areas due to: Faulty impression, damage to the working cast or warping of the base during processing or immersing in too hot water - Denture base not relieved in a region of undercut - Pearls of acrylic or sharp ridges on the fitting surface of the denture - Lack of appropriate relief over tori, atrophic mucosa - Overextension of peripheries, unrelieved frenal /muscle attachment - Pressure on mylohyoid ridge - Atrophic mucosa, spiky ridge - Postdam too deep Related to polished surface: Maxillary denture constraining the coronoid process. Related to occlusal surface: Slide form RCP to ICP Lack of incisal overjet Lack of appropriate freeway space Lack of occlusal contacts or even contacts Related to other causes: Instability of dentures Burning mouth syndrome Xerostomia TMD Problems in Speech Noise on speaking. Recognizing: Excessive OVD, occlusal interferences, loose dentures Sibilants, e.g., S Recognizing: Ask the patient to count from 60-70 to see how the letter S is pronounced, anterior teeth should be just out of contact. If they arent you have to check the vertical dimension. 6 Managing Problems & Immediate Dentures| Prosthodontics

 Bilabial sounds, e.g., P B Recognizing: You have to see if lip approximation is easily attained. You must check the vertical dimension and the incisal position. Labio dental sounds, e.g., F V Recognizing: Does the vermilion border of the lower lip rest against the incisal edges of upper teeth? On swallowing, does the lower lip overlap the labial surface of the maxillary incisors? If not we must check the position of upper teeth and the vertical dimension.

Regarding speech dont be meticulous in the registration stage because sometimes the shape of wax rim or the quantity of saliva could affect it. But generally when the patient is complaining from noise on speaking it could be excessive OVD dimension, occlusal interference or loose dentures.

Psychological Problems

Such as gag reflex. These are some of the techniques on how to handle such a case: Fixatives Training plates Desensitizing programs: ask the patient to brush his palate with a soft brush, over time that will desensitize the area. Hypnosis Professional psychological counselor

Other Problems Other problems such as burning mouth syndrome, denture stomatitis, angular chelitis, allergy and TMJ disorders. You think of those problems when you exclude the others.

Managing Problems & Immediate Dentures| Prosthodontics

Immediate Dentures What is an immediate denture? How does it differ from the conventional one? Some patients ask for immediate dentures especially in the private clinics, but in public hospitals you wont encounter such patients. An immediate denture is a partial or complete denture constructed for insertion immediately following the extraction of natural teeth. On the day of extraction your dentures should be ready. You send the patient to the surgery clinic, if you are not extracting the teeth yourself. He comes back to you and you insert the denture immediately. Today we will learn the concept of constructing an immediate denture, advantages and disadvantages, types of immediate dentures and how to fabricate them. It differs a little from the conventional dentures. You might get a patient who is very concerned about his appearance, but you dont see that these teeth provide any aesthetics for the patient, they are very poor. The patient says that he cant stay without teeth specially the anterior ones, so you have to provide him with an immediate replacement. When you check the radiograph, you will see that theres massive bone resorption and the teeth have poor prognosis and are all indicated for extraction. Treatment Options: - Extract all teeth and wait (6-8) weeks for the extraction sites to heal. - Convert an existing RPD into an interim immediate complete denture. - Fabricate a conventional immediate complete denture. You wont be doing an immediate denture in your training course but you should know the concept and technique. Its easier than the conventional denture, but its more difficult in the insertion visit. Thats why it costs more, because the patient will come for more relining and adjustment procedures, and there will be high resorption. Types of immediate dentures The immediate denture has two types: the interim immediate denture and the conventional or permanent immediate denture. Interim Immediate Complete Dentures (IICD) 8 The IICD is replaced with new dentures once healing is completed. Usually all remaining teeth are extracted on the insertion visit. Managing Problems & Immediate Dentures| Prosthodontics

If an existing RPD is present, the teeth to be replaced are added to the denture with the necessary base material.

Interim means temporary. I extract all the patients anterior and posterior teeth on the same visit. And then I place the denture. There are many sites of healing sockets, so there will be resorption and many changes will occur anteriorly and posteriorly. You place the dentures immediately and you see the patient after 24 hours, a week and a month in order to do adjustments and relining, because theres a lot of resorption. After 6-8 weeks or a little more, youll see that there are a lot of changes, even aesthetically, because the ridge has changed, as well as the occlusal orientation and the incisal show. So its an interim denture that serves the patient in a transitional stage, until the sockets have healed completely. Then you replace it with a conventional complete denture. If the patient didnt extract all his teeth and he doesnt want a conventional denture, he could order a partial one. Every time he loses a tooth, we replace it, until the denture looks like a patchwork. And then you change it. So the interim RPD serves the patient for a short time and transits him from being partially dentate to being completely edentulous. That partial denture is like a training plate that helps him to get used to the complete denture. You take an impression with the denture in place, after that the technician will remove the natural teeth on the model and add acrylic ones instead, then he does flasking and packing, and thats it. He turned the partial denture into a complete denture and thats the technique. You treat the case as if its an RPD, so you must register the occlusion. Conventional Immediate CD If you dont want to give your patient two dentures; a spare one and a new one, and hes really concerned about the aesthetics, you could extract the posterior teeth only, leave the anterior ones and wait until the sockets heal. When the posterior part heals, it becomes a stable site for the dentures. There will only be changes in the anterior part, and that is what we might reline. No matter how much changes will occur, the occlusal orientation will not change, the denture is stable posteriorly. If I extract everything at the same time, there will be huge changes in the dimensions and the aesthetics of the dentures, and the patient will have to change it. But if the denture was stable, only the anterior part will change and thats where I reline. Thats what we call a permanent immediate denture.

Advantages and Disadvantages Advantages of the immediate denture - The patient will have no time without teeth. Patients are therefore able to continue their social and business activities without embarrassment. - The general appearance is less affected. 9 Managing Problems & Immediate Dentures| Prosthodontics

Minimal changes in muscle tone and occlusal vertical dimension. Centric relation is easier to record, because there are remaining natural teeth. You copy the vertical dimension and theres no need to mark dots or measure the freeway space. As if you are doing a partial denture. You take the VD and the RCP for the natural teeth. Minimal changes in speech and chewing habits.

Disadvantages of the immediate denture - As healing proceeds and resorption occurs, the denture will not fit. The immediate denture needs to be relined or remade in 6 months to a year following insertion. Even if you try to make it permanent, there will always be changes that require recalls and adjustments. - The treatment with immediate denture is more costly. - There is no Try-in; the aesthetics of complete denture cannot be evaluated until the insertion appointment, because you left the natural teeth until the insertion visit and removed them from the model. You can do an impression to make sure that the centric is there. Are there enough teeth to hold the cast? If not I will make wax rims, just like the conventional one. I take a primary and a secondary impression, a registration if its needed, if not I go to the insertion stage. The technician removes them on the model and he replaces them with acrylic teeth as if he has extracted the teeth. He sets the teeth and he prepares it as a complete denture. Now that you have a complete denture you extract the teeth and put the denture. But here you are predicting. It is better if the dentist removes the teeth on the cast in order to predict how much healing will take place. - The anterior ridge is an undercut (often severe).

Fabrication of immediate denture History and examination - A full medical and dental history should be obtained from all patients requiring dentures. Details of past illnesses, present medications, difficulties with extractions, experience of anesthetics, etc assume a special significance in a patient for whom immediate dentures are planned. - As a result of this examination, it is sometimes possible to divide the natural teeth into four classes: o Teeth that are not to be extracted in the foreseeable future. The teeth may need conservative or periodontal treatment or selected teeth may be considered for overdenture abutments or abutments for an RPD. o Teeth that are to be extracted but no denture is fitted in the extraction site for about 6 months. These teeth are usually posterior and not required for aesthetics or maintenance of the occlusal vertical dimension. The object is to provide a stable site for the immediate denture.

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o o

Teeth which are to be extracted and immediately replaced with a denture. These are usually anterior teeth. Teeth with very limited prognosis which are worth retaining temporarily to aid the transition to denture wearing, because sometimes specially in the private clinics medico-legal issues arise. The patient has teeth with poor prognosis. You cant put a bridge or a partial denture and the patient refuses to extract them.

Treatment planning From the findings of the history and examination, the treatment plan may be: - No denture to be provided. - The provision of temporary acrylic partial dentures to fill the posterior edentulous spaces. This may be a valuable training device if it is considered that the patient is likely to show poor adaptation to complete dentures. - The provision of immediate dentures that may take the form of: o Additions to partial dentures. These are termed transitional immediate dentures. o New dentures, complete or partial, to replace those teeth that are already missing and those to be extracted. When immediate dentures are proposed, patients should be advised of the necessity for early relining and/or remaking with associated additional visits and extra costs.

Design of Immediate Denture One of the students I supervise on had a case in which the patient has good fullness, even without him wearing the dentures, because the ridge hasnt resorbed, yet. When the patient wears the denture there will be too much fullness and the patient will not accept that. Thats the case for the immediate denture. The ridge will be prominent and there may be an undercut. We either do a Labial flange (complete or partial) or Open-faced (socketed). A final decision is usually deferred until study casts are available. Advantages of a labial flange: Greater stability and increased retention forces Improved strength Tooth arrangement can be altered No interference with sutures Stable appearance Easier relining if there are any fractures to hold.

Disadvantages of a labial flange: - May produce unnatural fullness of the lip and the patient may not like the appearance. - Bony undercuts labial to the alveolar ridge may prevent the use of a flange unless they are surgically removed.

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The use of a partial flange overcomes the disadvantages of a full flange while retaining most of the advantages. It is therefore important to assess each case comprehensively before the trial insertion stage. Synopsis of Clinical and Laboratory Procedures Preliminary alginate impression for study casts Request spaced perforated acrylic special trays. Decontaminate. The impression is poured with dental stone. A custom tray is fabricated with acrylic resin. The remaining teeth are covered with a double thickness of baseplate wax. Working Impressions The custom tray is checked in the patients mouth as normal. The posterior palatal seal can be determined and transferred to the cast. The final impression is taken with a suitable impression material. When the teeth are very mobile, care must be taken to avoid extracting the teeth with the impression. The undercuts and interproximal areas can be blocked out with wax and petrolatum. In severe cases, a vacuum formed resin stent can be utilized as a protective sheath while making the impression

Recording the jaw relationship - If there is sufficient tooth contact to establish the required jaw relationship, an interocclusal record should be taken together with the shade and mould of the teeth. - If insufficient tooth contact, occlusal rims will be required. - Procedure undertaken as for partial dentures construction. - Take the shade and mould of the anterior teeth. - Indicate the occlusal configuration, size and material of the posterior teeth Decision as to whether open-faced or flange design - The depth of penetration of the labial portion of the cervical neck of the tooth is dependent upon the bone level around the teeth involved. This is determined by using a periodontal probe and radiographs. If a flange is to be provided, consider whether the surgical removal of bony undercuts is necessary. I have soft tissue that will disappear, so I have to predict how much the gum will collapse and resorb, based on that, I extract the teeth. If theres too much probing depth, that means that most of the gum doesnt have bone (no undercuts), and then you can decide if youll do a full flange, partial flange or no flange.

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If a partial flange is indicated, the labial surface of the alveolar ridge should be surveyed relative to the path of insertion and a line is drawn about 1mm beyond the survey line to indicate the extension of the flange.

Instructions to the laboratory - Teeth for extraction should be indicated on the working casts. - If the immediate restoration is a partial denture, specify undercuts which must be blocked out. - Instructions to set up the artificial teeth in the edentulous spaces for trial insertion in the mouth. Trial Insertion - The teeth that are to be extracted and immediately replaced by the new denture are still in situ in the jaws. Thus the positioning and aesthetics of the replacement teeth cannot be checked in the mouth before the denture is processed. - The trial dentures are checked for jaw relationship. - The patient checks the appearance of any visible teeth. - If appropriate, the post dam should be cut in the upper cast to the correct position, length, depth and width before decontamination. - Arrangement are made for the tooth extractions and the fit of the immediate denture at the next patient appointment

Preparations of the cast before processing - The dentist is responsible for removing the teeth from the cast and preparing the cast to receive the artificial teeth. This will be dependent upon the bone levels and previous measurements. You scrap the teeth off the model depending on your prediction. The more accurate you are, the less relining youll do later.

Instructions to the laboratory - A clear acrylic surgical template is constructed on a duplicate of the trimmed cast if an alveolectomy is to be performed. - Artificial teeth are fitted to the prepared working cast with any particular aesthetic requirement requested by the patient. - Indicate whether flange or open-faced design - The trial denture with the replacement teeth is processed.

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 Fitting the denture - Great care must be taken to avoid trauma to the anaesthetized tissues. - When fitting immediate dentures there are 3 common types of adjustment: o Removal of acrylic pearls and spicules. o Open-faced teeth that enter the lingual area of the socket. o Flanges which enter too far into bony undercuts. - On insertion of the denture obvious occlusal discrepancies and overextension must be corrected. However, a definitive adjustment of the occlusion is not possible because of swelling. - Cold packs are suggested for the first several hours. The patient must not remove the denture in the first 48 hours. Tissue inflammation and edema may prevent the reinsertion of the denture. A soft diet is preferred. Appropriate pain control medications are prescribed as needed.

Instructions to the patient Dentures should not be removed for 24 hours, because there might be swelling. If we remove it and theres swelling it will not fit anymore. That will also help control the bleeding. Once you fit the denture in the insertion visit the patient should not remove it until you see him after 24 hours. Post extraction instructions are given as normal. (antibiotics or medications if needed) Review at 24 hours Dentures are removed from the mouth and cleaned with a brush, soap and water. The mouth is examined for indications of border overextension or other excessive pressure from the denture base and adjusted accordingly. Obvious occlusal discrepancies are adjusted. You can use tissue conditioner or soft reline. Oral and denture hygiene is given together with a suitable patient handout. Identifying marks can be applied to the dentures. Review at 1 week All factors mentioned above at the 24 hour review should be checked again with proper evaluation and adjustment of the occlusion. Regular review appointments should be arranged - one month, three months, six months and then annually thereafter. Remind the patient that temporary relining will be necessary at a review in the near future and that permanent relining or the construction of new dentures will be necessary at a later stage.

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Best of luck, Sarah Farouk Ahmed

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Managing Problems & Immediate Dentures| Prosthodontics