Prosthodontics

Tim Friel

The ‘Anatomically Difficult’

Denture Case
Abstract: Complete loss of teeth from one or both arches is a disabling condition which is usually managed by a conventional removable
denture. Rehabilitation may be poorly tolerated by patients, particularly in the lower jaw, and is more difficult in situations when the
anatomy of the denture-bearing area is less favourable. These situations may require specific prosthodontic or surgical techniques, or a
combination of both. Prosthodontic solutions involve special impression techniques and the use of soft linings and it is vitally important to
manage patient expectations in such cases. This article describes prosthodontic management options for dealing with the fibrous (flabby)
anterior ridge and bony exostoses.
Clinical Relevance: Although tooth loss in the UK is diminishing, it is nevertheless important that dental practitioners are able to demonstrate
good prosthodontic skills for managing an ageing population. Surgical correction of anatomical defects may occasionally be employed.
Dent Update 2014; 41: 506–512

Complete dentures can be challenging for
both patients and the dental team at the best
of times. Even well-fitting dentures require the
development of some skill on behalf of the user
(habituation) to maximize success. Factors such
as chewing ability, dietary selection,1 speaking,
smiling and socializing2 are affected by the loss
of teeth and wearing dentures. Unfortunately,
by their very nature, removable dentures will
be less stable than fixed prostheses, which may
result in greater dissatisfaction for the user.
The proportion of the population
in the United Kingdom retaining some natural
teeth is increasing. The 2009 Adult Dental
Health Survey reports that only 6% of the
adult population is edentulous compared to
37% in 1968.3 While this is encouraging news,
it belies the fact that the complete denture
wearers as a whole are getting older and
becoming more frail. Therefore, the challenge
of providing well-fitting dentures to a sizeable
population will remain for the time being.
A number of factors have been
investigated to see if they relate to satisfaction
with complete dentures. These include
Tim Friel, BDS, MSc, Senior Clinical
Lecturer, Barts and the London School
of Medicine and Dentistry, Queen Mary
University of London, UK.
the quality of the residual oral tissues,4
patient personality traits,5 patient-dentist
relationship6 and depression.7 However,
many of these studies used relatively small
groups of patients, so it is difficult to draw
accurate conclusions. Studies involving larger
population groups suggest that patient
use of dentures is most closely linked with
the quality of the prosthesis provided.
Furthermore, a complete denture wearer
with a severely resorbed ridge is less likely to
be satisfied or use the dentures provided.8,9
While this may seem an obvious statement, it
is a relationship that has only recently been
demonstrated.
The ideal treatment of the
edentulous mandible is the placement of
a minimum of two endosseous implants
followed by the provision of an overdenture.10
This form of treatment has been extensively
researched and has been shown to
improve function in the form of chewing
ability,11 patient comfort, and psychological
acceptance leading to an improved quality
of life.12 Osseointegration in the anterior
mandible is known to be successful and
predictable and it may be argued that it offers
a more cost-effective option in the long term
compared with conventional lower complete
dentures.13 Unfortunately, the initial cost of
implant treatment is prohibitive for many
people. Furthermore, there may be reluctance
on behalf of the patient to undergo the
necessary surgical procedures required.
Denture construction may be
made more difficult by a number of factors
relating to the anatomy of the denture-
bearing area. Not only is it more difficult
to construct a well-fitting denture in these
situations, but there is a greater likelihood
that support, retention and stability will be
compromised. This article will concentrate
on two such anatomical difficulties: the
development of a fibrous ridge; and the
presence of bony exostoses.
Fibrous ridge formation
Tallgren demonstrated the
continual resorption of bone in patients who
were followed for a period of up to 25 years
following complete tooth loss.14 The majority
of bone resorption occurs in the first two years
after tooth loss and continues at a reduced
rate thereafter. A number of factors have
been studied in relationship to the degree
and extent of bone resorption. Chief amongst
these is the effect of local mechanical
stress,15 for example in the situation where an
edentulous arch is opposed by a fully dentate
one (Figure 1). In some situations, accelerated
bone resorption may be accompanied by
fibrous replacement. This fibrous tissue
provides poor support for complete dentures

506 DentalUpdate July/August 2014

 Prosthodontics

and is commonly referred to as a flabby ridge.
The formation of a fibrous
(flabby) upper anterior ridge was described
by Kelly who coined the term ‘combination
syndrome’.16 In this ‘syndrome’ Kelly described
the presence of four clinical features in
patients who were edentulous in the upper
jaw with retained lower anterior teeth. These
are summarized in Table 1.
There is little evidence to support
this ‘syndrome’ as Kelly described a very small
sample size and not all subjects exhibited
every feature. Fibrous ridge formation is not
an inevitable consequence of an edentulous
upper ridge opposed by lower anterior teeth
and is only seen in approximately 24% of such
cases,17,18 according to a study of patients
attending a dental school.
The mechanism for fibrous ridge
formation is unclear. Bone is known to resorb
under compressive load, but why should it
be replaced by a layer of fibrous tissue in
some situations? It has been suggested that
this is an inflammatory mechanism which
may be related to denture wear. An upper
complete denture opposing lower anterior
teeth results in excessive occlusal load on the
anterior part of the underlying ridge, with
consequent rotation of the denture and the
potential for trauma to the underlying tissues.
Interestingly, fibrous ridge formation has
been demonstrated in the edentulous maxilla
following the placement of implants in the
anterior mandible.19
Management of the fibrous ridge
The best management for the
fibrous ridge is to prevent its formation in the
first place. This may be achieved by: a
 Avoiding total extraction of teeth in the
maxilla;
 Retaining upper anterior roots as
overdenture abutments;
 Placing maxillary implants at or shortly after
tooth extraction.
Retaining roots as overdenture
abutments has been demonstrated to reduce
alveolar bone resorption20 (Figure 2). Root
retention also improves proprioception b
and bite force in denture wearers and is a
successful treatment modality if case selection
is appropriate. Overdenture provision
usually requires that endodontic treatment
be carried out in the abutment tooth and
requires careful maintenance by the patient.
Caries is a frequent finding in overdenture
abutments and patients are particularly at
risk if they wear their dentures at night.21
The preservation of roots and alveolar bone Figure 1. (a, b) Advanced alveolar resorption in
may also compromise the space available a patient with an edentulous upper arch with a
for restoration and so this needs to be near full complement of lower teeth. Note the
carefully planned, particularly if root surface ulceration and hyperkeratosis associated with the
attachments are to be employed. trauma from excess loading.
Restoration of the opposing arch
provides even occlusal loading on the upper
arch and can be achieved with a well-fitting
denture. Meticulous planning and attention
to detail can result in a prosthesis that is
stable enough to meet the requirements of
most patients. However, where lower anterior
teeth are present there is less incentive for
the denture to be worn. The concept of
accepting a shortened dental arch22 and Figure 2. Preservation of roots in the anterior
restoring the saddle areas with single unit maxilla will prevent the formation of a fibrous
cantilever resin-bonded bridges rather than a ridge. Cast copings may be required to protect
removable denture may be a more successful the root face from fracture.

Feature Possible aetiology Comments

Fibrous ridge  Traumatic occlusal load  Prevalence of approximately 24%

Enlarged tuberosities  Supererupted maxillary molars (prior to  Weak evidence suggests that enlarged
extraction) tuberosities are more common when a
 Masticatory forces lower RPD is not worn

Papillary hyperplasia  Candida  No evidence to support the presence

 Nocturnal denture wear of papillary hyperplasia

Extrusion of lower anterior teeth  Loss of occlusal contact  Limited supporting evidence
 Soft tissue forces

Table 1. Key features of combination syndrome as described by Kelly.

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 Prosthodontics
option.23−25 Here the provision of an occlusal
table that extends far enough back to prevent
tipping forces on an upper complete denture
may reduce the tendency to fibrous ridge
formation.
The problem of providing a
denture on a fibrous edentulous ridge relates
to the lack of available support (Figure 3).
This may lead to pain under the denture-
bearing area and rotation of the prosthesis,
leading to loss of retention and stability. The
problem is compounded by the extrusion of
lower anterior teeth, thus compromising the
occlusal plane. Techniques to manage the
fibrous ridge include:
 Surgical reduction of the fibrous tissue;
 Impression techniques to minimize
displacement of the fibrous ridge.
Surgical reduction
Surgical reduction involves
removing an elliptical wedge of fibrous tissue
and may be combined with vestibuloplasty,
to increase the depth of the labial sulcus,
or removal of any associated hyperplastic
tissue. Unfortunately, surgical techniques
do not address the loss of alveolar bone
and its associated problems so they are not
commonly employed.
Impression techniques
Before considering any ‘special’
impression technique, it is important for the a
clinician to have a thorough knowledge of
the anatomy of the denture-bearing area. This
will not be discussed here but the reader is
directed to a recent article which refers to this
subject.26
Oral mucosa displaces when
loaded under a denture and the degree
of displacement will vary according to
the thickness and quality of the mucosa.
Displacement is also time dependent, the
majority of it taking place soon after the
load is applied, but reaching a maximum
after a few hours, assuming that the load is
maintained.27 In the upper arch, the mucosa
overlying the palate provides a more suitable
denture-bearing area than the fibrous ridge
as the thinner, more tightly bound mucosa
does not displace as much under load. The
aim of the impression technique is therefore
to displace the tissue in the palate, while the
fibrous ridge tissue remains undisplaced, a
so-called selective displacement technique
508 DentalUpdate July/August 2014
(Figure 4). A number of techniques have been  The impression compound overlying the
recorded in the literature28,29 which, broadly non-fibrous tissue is heated and border
speaking, adhere to the following principles: moulded as appropriate. Pressure is applied
 A primary impression is made using to the premolar region to displace the firmly
alginate or similar mucostatic material. Care bound tissue. The rigid compound overlying
must be taken to avoid distortion of the the fibrous tissue prevents the distortion in
fibrous ridge during this impression stage; this area.
 The cast of the impression is marked to
circumscribe the fibrous area and a custom
tray is made which contains a window or relief a
of this area;
 The tray is adjusted if necessary after
trying in the mouth and border moulded as
appropriate. A mucodisplacive impression of
the non-fibrous area is recorded.
Material which flows into the
region of the fibrous tissue is removed from
the tray. The tray is then replaced in the
mouth and the fibrous area is recorded by
painting on or syringing an appropriate b
material, such as low viscosity silicone. This
technique allows the fibrous ridge to remain
undisplaced.
An alternative to this technique
has been advocated by Watt and MacGregor30
and is particularly suited to extensive areas of
fibrous tissue:
 The primary impression is made as detailed
before and a spaced custom tray is made;
 The primary cast is soaked in water and an Figure 3. (a) Extensively resorbed upper alveolar
impression of it is made in compound using ridge. Note the pattern of resorption in relation to
the custom tray; the fresh extraction socket. (b) Application of light
pressure to the fibrous ridge results in distortion
c
b d
Figure 4. (a) A special tray with a window over the fibrous tissue. (b) The tray is border moulded and a
displacive impression of the non-fibrous area is made. (c) The fibrous area is recorded by syringing low
viscosity impression material ‘through the window’. (d) The completed impression.
 Prosthodontics

Figure 5. The finished upper and lower in situ.
The lower teeth on the left side were set in cross-
bite as there was a perceived need to increase
space for the tongue. Note the extrusion of the
lower anterior teeth.
Management options for the
fibrous anterior ridge are summarized in
Table 2.
Jaw registration
It is important to ensure that
there is minimal displacement of the denture
base during jaw registration. Although more
costly, a heat-cured acrylic resin, or other well-
fitting hard base, allows an assessment of the
available support and retention to be made
and facilitates this stage. The aim of this stage
is to allow provision of bilateral even contacts
in centric relation. When setting the upper
anterior teeth to avoid unwanted deflective
contacts from the lowers, it may occasionally
be necessary to position them in a crossbite
(Figure 5).
In spite of using careful
technique, support and retention may still be
compromised, so it is important to counsel
patients about this at the outset of treatment
and manage their expectations accordingly.
Bony exostoses
Palatal and mandibular tori
A torus is a benign outgrowth
consisting usually of dense cortical bone
covered by a thin layer of poorly vascularized
mucosa. Tori are most commonly present
in the palate but may also be seen in the
mandible and are an incidental finding.
They usually develop from the age of 30 to
50 and are thought to have both genetic
and environmental predisposing factors.31
Studies have shown the prevalence of tori to
be between 12 and 14% and, while they do
not in themselves cause symptoms, they can
make the denture construction difficult. This is
particularly true in edentulous patients where
full coverage of the palate is beneficial to
maximize the support, retention and stability
of the denture. The size, shape and position
of the torus will determine whether it is likely
to cause a problem (Figure 6). A flat torus can
usually be covered by a denture base with
light relief of the fitting surface. If the torus
is larger or lobulated, a decision needs to
be made as to whether to reduce surgically
or avoid coverage. A palatal torus which is
situated close to the junction of the hard and
soft palate may interfere with the posterior
palatal seal and require surgical removal.
Mandibular tori frequently
interfere with correct extension of the lower
complete denture so that their removal is
more likely to be warranted (Figure 7).
Enlarged tuberosities
Enlarged tuberosities, like tori, can
cause problems with correct extension of the
upper denture, resulting in a compromised
border seal. It has been proposed that
enlarged tuberosities, as with tori, may be
associated with genetic factors and increased
occlusal stress through parafunctional habits.32
Management of enlarged tuberosities will vary

Treatment Rationale Comments

Surgical

Reduction of fibrous tissue Reduce displacement of denture under load

Vestibuloplasty Allow increased extension of denture base Extensive resorption limits scope for
deepening sulcus

Prosthodontic

Selectively displaced impression Prevent distortion of fibrous tissue Mucostatic impression of fibrous ridge
may result in increased displacement
under load

Provision of lower RPD Provide even occlusal contacts to reduce Incentive to wear denture may be low. A
load on upper anterior ridge shortened dental arch with single unit
resin retained cantilever bridges may be
a more suitable option

Surgical plus prosthodontic

Upper implant stabilized prosthesis Maximize stability of the prosthesis and Limited bone availability may prevent
prevent displacement of the fibrous ridge implant placement without grafting.

Table 2. Summary of management options for the fibrous anterior ridge.

510 DentalUpdate July/August 2014

 Prosthodontics

according to: a
 Site, ie unilateral vs bilateral;
 Size of the tuberosity;
 Displaceability of the overlying mucosa.
If the tuberosity is relatively small
and the mucosa overlying it can be displaced,
it may be possible to negotiate the undercut
region without any special management
techniques. A larger, but unilateral undercut
tuberosity may be negotiated by adopting
a rotational path of insertion whereby the b Figure 7. Mandibular torus with buccal exostoses.
denture is first engaged into the undercut area Surgical removal will be necessary to allow
and rotated into the non undercut side. This correct extension of the denture base. (Courtesy
may require slight relief of the fitting surface of of Professor Paul Wright).
the denture but has the advantage of retaining
a
some mechanical undercut in addition to the
border seal. Bilateral undercut areas may be
blocked out on the master cast, if they are not
too big, so that a fully extended base can be
made (Figure 8). Alternative strategies include
the use of soft lining materials to engage the c
undercut areas33,34 with the risk of increasing
the bulk of the prosthesis; or underextending
the base with the risk of making an unretentive
denture.
b
Other bony prominences
Patients with severe resorption
of the mandible may demonstrate prominent
mylohyoid ridges and/or genial tubercles Figure 6. (a) Palatal torus in an edentulous patient
(Figure 9). Although not true exostoses, these which is anterior to the position of the posterior
denture border. It is usually possible to cover a torus
structures may nevertheless cause problems
of this size with some relief of the fitting surface.
with denture construction. In most cases,
(Courtesy of Professor Paul Wright). (b, c) Palatal
relieving the denture in the offending area will torus and enlarged tuberosities in an elderly patient
be adequate and surgical reduction is rarely requiring an upper denture. It will not be possible
indicated. A denture flange which overlies a to extend the denture onto the torus and surgical
sharp mylohyoid ridge typically causes pain removal would be very traumatic.
c
on chewing or swallowing. In order to relieve
the denture correctly, it is placed into the
mouth following the application of a thin layer
of pressure indicating paste. The denture is is empirical. Undergraduate teaching in
loaded on the occlusal surface of the molar removable prosthodontics is reducing,35 while
teeth and twisted from side to side, and it the population requiring complete dentures
is a good idea to warn the patient that this is getting older and perhaps more difficult to
may cause some discomfort. On inspection, treat. Skilful management of the ‘anatomically
the impingement of the mylohyoid ridge will difficult’ patients is required to maximize
be seen to be short of a correctly extended support retention and stability while ensuring
flange (Figure 10). This is an important point comfort. Special impression techniques or Figure 8. (a−c) Bilateral enlarged tuberosities
because the flange may unwittingly be the application of soft lining materials may in a patient with restricted mouth opening due
overtrimmed with a resultant reduction in be of use in selected situations. Oral surgery to scleroderma. Surveying and blocking out
stability of the denture. may occasionally be necessary so that a the undercut area on the master cast allowed
multidisciplinary route to care is adopted. construction of a fully extended base and
maintenance of peripheral seal. Care needs to be
Conclusion taken to ensure that the base does not interfere
Much of the evidence supporting
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July/August 2014 DentalUpdate 511
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Figure 9. Prominent mylohyoid ridges (black
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