Managing Problems in Complete Dentures

Managing Problems in Complete Dentures
Dent 445 Removable Prosthodontics (4) Dr Esam Alem T extbook Reference: Chapter 17
Complete Prosthodontics: Problems, diagnosis and management AA Grant, JR Heath, JF McCord p. 33-88
Managing Denture Problems

I. Direct from denture II. Indirect from denture III. Related to patients

I. Direct from denture
A. Related to denture surfaces B. Related to denture function C. Related to esthetics D. Related to phonetics

A. Related to denture surfaces
1. 2. 3. 4. Borders Fitting surface Polished surface Teeth
II. Indirect from denture III. Related to patients

1. Borders
a. b. c. d. Overextension Underextension Overcontoured flanges Undercontoured flanges

1. Borders
a. Overextension
SHORT TERM COMPLAINTS
LONG TERM

1. Borders
a. Overextension i. Immediate effect - Pain - Bleeding and ulcer - Loss of retention before functional movements - Loss of retention during functional movements - Seen as areas exposed through PIP

1. Borders
a. Overextension ii. Delayed (late) effect - Ulcer - Erythema (red area) - Fibroma - Hyperkeratinized mucosa - T MD - Loss of retention on functional movements
Managing overextensions
Method 1 Patient complaint
Let the patient point to the area
Problems with this technique:
Patient may not point correctly to the area Reductions are not controlled in amount or location Not all overextensions cab be detected by this method
Method 2 Indelible (Copier) pencil
Locate area of erythema or ulceration Mark it with copier (indelible) pencil Seat the denture and allow the copier pencil ink to imprint on the denture
Method 3

Locate area of tissue reaction lesion Place PIP / disclosing wax

Paste Wax Rubber
Perform functional movements in the affected area Trim the denture flange where the border is exposed through the disclosing wax Repeat until no PIP / wax is displaced
Note the ulcer associated with the denture border overlying the canine eminence.
PIP or disclosing wax is used to check the length of the denture borders. In this example it has been placed in a disposable syringe. Disclosing wax is tempered in a water bath. Apply PIP or disclosing wax to the dried denture border. Carefully insert the denture and mold the borders of the selected area.
Note the posterior palatal seal area: The bead is too deep and too sharp. Note the ulcer at the midline.
Other examples of commonly overextended areas

These flanges are too thick
Carefully adjust the denture flange as necessary. Reapply, border mold and adjust until areas of overextension are eliminated. These flanges are too long

1. Borders
a. Overextension i. Delayed (late) effect - Ulce rs unde r labia l f la nge Causes: Overextended Flanges Shorten Excessive overbite Adjust anterior occl. Habitual mastication in protrusive relationship train patient to masticate in CR
These flanges are too thick
These flanges are too long

1. Borders
b. Underextensions i. Immediate effect - Lo ss of retentio n bef o re f unctio nal mo veme nt - Lo ss of retentio n d uri ng f unctio na l mo veme nt
Managing underextensions
Method
Check for overextensions Check retention
Anterior retention Lateral retention Posterior retention
Add green stick to build in the area under suspicion Border mold with functional movements intra-orally Recheck retention Replace green stick with cold-cure acrylic (partial reline)
Anterior (labial flange) retention check Hold anterior teeth and pull denture down labially
Lateral (buccal flange) retention check Hold contralateral posterior teeth and rotate flange away from sulcus
Posterior (post dam) retention check Place finger palatal to anterior teeth and push upward to rotate denture down posteriorly
Posterior (hamular notch) retention check Press upwards on contralateral canine to rotate denture down posteriorly in hamular notch area

2. Fitting Surface
a. Lateral Ridge Slopes i. Nerve compression ii. Unfavorable undercuts b. Flat Areas i. Palatal rugae area ii. Palatal suture area c. Crest of residual ridges

2. Fitting Surface
a. Lateral Ridge Slopes i. Nerve compression - Inferior Dental Nerve - Mental Nerve

2. Fitting Surface

2. Fitting Surface

2. Fitting Surface
a. Lateral Ridge Slopes ii. Unfavorable undercuts

ii.
Managing undercuts
Leave engaged
No trauma A path of insertion present Minimal undercut
E.g. normal max. ant. and tuberosity undercuts Lingual undercuts in lateral wall of ling. pouch
Unfavorable Undercuts
Maxillary
Natural due to anatomy of ridges
T uberosities Premaxillary (anterior) area
Uncompressed extraction sockets
Mandibular
Natural
Anterior area Internal oblique ridge Mylohyoid ridge Mandibular tori
Uncompressed extraction sockets
Managing undercuts
Leave but partially block on cast
Minimal trauma A path of insertion is present Minimal undercut
Block undercut with dental stone before flasking and packing
Managing undercuts
Reduce one side
Minimal trauma Minimal undercut
Managing undercuts
Preprosthetic surgical removal or block-out and use implant-retained prosthesis
If undercut is severe If blockout/relief of denture will compromise retention If undercuts encircle more than 180
Reduce both sides without compromising retention

2. Fitting Surface
b. Flat Areas i. Palatal rugae area nasopalatine nerve compression ii. Palatal suture area thin mucoperiostium check post dam iii. Lateral palate posterior palatine nerve compression

2. Fitting Surface
c. Crest of residual ridges i. From ridge: Bone spicules, knife edge, impacted roots, impacted teeth, cysts, nerves, thin mucosa ii. From denture: Denture surface may include sharp prominences or irregularities iii. From occlusion: Heavy occlusal interferences

3. Polished surface
Finish borders with an acrylic bur. Remove excess resin beyond the land. Be careful to preserve the border width and contour.

Remove small particles of stone from the proximal areas with a brush wheel. The palatal portion should be about 3 mm thick (minimum 2 mm).
Remove all plaster or stone. Smooth the denture bases to the proper co ntour with your acrylic burs. Bubbles and other irregularities around the denture teeth can be rem oved with chisels or scrapers.
Check the bearing surfaces of the dentures for bubbles and sharp projections.
Use a very wet rag wheel wi th liberal amounts of wet pumice to polish the pala tal, lingual, labial and buccal areas. The periphery of the denture must also be carefully polished. Use the edge of the wheel as shown during polishing to avoid burning the acrylic resin. Do not overpolish and thereby loose the contours that were devel oped during festooning.
Polished dentures
Note that the borders are rounded and smooth, and the palate is highly polished and the proper thickness
Reexamine the tissue side of the dentures and carefully remove any bubbles present with a sharp instrument.
Be careful not to overpolish the occlusal or incisal surfaces of the denture teeth.
Prior to delivery the dentures must be soaked in water for 72 hours.
Do not over polish

4. Teeth
a. Cheek-biting b. T ongue biting c. Unfamiliarity w ith modifications

a. Cheek-biting Causes
Thin or overextended periphery (denture base material does not provide enough support for the cheek) Loss of tone of cheek musculature in old patients Insufficient inter-arch clearance between distal part of denture Inadequate horizontal overjet in molar region (posterior edge-to-edge occlusion)

a. Cheek-biting T reatment
Build out thin areas, or extend the short periphery Trim maxillary denture buccal to tuberosity and/or from over retromolar pad of mandibular denture Tooth positions
Re-set teeth in correct relationship Recontour and polish buccal surface of mandibular posterior teeth to create horizontal overjet

b. Tongue-biting Causes
Artifcial teeth positioned too far lingually Occlusal plane of is too low Large tongue : if lower posterior teeth missing for long time, tongue muscles will lose muscle tone and tongue will become broad and flattened. Tongue will regain normal contour with time


B. Related to denture function
1. Denture Instability
a. b. Looseness of mandibular denture Looseness of maxillary denture
2.
Denture Interference
a. During sw allow ing b. T ooth clicking

a. General looseness of mandibular denture i. Causes Error in occlusion (centric occlusion not in harmony w ith centric relation) occlusal plane too high underextension of periphery (deficient impression) Inability of patient to adapt and control denture Poor tongue position (retracted/guarded tongue position)

a. General looseness of mandibular denture i. T reatments Correct faulty occlusion by remount procedures and occlusal adjustment Reset teeth at low er occlusal plane Reliner/rebase denture providing proper extension

a. Looseness of mandibular denture i. While yaw ning or opening w ide ii. While rinsing iii. While talking

a. Looseness of mandibular denture i. While yaw ning or opening w ide
Manidible - While yawning or rinsing

Cause s Denture base too thick in buccal posterior area (masseter exerts forward force on posterior part of denture) Overextended in retromolar area (pterygomandibula r raphe interference) Treatm ent Reduce thickness of denture base Shorten denture until pterygomandibular ligament does not exert tension on posterior border when mouth opens wide
Mandible - While talking

Cause s Inadequate seal in lingual pouch area Lingual flange overextensions T r e at m en t Correct seal with reline Shorten overextensions until tongue does not interfere causing lifting up of denture and breakage of seal

b. Looseness of maxillary denture i. Occasional ii. When eating on sides iii. Approximately every 2 hours iv. While yaw ning/opening w ide v. While rinsing vi. While bending over vii. While talking viii. Looseness w hen occluding in centric relation
Maxilla occasional looseness

Cause s Underextension in localized area Faulty occlusion Overextension of peripheries Xerostomia Displacement of flabby tissues during impression Treatm ent Reline Correct occlusion Adjust denture Treat cause Modify impression technique to change primary denture bearing area
Maxilla when eating on sides

Cause s Non-yielding area in hard palatemidpalatine raphe (crestal ridge tissues yield under chewing stresses so denture rocks or see-saws across mid-palatal fulcrum) Incorrect tooth position (too far buccally) Chewing resistant foods Treatm ent Provide relief area over rigid area Rebalance in lateral excursions; reset teeth in correct relationship to ridge Instruct patient to maintain soft diet until mouth is conditioned to wearing dentures
Maxilla approx. every 2 hrs

Cause s Heavy mucinous saliva Incorrect tooth position (teeth too far buccally or labially) Improper incising habits Loss of posterior palatal seal (seal on palate; posterior limit not in hamular notches) Treatm ent Prescribe astringent mouth wash; regular cleaning of dentures; reduction of carbohydrate intake may help Train patient to masticate in centric relation
Maxilla - While yawning or rinsing

Cause s Denture base too thick in buccal posterior area (masseter exerts forward force on posterior part of denture) Overextended in retromolar area (pterygomandibula r raphe interference) Treatm ent Reduce thickness of denture base Shorten denture until pterygomandibular ligament does not exert tension on posterior border when mouth opens wide
Maxilla while bending over

Cause s Overextended in posterior palatal seal area Overextended in hamular notch area T r e at m en t Reduce thickness/extension of posterior palatal seal area Valsalva maneuver / pip
Maxilla while talking

Cause s Inadequate posterior palatal seal area Overextended in posterior region Treatm ent Reline posterior palatal seal Shorten posterior extension until soft palate does not lift upward and break contact with denture base
Maxilla in RCP
Cause s Incorrect occlusion Poor denture foundation (flabby tissues over ridge) Teeth set too far buccally / labially Centric occlusion not in harmony with centric relation Midpalatine suture fulcrum Treatm ent Correct occlusion Selective pressure impression / special impression / preprosthetic surgery Reset teeth Enlarge centric area Provide relief in area of midpalatine suture

a. Looseness of mandibular denture b. Looseness of maxillary denture
When swallowing
Cause s
Maxillary denture too thick or overextended in posterior region Mandibular denture too thick or overextended in posterior lingual flange area Insufficient VDO Excessive VDO Incorrect tooth position (posterior teeth set too far lingually tongue is crow ed)
T r e at m en t
Reduce thickness or adjust posterior area Reduce thickness or adjust posterior lingual flange area Increase VDO Reduce VDO Reset teeth
2.
Denture Interference
a. During sw allow ing b. T ooth clicking


C. Related to esthetics
1. 2. 3. 4. 5. Fullness under nose Depressed philtrum Upper lip sunken in Too much of the teeth are exposed Artificial appearance

1. Fullness under nose
a. Cause: labial flange of denture too long or thick b. T reatement: reduce flange length or thickness

4. Too much of the teeth are exposed
Causes: i. excessive VDO ii. Incisal plane too low iii. Cuspids and lateral incisors too prominent b. T reatment: i. Reduce VDO ii. Reset teeth at higher plane iii. Adjust a.
2.
Depressed philtrum
a. Cause: Labial flange too short b. T reatment: increase length or thickness of flange
3.
Upper lip sunken in

a. Cause: maxillary teeth set too far lingually b. T reamtent: reset anterior teeth labially
5.
Artificial appearance
4. 5.
Too much of the teeth are exposed Artificial appearance

5. Artificial appearance
a. Causes i. T echnique setup (teeth are too regular in alignment too perfect) ii. All teeth have same shape lack of individualization b. T reatment i. Individualization by rotating and shortening some teeth ii. Choose different but complimentary shades/ use staining techniques iii. Grind incisal edges and angles iv. Individualize gingival contour and color
Anterior Maxilla Pattern of Resorption Following extraction, resorption is from labial towards the lingual. Therefore anterior teeth should NOT be placed directly over the ridge.
Average Value Positions

Labial incisal position On average the distance from the center of the incisal papillae to the labial surface of the central incisor is 8-10 mm. This average influenced by the age and gender of the patient.
8
Average Value Positions

Maxillary incisal length On the average the position of the maxillary central incisor edge is 22mm measured from from the labial sulcus adjacent to the labial frenum. Visibility of the central incisor should be approximately 1.0 with an average length upper lip in a middle aged patient.
Female Young 8 Middle 7 Old 6
Male Young 6 Middle 5 Old 4
In older patients or in patients with longer lips the visibility decreases. In younger patients or with patients with shorter lips visibility increases
Tooth Length - esthetics Incisor length is important for those patients who have a significant display of anterior teeth. We normally expect to see approximately 2/3 3/4 of the facial surfaces of the maxillary anterior teeth when the patient smiles widely. However, the degree of display of maxillary anterior teeth varies greatly between individuals. An average high smile line is one where the patients upper lip lies approximately 6-7 mm above the incisal edge of the maxillary wax rim when the patient smiles or laughs. If a patient has an average high smile line 7 mm above the incisal edge, then an appropriate length of tooth to select for good esthetics would be: 7 x 3/2 = 10.5 mm
Tooth Length resorption of residual ridge In some cases the amount of residual ridge resorption will take precedence over the high smile line and esthetics when tooth length is concerned. In patients who have had recent extraction, the residual ridges are large because ridge resorption has not progressed significantly yet. When the maxillary anterior residual ridge is large then the overlying occlusal rim will be relatively short and there will only be limited height for the anterior teeth to be set. In such cases, shorter teeth are often selected to make setting easier without the need of trimming the root end (ridge-lap) end of the artificial teeth.


D. Related to phonetics
1. 2. 3. 4. 5. 6. Whistle S sound Lisp S sound (S sounds like Th) Upper and lower incisors contact during S/ Ch/ J sounds F sounds like V These/Those sound like Dese/Dose General speech difficulty
Phonetic Considerations
The anterior teeth, tongue, and lips act as a part of the valving mechanism which modifies the flow of air to produce speech sounds Linguopalatal sounds: s, sh are made by contact between the tip of the tongue and the palate at the rugae area with a small space for the escape of air Labiodental sounds: f v are produced by contact between the maxillary incisors and the posterior one-third of the lower lip (vermillion border) Labial sounds: p b if the lips are not supported properly by the teeth these sounds may be defective
Linguopalatal sounds: s
The s so und is made by co ntact between the tip of the tongue and the palate at the rugae area with a small space for the escape of air. If the space is too small a whistle usually results and if the space is too broad and thin, the s so und is replaced by the sh sound which sounds like a lisp. (1) This is affected by the shape and thickness of the denture base in the palatal regio n.
(2) The s and sh sounds also indicates whether the (anterior-posterior position) of the upper incisors is correct. If the patient says sh when he means to say s, then the teeth may be too far forward.
Linguopalatal sounds: s closest speaking space

(3) The s sound also indicates whether the patient has adequate freeway space or interocclusal clearance. When we speak, our upper and lower teeth do not normally contact each other. (They only contact during function and swallowing). During speech, our teeth come closest together (1.0 mm) during the pronunciation of the s or sibilant sounds. (They also come close together during ch and j sounds). During pronunciation of all other sounds, the space between the upper and lower teeth is larger than this. That is why we call the 1.0 mm space between the upper and lower teeth during speech the closest speaking space
Normal position
Teeth set too far palatally
Teeth set too far labially
If we dont give the patient enough freeway space during jaw relation records, then the patients denture teeth will start hitting each other when the patient pronounces the s sound.

1. Whistle S sound
a. Cause: i. Existence of too narrow an air space on the anterior part of the palate for the tongue (mis-shapen palate) ii. iii. b. Anterior teeth (i.e. central incisors set too far forward; increased horizontal overjet)

2. Lisp S sound (S sounds like Th)
a. Cause: i. Existence of broad air space on the anterior part of the palate ii. When anterior palatal air channel is obliterated iii. Anterior teeth placed too far palatally b. T reatment: i. Adjust thickness of anterior palatal area; reduce thickness of palatal acrylic if necessary ii. Reposition teeth further anteriorly if necessary
Anterior part of tongue is crowded by maxillary premolars set too far palatally Treatment Reshape palatal contour correctly to mimic underlying palatal contour (remove thick acrylic in rugae area if necessa ry) Correct overjet and anterior/premolar tooth positions if necessa ry
i.
ii.

3. Upper and lower incisors contact during S/ Ch/ J sounds
a. Cause: i. Vertical dimension of occlusion too great ii. Reduced horizontal overlap (low er anterior teeth set too far anteriorly) b. T reatment: i. Reduce vertical dimension of occlusion ii. Reset low er anterior teeth for increased horizontal overlap

4. F sounds like V
a. Cause: i. Upper anterior teeth set too inferior (long) ii. (Occasionally, upper anterior teeth too far palatal and inferior) b. T reatment: i. Reset upper anterior teeth in a more superior position (shorter)

Labial dental F & V sounds The f and v sounds indicate whether the length (superiorinferior position) of the upper incisors is correct. The upper lip contacts the the wet-dry line of the lower lip during speech production of f and v sounds. If the upper anterior teeth are set too long, then a v sound is made when the patient means to make an f sound.
I.
Direct from denture

5. These/Those sound like Dese/Dose
a. Cause: Upper anterior teeth set too far lingually b. T reatment: Reset teeth anteriorly
6.
General speech difficulty

a. Initial disturbance of speech is to be expected (especially for patients w ho are first-time denture wearers) b. Increased vertical dimension of occlusion c. Poor retention


II. Indirect from denture
A. B. C. D. E. F. G. H. I. Generalized discomfort Generalized soreness (pain) Generalized burning sensation Gagging Temperomandibular joint pain Fatigue of muscles of mastication Difficulty during mastication Excessive salivation Unpleasant taste

A. Generalized discomfort
1. Cause: i. Improper occlusion ii. Centric occlusion not in harmony w ith centric relation iii. Excessive vertical dimension of occlusion T reatment i. Correct occlusion ii. Enlarge centric contact area iii. Reduce vertical dimension of occlusion

B. Generalized soreness (pain)
1. Cause: i. Heavy biting force strong musculature ii. Excessive vertical dimension of occlusion (VDO) iii. Locked occlusion (no freedom of movement in CR) iv. Failure to provide freedom for Bennett movement (soreness usually on working side only) v. Improperly processed base acrylic material Treatment i. Reduce buccolingual width of teeth, reduce VDO, use soft lining material if necessa ry) ii. Enlarge centric relation contact area to allow some freedom of movement in centric relation. Possibly change occlusal scheme from anatomic to flat monoplane occlusion iii. Rebase acrylic of denture if necessa ry
2.
2.

C. Generalized burning sensation
1. 2. 3. 4. Common during menopause in middle-aged females Allergy to acyrlic resin (but this condition is very rare) remake material using alternative polymers or metal base Dentures incorrectly processed (excessive free unpolymerized monomer remains) rebasing may be necessary Pressure on nerve
a. Maxillary anterior ridge generalized burning sensation due to pressure on anterior palatine nerve relieve area over incisive papilla b. Maxillary premolar/molar/tuberosity generalized burning sensation relieve area greater+lesser palatine nerves c. Mandibular anterior region generalized burning sensation relieve area over mental foramen

D. Generalized gagging
1. Alteration of the vertical dimension of occlusion: a. Decreased vertical dimension results in crowding of the tongue and soft tissues gagging b. Increased vertical dimension results in loss of freeway space which can cause exhaustion and spasm of the levator and tensor veli palatini muscles of the palate gagging

II.
E.
1.

F. Fatigue of muscles of mastication Excessive VDO decrease VDO 2. Reduced VDO increase VDO
1.
Indirect from denture

Temperomandibular joint pain
Cause: a. Insufficient VDO b. Centric occlusion not in harmony w ith centric relation c. Arthritis d. T ruama
G. Difficulty during mastication

Most patients w ho have trouble chew ing at first, have not had posterior teeth for several years. T he patient has lost the neuromuscular skills required to use the posterior teeth in grinding the food. T he patient should be informed that a reasonable period of time is necessary to relearn the masticatory process. T he length of time w ill depend, to some extent, on the patients innate neuromuscular coordination and on the duration of the edentulous state.
2.
Treatment:
a. Increase VDO b. Make new centric relation record (clinical remount) correct occlusion c. Refer to physician d. Remove dentures and treat w ith analgesics

F. Difficulty during mastication
1. Food under denture due to movement, flabby ridge, or poor adaptation to tissues and general lack of retention Blunt cusps or w orn dow n cusps of teeth Increase or decrease in VDO Pain and soreness under denture prevents patient from chew ing normally Occlusal disharmonies Excessive bulk/thickness of denture Patient takes too much food into the mouth at once T he patient should be adv ised to avoid extremely tough, stringy, or sticky food, especially during the initial period of adjustment

G. Excessive salivation This is often a normal physiological response to a foreign body by the autonomic nervous system. It usually persists for a short period of time and then secretion returns to normal. H. Unpleasant taste
1. 2. 3. If metal base is used (metallic taste) If denture is not kept clean If denture is incorrectly polymerized, residual monomer may create bad taste
2. 3. 4. 5. 6. 7. 8.


III. Related to patients
A. Patient psychology: remember Houses classification: which patient is most likely to find fault with the denture? Philosophical, critical, skeptical, orindifferent. B. Disabilities: neuromuscular, Parkinsons, etc. C. Medical conditions D. Systemic medications

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Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

II. Indirect from denture III. Related to patients

Managing Denture Problems

Managing Denture Problems

SHORT TERM COMPLAINTS

Managing Denture Problems

Managing Denture Problems

Locate area of tissue reaction lesion Place PIP / disclosing wax

Other examples of commonly overextended areas

Managing Denture Problems

These flanges are too thick

These flanges are too long

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Uncompressed extraction sockets

Uncompressed extraction sockets

Reduce both sides without compromising retention

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Prior to delivery the dentures must be soaked in water for 72 hours.

Do not over polish

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

II. Indirect from denture III. Related to patients

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

Manidible - While yawning or rinsing

Mandible - While talking

Managing Denture Problems

Maxilla occasional looseness

Maxilla when eating on sides

Maxilla approx. every 2 hrs

Maxilla - While yawning or rinsing

Maxilla while bending over

Maxilla while talking

Managing Denture Problems

Managing Denture Problems

Managing Denture Problems

II. Indirect from denture III. Related to patients

Managing Denture Problems

Managing Denture Problems

Upper lip sunken in

Too much of the teeth are exposed Artificial appearance

Managing Denture Problems

Average Value Positions

Average Value Positions

Female Young 8 Middle 7 Old 6

Male Young 6 Middle 5 Old 4