PRACTICE prosthetics Identification of complete denture problems: 10 a summary J. F. McCord,1 and A. A. Grant,2
In this part, we will discuss: In this section, guidelines to the diagnosis of • Factors resulting in complete denture problems are presented in discomfort associated tabular form. Suggestions to the management with dentures of these problems are listed. • Factors resulting in looseness of the dentures • Factors associated with problems of adaptation 1*Head of the Unit of Prosthodontics, 2Emeritus Professor of Restorative Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, here is, inevitably, the potential for problems Factors causing problems may be grouped, Manchester M15 6FH Tto arise subsequent to the insertion of com- essentially into four causes. *Correspondence to: Prof. J. F. McCord plete dentures. These problems may be transient email: [email protected] • Adverse intra-oral anatomical factors eg REFEREED PAPER and may be essentially disregarded by the patient atrophic mucosa. © British Dental Journal or they may be serious enough to result in the • Clinical factors eg poor denture stability. 189: 2000; 128–134 patient being unable to tolerate the dentures. • Technical factors eg failure to preserve the
Table 1 List of factors resulting in discomfort related to the impression surface of dentures
Symptoms/clinical findings Cause Treatment
Related to impression surface Pearls or sharp ridges of acrylic on the fitting Locate with finger, or snagging dry cotton wool Discrete painful areas surface arising from deficiency in fibres. Use disclosing material to assist locality to laboratory finishing ease denture
Pain on insertion and removal, possibly Denture not relieved in region of undercuts Use disclosing material to adjust in region of inflamed mucosa on side(s) of ridges ’wipe off’. Exercise care as excessive removal may reduce retention. Also clinician should only insert denture and then remove it - the patient should not occlude as this may confuse an occlusal fault with support problems
Areas painful to pressure Pressure areas resulting eg from faulty Use disclosing material to accurately locate area impressions, damage to working cast, to be relieved. If severe, remake may be required. warpage of denture base. Consider also Consider removal of root residual pathology (eg retained root), lack of relief for active frena, non-displaceable mucosa over bony prominence (eg torus)
Over-extension of lingual flange. Painful Over-extended lower impression: Determine position and extent of over-extension mylohyoid ridge; denture lifts on tongue instructions to laboratory not clear or using disclosing material and relieve accordingly protrusion; painful to swallow non-existent
Generalised pain over denture-supporting Under-extended denture base - may be the Extend denture to optimal available denture area result of over-adjustment to the periphery, support area. If insufficient FWS, remake may be or impression surface. Check for adequacy required of FWS
Lack of relief for frena or muscle attachments; Peripheral over-extension resulting from Relieve with aid of disclosing material. Care with pinching of tissue between denture base and impression stage and/or design error. adjustment of post dam - removal of existing seal retromolar pad or tuberosity. Sore throat, Palatal soreness as post dam too deep and its replacement in greenstick prior to difficulty in swallowing permanent addition may be required
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Table 2 List of factors resulting in discomfort - relating to occlusal and polished surfaces of dentures
Symptoms/clinical findings Cause Treatment
Related to occlusal surfaces Anterior prematurity or posterior prematurity, Determine where occlusal prematurities exist. Pain on eating in presence of occlusal incisal locking, lack of balanced articulation Adjust occlusion by selective grinding. If severe imbalance (no support problems) error remount using facebow and new interocclusal records
Pain lingual to lower anterior ridge If no over-extension present, look for Mark deflecting inclines of posterior teeth with thin protrusive slide from RCP to ICP articulating paper. If slide exceeds half a cusp width, re-register and reset
Pain and/or inflammation on labial aspect of If no impression surface defect, may be lack Reduce incisal vertical overlap. If appearance lower ridge of incisal overjet causing incisal locking compromised, resetting the incisors may be required
Pain about periphery of dentures possibly Vertical dimension of occlusion more than If excess less than 1.5 mm, grind to provide FWS. accompanied by pain in masseter and patient can tolerate If greater than 1.5 mm, re-register to reset dentures posterior temporalis muscles (classically pain at new OVD increases as the day progresses)
Cheek and or lip biting For cheeks - likely that functional width of For cheek biting, restore functional width of sulcus sulcus was not restored. and/or reset. For lips, grind lower incisors to For lips - poor lip support/inadequate provide a more appropriate incisal guidance anterior horizontal overlap angle
Tongue biting Lack of lingual overjet - teeth generally Remove lower lingual cusps, or reset teeth placed lingual to lower ridge
Related to polished surfaces Flange on buccal aspect of tuberosity too Use disclosing material to accurately define area Pain at posterior aspect of upper denture on thick and constraining coronoid process involved, relieve and repolish opening
peripheral roll on a master cast. a logical and systematic way. That is to say, an • Patient adaptional factors. adequate history of the problem must be obtained and a careful examination of the By far the most critical factors are the patient mouth carried out so that an accurate diagno- adaptional factors. Many patients with positive sis can be made, and an appropriate treatment stereotypes may overcome errors of prescrip- plan devised. tion. Some patients, however, are unable to Without doubt listening to the patient (as adapt physically and/or psychologically to den- their difficulties are described) is the most tures that satisfy clinical and technical prostho- important first step in the process, and its dontic norms. Clearly it would be in the best importance cannot be overemphasised. interests of the clinician and the patient to deter- Because of the plethora of potential com- mine this at the assessment stage, and was plete denture problems, this section is largely referred to in Part 2. confined to those that are most commonly The prescribing clinician is responsible for encountered at the time of insertion of planning complete dentures after diagnosing replacement dentures or during review potential problems; be they anatomical, appointments in the days and weeks after physiological, pathological or emotional. insertion. For a comprehensive overview of Once a denture-wearing problem becomes the diagnosis and management of complete apparent, it is important that it is addressed in denture problems, readers are referred to
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Table 3 List of factors resulting in discomfort - factors with possible systemic associations. Some of these conditions may occur several months post insertion
Symptoms/clinical findings Cause Treatment
Burning sensation over upper denture Burning mouth syndrome often seen in Correction of any denture faults, may require supporting tissues, but may involve other middle-aged or elderly females. Denture multivitamin/nutrition advice and treatment. intra-oral tissues, eg tongue. faults must be excluded, also general Possibly antidepressant therapy. Refer to organic and pyschogenic factors Consultant in Oral Medicine
Beefy red tongue, possibly glossodynia Vitamin B12/folate deficiency Refer for medical treatment
Frictional lesions related to dentures, Xerostomia, commonly side effect of Where some saliva flow is present, sugar-free mucosa may adhere to probing finger, prescribed drugs citrus lozenges may help. Where there is an may be complaint of dry mouth obvious paucity of saliva, artificial saliva may be considered
Tongue thrusting. Empty mouth ’chewing’. May have neurological or psychological Difficult to manage. Treatment may be required Often seen in elderly patients aspects. Possibly drug related to include occlusal adjustment and/or occlusal pivots
Presence of herpetiform ulcers in mouth Herpes simplex or Herpes zoster virus. Dentures merely coincidental to the condition. History and distribution of lesions to confirm May be useful to suggest preventive remedy (eg acyclovir) for some sufferers
Painful ’click’ related to TMJ on opening TMJ pain dysfunction syndrome may be If denture faults present, careful correction and/or closing mouth and/or tenderness related to rapid change on OVD (either required with special care to registration and of muscles of mastication gross increase or decrease) on production vertical dimension of new denture. May have psychological aspects, occasionally part of general joint disease
Patient complains of allergy to denture Rare symptoms may relate to higher residual If excess residual monomer detected, rebase material monomer content of acrylic denture using controlled heat cure cycle. May need to consider remaking denture using polycarbonate resin
Painless erythema of mucosa related to Denture-related stomatitis. Often has a Best to leave denture out until condition clears, support of (usually) upper denture, may be frictional element due to ill-fitting denture then remake. If not possible, correct denture accompanied by angular cheilitis plus opportunistic candidal infection. faults, eg using occlusal pivots, regularly Occasionally related to iron or folate supervised and replaced tissue conditioners deficiency prior to remake. If angular cheilitis present, combinations of antifungal and antibacterial agents (eg miconazole) useful
standard prosthodontic texts. Discomfort associated with dentures Problems reported by patients shortly after Many patients experience some discomfort for provision of replacement dentures include dis- a period of up to a few days following receipt of comfort, looseness or general problems in new or replacement dentures. The great major- relation to adaptation. Some of these prob- ity of patients achieve comfortable co-exis- lems/difficulties may have a very large number tence with their appliances following a short of possible causes, and, indeed, can be multi- period of adjustment to the new conditions. factorial in origin. For simplicity the problems This can be greatly assisted by a careful, will be discussed in the order they tend to detailed explanation of any difficulties that the occur most frequently. operator might anticipate. In the following tables, a list of causes and For some, however, especially where poten- suitable forms of treatment to address the prob- tial problems were not identified at examina- lems are summarised. tion or at the time of insertion, the consequent
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Table 4 List of factors resulting in looseness of dentures - arising from decreased retention forces
Symptoms/clinical findings Cause Treatment
Lack of peripheral seal Border under-extension in depth
Border under-extension in width. Add softened tracing compound to relevant border, mould digitally Often a particular problem in and by functional movements by patient. Replace compound with disto-buccal aspects of upper acrylic resin. As a temporary measure a chairside reline material periphery which may be displaced may be used as described above by buccinator on mouth opening.
Posterior border of upper Check border is correctly sited on fixed tissue at junction with mobile denture tissue of soft palate. Trace thin string of softened tracing compound along impression surface of posterior border and seat denture firmly in mouth. Replace compound with acrylic resin. For temporary solution, use butymethacrylate resin as above
Inelasticity of cheek tissues Consequence of ageing process; Mould denture borders incrementally using softened tracing- scleroderma, submucous fibrous compound as functional movements are performed - aim to slightly under-extend depth and width of denture periphery. Repeated treatment may be required as inelasticity progresses
Air beneath impression surface. Deficient impression. Damaged Reline if design parameters of denture satisfactory, otherwise remake Denture may rock under finger cast. Warped denture. as required. Ensure that areas of heavy contact between denture and pressure. May see gap between Over-adjustment of impression tissues are relieved prior to impression making. Where change in periphery of flange and ridge. surface. Residual ridge resorption. tissue fluid distribution is suspected check medication (eg diuretics) Occlusal error subsequent to Undercut ridge. Excessive relief posture (eg heart failure) lack of recovery of tissues from effects of old warpage chamber. Change in fluid denture prior to working impressions being obtained. Stabilise fluid content of supporting tissues content of tissues and use minimal pressure impression method
Xerostomia Reduces ability Medication by many commonly Design dentures to maximise retention and minimise displacing to form a suitable seal prescribed drugs, irridation of forces. Prescribe artificial saliva where appropriate head and neck region, salivary gland disease
Neuromuscular control Basic shape of denture incorrect, Correct design faults by, eg removal of lingual cusps of posterior teeth. Essential for successful lower molars too lingual; occlusal Flatten polished lingual surface of lower from occlusal surface to denture wearing: speech plane too high: upper molars periphery, fill sulci to optimal width. May require remake to optimal and eating difficulties occur buccal to ridge and buccal flange design. Use information from successful previous denture if not wide enough to accommodate available. Denture adhesives may be deemed to be necessary this; lingual flange of lower convex. Patient of advanced biological age, infirm
discomfort can be prolonged. Looseness of dentures In addition, discomfort may arise some time Looseness of dentures (Tables 4, 5 and 6) is after apparently successful prosthodontic pro- more commonly associated with the lower den- vision as a result of intra-oral or systemic ture, and may be referred to by patients as their changes or of denture wear or damage. denture ‘rocking’, ‘falling’ (complete upper) or Discomfort is most frequently — but not ‘rising’ (complete lower), ‘shifting’ or some- exclusively — associated with the lower den- times that they ‘feel too big’. ture supporting area. In simple terms, retention and stability of The Tables (Tables 1, 2 and 3) summarise complete dentures may be likened to a simple commonly experienced sources of discom- balance ie on one side retaining forces and on fort, and means of addressing the causative the other displacing forces. If the latter exceed factors. the former, instability/looseness will arise. It
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Table 5 List of factors resulting in looseness of dentures: arising from increased displacing forces
Symptoms/clinical findings Cause Treatment
Denture borders If buccal to tuberosities, denture Slightly under-extend denture flange Over-extension in depth displaces on mouth opening, or and accurately mould softened Slow rise of lower denture when cheek soreness occurs. Thickened tracing compound. Check borders mouth half open, line of lingual flange enables tongue to of record rims and trial dentures at inflammation at reflection of sulcal lift denture; thick upper and lower the appropriate stages. Deep post tissues; ulceration in sulcal region. labial flanges may produce dam to be cautiously reduced and Deep post dam on upper base displacement during muscle denture worn sparingly until may cause pain, ulceration activity inflammation clears
Overextension in width Design error Reduce over-extension. Use Cheeks appear plumped out. In disclosing material to determine lower, the buccal flange may be what is excessive palpated lateral to external oblique ridge
Poor fit to supporting tissue Poor/inappropriate impression Reline if all other design parameters Recoil of displaced tissue lifts technique especially in posterior satisfactory, otherwise remake. denture lingual pouch area Ensure denture is removed from mouth 90 mins prior to impression
Denture not in optimal space Molars on lower denture lingual Remove lingual cusps and lingual to ridge, optimum triangular surface from relevant area, repolish. shape of dentures absent If triangular form not restored, reset teeth or remake dentures Posterior occlusal table too Narrow posterior teeth and/or broad, causing tongue trapping remove most distal teeth from dentures. Reshape lingual polished surface Thick lingual flanges encroaching Thin lower labial flange, ensure on tongue space, causing lifting. optimal extension to retromolar Excess lip pressure to lower pads to resist displacement, reset anterior aspect - teeth anterior anterior teeth if necessary to ridge, thick periphery Usually requires remaking denture Excess pressure from upper lip to upper denture arising from teeth too labially sited to acute naso-labial angle; or failure to adequately seat denture during relining impression procedure
must be stressed, however, that the fulcrum is the patient, or rather the patient’s ability to Retaining forces Displacing forces adapt to dentures — this is less easy to antici- pate. This is illustrated in Figure 1, which is a line drawing of factors influencing complete denture stability. Patient’s ability to control dentures can increase apex Problems relating to an inability to adapt of fulcrum and stability to dentures There are a variety of symptoms which may be Fig. 1 Factors influencing complete denture stability functionally-related (ie eating associated prob-
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Table 6 List of factors resulting in looseness of dentures - arising from increased displacing forces - occlusal and anatomical factors
Symptoms/ Cause Treatment clinical findings
Occlusal errors Uneven tooth contact causing Adjust occlusion until even initial contact ttilting of dentures and prevents in RCP obtained. If gaps between teeth even seating of loosened exceeds 1.5 mm reset teeth or remake appliances dentures. For gaps less than 1.5 mm it may still be necessary, in the interest of accurate diagnosis, to remount the dentures, as a patient’s mouth may be too tender to permit chairside adjustment. ICP and RCP not coincident Adjust occlusion for coincident ICP/RCP - disrupts border seal and contact. If error is greater than half width prevents accurate reseating of cusp, all teeth on at least one denture need resetting. Lack of freedom in ICP Remount dentures on adjustable (occlusal-locking) dentures will articulator and adjust area of occlusal shift on supporting tissues for contact. Allow 1.5 mm of anterior those patients with poor control movement from RCP. May use cuspless of mandibular movements teeth where appropriate
Ulceration labial to lower Excessive vertical overlap of Reduce height of lower anteriors. ridge anterior teeth. Lack of balance Aesthetic problems may necessitate and anterior tooth contact may resetting of teeth cause tilting, soreness in lower ridge Last mandibular molars placed Remove most posterior teeth from denture too far posteriorly and lie over retromolar pad or ascending part of ramus. Occlusal contact on this ’inclined plane’ causes denture to slip forward Occlusal plane/s not Usually requires teeth to be reset or orientated appropriately dentures to be remade and masticatory forces tend to move dentures over supporting tissues
Fibrous displaceable ridge Masticatory forces tend to Reline after removal of acrylic from cause denture to sink into impression surface until no contact with and tilt towards supporting displaceable tissue, provide many vent tissues holes, low viscosity impression material, maximise posterior border seal
Bony prominence covered Denture rocks over prominence Remove acrylic from impression surface by thin mucosa (eg tori) which may be covered with where disclosing material shows inflamed tissue excessive loading of supporting tissues. Do not create excessive relief or loss of retention may result
Non-resilient soft tissue Does not adapt to impression Reline dentures to obtain optimal border surface of denture reducing extensions in depth and width, use low support and retention factors viscosity impression material
Pain avoidance mechanisms Use of excessive amounts of Eliminate the cause of pain fixative, or self-applied reline material, or even cotton wool, to attempt to relieve contact with supporting tissues
lems, speech etc), psychologically-related or A brief list of factors affecting adaptation to may relate to patience. Clearly there is a need to dentures including their causes and modes of diagnose the former at the planning stage of treament are listed in Table 7. treatment and to avoid the latter by virture of trial denture visits which focus on the Summary functional and aesthetic components of the This chapter has attempted to summarise in a compete dentures. tabular form a list of factors that are commonly Some of the psychologically-related prob- found at recall visits. The tables themselves are lems may be recognised at an early stage but self-explanatory and serve as a ‘useful tip’ list. even if psychological assessments are taken, not For more detailed lists, readers are referred to all are infallible. standard prosthodontic text.
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Table 7 List of denture problems associated with problems of adaptation
Symptoms/clinical findings Cause Treatment
Noise on eating/speaking May be lack of skill with new Where unfamiliarity present, May be apparent on first insertion dentures, excessive OVD, occlusal reassurance and persistence or may appear as resorption interference, loose dentures, or recommended. Address specific causes dentures to loosen poor perception of patient to faults or remake as required denture wearing
Eating difficulties Unstable dentures. Check that Construct dentures to maximise Dentures move over supporting retentive forces are maximised retention and minimise displacing tissues and displacing forces minimised forces and all available support has been used
’Blunt teeth’ Broad posterior occlusal surfaces Where non-anatomical teeth used, which replaced narrow teeth on careful explanation of rationale is previous denture. Non anatomical required, may be possible to type teeth used where cusped teeth reshape teeth. Routine use of previously used narrow tooth moulds recommended.
’Jaws close too far’ Lack of OVD, so that mandibular May increase up to 1.5 mm by elevator muscles cannot work relining but if deficiency is greater, efficiently remake denture
’Cannot open mouth wide enough Excessive OVD Can remove up to 1.5 mm from for food’. May be speech occlusal plane by grinding, but if problems and facial pain more is required, remake dentures especially over masseter region
Speech problems Cause may not be obvious. May Check for vertical dimension Uncommon, but presence is of be unfamiliarity - check that accuracy, and that vertical incisor great concern to patient. May problem not present with old overlap not excessive. Palatal affect sibilant (eg s), bilabial dentures contour should not allow excessive (eg p,b), labiodental (eg f.v) tongue contact or air leakage - assess using disclosing paste over denture palate while sound is made. NB It is recommended that the patient’s speech is assessed at trial insertion visit
Gagging May be loose dentures, thick distal Construct dentures to maximise May be volunteered by patient border of upper denture: lingual retention and minimise displacing prior to treatment, or apparent at placement of upper posterior teeth forces. Use ’condition’ appliance commencement of treatment or on or low occlusal plane causing eg fully extended base for home insertion of denture contact with dorsal aspect of use. Psychological assessment if tongue indicated
Appearance Patient failed to comment at trial Accurate assessment of patient’s Complaints may arise from patient stage, or has subsequently been aesthetic requirements. Ample time or relatives. Common complaints swayed by family or friends. for patient comments at trial stage. include: shade of teeth too light or Perhaps the change from the old Use any available evidence to dark; mould too big/small; denture to the replacement denture assist - photographs, previous arrangement too even or irregular is too sudden/severe dentures. Consider template or lacking diastema prosthesis
Too much visibility of teeth Level of occlusal plane Accurate prescription to laboratory unacceptable, teeth placed on via optimally adjusted occlusal rim upper anterior ridge and no/poor lip support
Creases at corners of mouth Labial fullness and anterior tooth Adjust tooth position as appropriate. position may be inaccurate. OVD If OVD problem, re-register jaw may be inadequate relations
Colour of denture base material Patient’s skin colour not taken into Remake using suitable base material ’unnatural’ account in determining colour of base material
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