DentureProsthodontics
J Fraser McCord Philip Smith and Sachin Jauhar
Complete Dentures Revisited Abstract: The aim of the article is to assist practitioners in the diagnosis and management of complete denture problems by addressing the problems from a theoretical viewpoint and in a clinically diagnostic way. Clinical Relevance: To assist practitioners and undergraduates to understand the clinical basis of complete denture prosthodontics. Dent Update 2014; 41: 250–259
In 1984, Applebaum wrote:1 “...a man with no eyes cannot see, a man with no legs cannot run but a man with no teeth expects to eat and chew with dentures as well as he did when he had natural teeth.” While the second statement has since been disproved, via prostheses, this aphorism is still apt when complete dentures are considered. It underlines the importance of appreciating the contribution the patient can make to the success of dentures, in addition to the overall value of the dental team operating optimally. This is demonstrated in Figure 1, which summarizes the four essential factors involved in creating a good outcome for complete denture treatment. The foremost is of course the patient and, unless the patient is accepting of her/his edentulous state and,
J Fraser McCord, BDS, DDS, FDS DRD, RCS(Ed) FDS(Eng), FDS RCPS(Glas), FCD(HK) CBiol, FSB, Retired Professor, Stockport, Philip Smith, BDS, PhD, FDS DRD, MRD RCS(Ed), FDS(Rest Dent) RCS(Ed), Senior Lecturer in Restorative Dentistry, Liverpool Dental School and Sachin Jauhar, BDS, MSc, MFDS FDS(Rest Dent), Consultant in Restorative Dentistry, Glasgow Dental School, UK.
250 DentalUpdate
Clinical Skills
Dental Staff
Patient Attitude and Skill
Technical Skills
Figure 1. The four basic components of the denture team. All four must contribute optimally for optimal results.
further, is capable of some denture control, then a favourable outcome is doubtful. Experienced clinicians will recall delivering prosthodontically acceptable dentures
which patients cannot tolerate; they will also doubtless recall examining patients who have coped, or are coping quite well with dentures which fly in the face of conventional April 2014
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 30, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
DentureProsthodontics
(prosthodontic) wisdom. The importance, therefore, of determining the expectations and denture-wearing history cannot be under-emphasized. The purpose of this article is to give guidelines as to the identification and diagnosis of complete denture problems.
Diagnosis of complete denture problems In their fine articles outlining the basics of complete denture prosthodontics, in 1983 Jocobsen and Krol listed and defined the three principal features as being: 2 1. Support: that property of the denture-bearing tissues which resists movement of the denture towards these tissues. 2. Retention: the resistance to displacement of the denture base away from the ridge (this might more appropriately be termed the peridenture tissues). 3. Stability: the resistance of the dentures to horizontal or rotational forces (perforce, this is a paradigm of muscle and occlusal harmony or ‘balance’). While all three of the above have implications on function, there are, additionally, several other areas which need to be considered: Appearance: while aesthetic dentistry has developed into an apparent subspecialty, this invariably falls into the domain of Operative Dentistry and the art of complete dentures has received scant attention since the days of Frush and Fischer3 (1956–1959). More recent reviews, by Smith and McCord4 and Critchlow et al,5 mention the need to involve the patient in formulating the appearance, even as far as allowing the patient to take the try-in home for approval (if he/she so desires). Unfortunately, no hard and fast rules apply and, in 2012, Cooper et al6 demonstrated significant differences between aesthetic perceptions among dentists, technicians and patients and also recommended that the ‘individual variability in patient response should be taken into account during treatment planning’ of complete dentures. Miscellaneous: this covers a variety April 2014
of factors such as allergy, xerostomia, atypical pain and stomatitis/angular cheilitis and TMJ Pain Dysfunction syndrome; although some of these affect function directly, there may be other symptoms which affect success of the dentures indirectly. Intrinsically, there are objective normative means by which denture problems may be diagnosed and also indirect means via anamnestic symptoms related to the clinician. For simplicity, objective normative means will be confined to support, retention and stability. Guidelines to deductions from anamneses will also be presented in tabular form.
Figure 2. This shows a typical ‘flabby’ ridge (arrowed) which presents support problems that have an impact on (upper) denture stability.
Theoretical recognition of complete denture problems Recognition of support problems
It is not the purpose of this article to carry out a resumé of the oral and facial anatomy relevant to complete denture prescription; nevertheless, it could be argued that this facet should be the easiest for the practitioner to identify. The absence of well-defined ridges means that, in theory, there is less denture-bearing tissue to carry the functional loads and this should highlight problems of support. Careful examination of the denture-bearing areas of both arches is therefore required but this does not mean a reliance on visual scanning. This will give little meaningful information on the ability of the denture-bearing tissues to withstand pressure7 (although it may draw the clinician’s attention to potential problems (Figure 2). Further assessment, for example by digital pressure over the dental-bearing areas, is therefore essential to identify where problems are (Figure 3). This will help the clinician to plan which impression material to use (vide infra) in addition to helping her/him to prescribe appropriate relief if required, eg over a torus or bony prominence (Figure 4). Recognition of retention problems
Retention of complete dentures is principally achieved via a peripheral seal; anything which
Figure 3. This shows areas of blanched tissue which indicate potential support problems which may be detected on palpation.
Figure 4. This shows the presence of a torus and also a spur of bone near the (left) canine area.
Figure 5. The presence of a muscle attachment on the ridge (arrowed) means that a peripheral seal is impossible. Stability will also be compromised.
DentalUpdate 251 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 30, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
DentureProsthodontics
prevents/impairs the potential for a peripheral seal therefore should be identifiable as a potential problem in the successful prescription of complete dentures. High muscle attachments, which are attached to the crest of a ridge, therefore will not only affect stability of a denture, but will make the achievement of a peripheral seal impossible (Figure 5). Similarly, the presence of a palatal fissure in the postdam area will present problems which will require modification of the master cast (vide infra) (Figure 6). In the same way that digital pressure is recommended in the identification of support problems, it is recommended that the clinician determines the relative displaceability of the tissues of the post dam, as there tends to be more glandular and connective tissue laterally than there is centrally (Figure 7). Although it has been stated that the principal factor in retention is peripheral seal, proximity of fit of the denture base to the tissues is also of importance, as is surface tension; factors influencing these may also therefore affect the retention of a complete denture. This will be dealt with later.
Recognition of stability problems
As was described earlier, stability of complete dentures, if achieved, is a paradigm of muscle balance and occlusal balance. The achievement of successful stability is, in the opinion of the authors, the single-most difficult thing for a clinician to achieve. While careful impression techniques may ensure a good peripheral seal, eccentricities of muscle form may displace a proficiently made denture. On the other hand, patients with neuro-muscular diseases/ conditions may have uncontrollable tremors which make it almost impossible to achieve acceptable muscle balance. While not all occlusal problems may be overcome, each clinician should be able to identify where occlusal tables are too long (Figure 8) and too broad (Figure 9). In addition, where prosthodontic guidelines are disregarded and inappropriate occlusal planes are prescribed, the result can be instability
252 DentalUpdate
caused by clinical displacement of the mandibular denture in accordance with the principles of an inclined plane (Figure 10). It is perhaps prudent here to indicate that, while the authors accept that it is highly unlikely that clinicians will be able to prescribe balanced articulation clinically, the minimal requirement, prosthodontically speaking, for complete dentures is balanced occlusion in Retruded Contact Position (RCP). As instability occurs when spaces occur between dentures, then the concept of balanced articulation was introduced as a means of improving stability. This should be achievable on all cases on an articulator. Sadly, semiadjustable articulators do not equate to the ginglymo-diarthrodial TMJ apparatus of patients and true balanced articulation is probably achieved only rarely. This, however, should not mean that the clinician does not aspire to achieve it! In addition to the above, good common sense and careful historytaking might alert the clinician to the potential for denture-wearing problems. Figure 11 shows a patient who obviously wears spectacles. The pressure of the spectacles on the keratinized tissues on the bridge of the nose would lead one to be sceptical about the ability of the (non–keratinized) tissues overlying the residual ridges to withstand robust oral function; this is also a useful guide to the biological age of the patient. The mention of function does raise the important question of what functions are being sought. If we include appearance as a function (strictly speaking it is not), then there are four principal functions of complete dentures: 1. Speaking; 2. Eating (chewing and clenching); 3. Swallowing; 4. Appearance. Although the diagnosis of these problems in these areas will be dealt with later, it is important to determine the functional needs of a patient before commencing treatment. Speech problems may not always be treatable via replacement dentures and not all foods may be tackled as with a natural dentition; nevertheless, it would be sensible to know how a patient
Figure 6. The presence of a palatal fissure (arrowed) means that a peripheral seal is impossible. The master cast will require to be modified.
Figure 7. The post dam area exhibits differing areas of thickness which ought to be so identified on the master cast. This is the responsibility of the clinician.
Figure 8. The occlusal plane here is too long as the second molar is encroaching on the ascending portion of the ridge; this overextension will induce a protrusive slide on closure by dint of an inclined plane effect.
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DentureProsthodontics
Figure 9. The occlusal plane here is too broad and the presence of lingual undercuts (arrowed) will induce instability.
Figure 10. The occlusal plane here drops posteriorly. This would impart a protrusive slide from RCP.
eats. By giving a patient a biscuit and observing how he/she eats; a guide to posterior tooth form may be gleaned. If mandibular movements are vertical, then it may be quite acceptable to prescribe flat-cusped teeth. If, however, ruminatory movements take place, then cusped teeth will be required to prevent destabilizing spacing between dentures. In conclusion, although it is recommended that the clinician is aware of the philosophical basis of complete denture prosthodontics, such problems rarely fall into one category and care has to be taken to take into account what the clinician sees but also what he/she palpates and hears. For that reason, the next section in this article will be on diagnosis of symptoms reported by the patient (anamnestic reports). The symptoms will relate to commonly presenting symptoms such as: Looseness: this is typically the mandibular denture but may also be the maxillary denture, especially if copious easing of undercut areas has been performed, or in cases where considerable residual ridge resorption has occurred. Pain: again this is commonly associated with atrophic mandibular ridges but may be a feature of undercut ridges, retained roots, tori or induced support problems (eg surface imperfections on newlyprescribed dentures). Lack of appropriate freeway space is also classically described. Problems eating: this may be a consequence of problems of support, retention and stability and needs careful assessment.
Speech problems: relate principally to appropriate freeway space and also labio-dental sounds; the appropriate positioning of the maxillary teeth is critical. Miscellaneous problems: these range from problems of appearance to social problems to problems of more obscure origin, eg allergy. For simplicity, these complaints will be presented in tabular form (Table 1). As is normal in clinical practice, however, diagnosis is just part of the problem. The next problem is how to manage the problem (more often it is more than one problem) and this article has given a brief introduction to most of the common ones and readers are referred to a standard textbook of Prosthodontics7 for more detailed coverage of the matter.
April 2014
Conclusion This manuscript has been written in an attempt to facilitate diagnosis of complete denture. Reference has been made4,5,6 to the need to take the patient’s views into account before commencing (as well as during) the provision of dentures. A recent article, however,8 raises the question of the need for practitioners to keep abreast of the literature as this critical systematic review of the literature indicated that, while some patients may benefit from traditional elaborate techniques and impression materials, for many patients, simple techniques have been demonstrated to serve the needs of many edentulous patients.
Figure 11. Note the inflamed nature of the tissues under the nose rests of the spectacles. This may indicate that the biological age of the patient is greater than the chronological age and, therefore, consideration should be given to the denture-supporting tissues.
References 1. Appelbaum M. Plans of occlusion. Dent Clin N Am 1984; 28: 273–276. 2. Jacobsen TE, Krol AJ. A contemporary review of the factors involved in complete denture retention, stability and support. J Prosthet Dent 1983; 49: 5–15; 165– 172; 306–313. 3. Frush JP, Fisher RD. Complete dentures: the dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958; 8: 558–581. 4. Smith PW, McCord JF. What do patients expect from their complete dentures? J Dent 2004; 32: 158–170. 5. Critchlow SB, Ellis JS, Field JC. Reducing the risk of failure in complete denture patients. Dent Update 2012; 39: 427–436. 6. Cooper GE, Tredwin NT, Cooper NT, Petrie A, Gill DS. The influence of maxillary central incisor heightto-width ratio on perceived smile aesthetics. Br Dent J 2012; 212: 589–599. 7. McCord JF, Smith PW, Grey NJA. Treatment of the Edentulous Patient. London: Elsevier Books, 2004. 8. Carlsson GE, Örtorp A, Omar R. What is the evidence base for the efficacies of different complete denture impression procedures? A critical review. J Dent 2013; 41: 17–23. DentalUpdate 255
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DentureProsthodontics
Table 1. (1–5) Identification of denture problems from symptoms reported by patient (pre-construction of C/C). 1. Looseness of Dentures Descriptor
Likely Cause
All the time, lower only
May be under- or over-extended. Occlusal surface may be too large. May have high muscle attachments, ie retention and stability problems. May require template dentures.
All the time, both
As per above, but loose maxillary denture may also have a support problem (eg flabby anterior ridge).
On eating – lower only
Occlusal problem most likely – may be related to position of maxillary anterior teeth.
On eating – both
Unlikely to be solely occlusal with the upper – probably muscle balance problem.
After a time (2 hours post insertion)
Likely to be related to tissue contact and possibly salivary flow. Is patient on diuretic medication or is he/she diabetic?
‘When I purse my lips’
Likely to be a consequence of lack of appropriate border moulding.
‘When I talk’
Stability problem. Could be problems associated either with over-extension of the denture base or the occlusion.
2. Pain Descriptor
Likely Cause
On insertion
May be a support problem, eg retained root, undercut, torus or a pearl of PMMA on tissue surface of denture.
On insertion and removal
Undercut(s)
On eating
May be support or stability (over/under-extension) or occlusal problem. May be neural, eg pressure on mental nerve(s).
On yawning
Posterior buccal flange is impinging on coronoid process(es).
As day progresses
This is pathognomonic of insufficient freeway space (FWS).
All the time
Likely to be support problem such as atrophic mandibular arch.
Even with C/C out
Do not start treatment. Should have this investigated by a consultant in oral medicine.
3. ‘Can’t eat’ Descriptor
Likely Cause
‘Painful to eat’
Most likely reason is support, directly as in an atrophic ridge but could be under- extension of denture base. Occlusal causes also likely.
‘Dentures move’
Muscle imbalance and/or occlusal imbalance likely.
‘No room to eat’
Likely cause is inappropriate freeway space.
‘Teeth lock’
Inappropriate selection of posterior teeth. May also be poor positioning of anterior teeth, creating a locked occlusion.
256 DentalUpdate
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DentureProsthodontics
4. ‘Can’t speak clearly’ Descriptor
Likely Cause
‘Dentures too big’
Periphery perhaps over-extended. Perhaps too big a change from previous denture.
‘Dentures move too much’
Check for over/under-extension of lower denture.
‘Sounds muffled’
Check for sufficient freeway space/closest speaking space. Also check for appropriate restoration of upper lip.
5. ‘Don’t like them’ Descriptor
Likely Cause
‘Don’t like the look of them’
May happen even after several trial visits. If the dental team has worked accurately, may be a good time to exit!
‘Don’t like the colour’
Sometimes bleaching of the bases can occur when dentures are placed in bleach or boiling water.
‘My family don’t like them’
This highlights the importance of determining what the needs and expectations are. Again a good reason where indicated, to prescribe a template technique.
‘Experiencing burning sensation’ May be an allergic response or Burning Mouth Syndrome – refer to consultant in oral medicine. ‘Don’t like the overlap’ Patients may not realize that wear of older dentures occurs and that overjets (anterior and buccal) are reduced. Clinicians should explain what they are attempting to do by way of rehabilitation. ‘You’ve given me fewer teeth than my old dentures’
Sometimes, and for perfectly good reasons, a clinician will not prescribe 2 premolars and 2 molars in each posterior quadrant. Patients should be told why this is being done – they will certainly be aware of the difference!
Table 1. (1–5) Identification of denture problems from symptoms reported by patient (pre-construction of C/C).
April 2014
DentalUpdate 259 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 30, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
J Fraser McCord Philip Smith and Sachin Jauhar
Complete Dentures Revisited Abstract: The aim of the article is to assist practitioners in the diagnosis and management of complete denture problems by addressing the problems from a theoretical viewpoint and in a clinically diagnostic way. Clinical Relevance: To assist practitioners and undergraduates to understand the clinical basis of complete denture prosthodontics. Dent Update 2014; 41: 250–259
In 1984, Applebaum wrote:1 “...a man with no eyes cannot see, a man with no legs cannot run but a man with no teeth expects to eat and chew with dentures as well as he did when he had natural teeth.” While the second statement has since been disproved, via prostheses, this aphorism is still apt when complete dentures are considered. It underlines the importance of appreciating the contribution the patient can make to the success of dentures, in addition to the overall value of the dental team operating optimally. This is demonstrated in Figure 1, which summarizes the four essential factors involved in creating a good outcome for complete denture treatment. The foremost is of course the patient and, unless the patient is accepting of her/his edentulous state and,
J Fraser McCord, BDS, DDS, FDS DRD, RCS(Ed) FDS(Eng), FDS RCPS(Glas), FCD(HK) CBiol, FSB, Retired Professor, Stockport, Philip Smith, BDS, PhD, FDS DRD, MRD RCS(Ed), FDS(Rest Dent) RCS(Ed), Senior Lecturer in Restorative Dentistry, Liverpool Dental School and Sachin Jauhar, BDS, MSc, MFDS FDS(Rest Dent), Consultant in Restorative Dentistry, Glasgow Dental School, UK.
250 DentalUpdate
Clinical Skills
Dental Staff
Patient Attitude and Skill
Technical Skills
Figure 1. The four basic components of the denture team. All four must contribute optimally for optimal results.
further, is capable of some denture control, then a favourable outcome is doubtful. Experienced clinicians will recall delivering prosthodontically acceptable dentures
which patients cannot tolerate; they will also doubtless recall examining patients who have coped, or are coping quite well with dentures which fly in the face of conventional April 2014
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 30, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
DentureProsthodontics
(prosthodontic) wisdom. The importance, therefore, of determining the expectations and denture-wearing history cannot be under-emphasized. The purpose of this article is to give guidelines as to the identification and diagnosis of complete denture problems.
Diagnosis of complete denture problems In their fine articles outlining the basics of complete denture prosthodontics, in 1983 Jocobsen and Krol listed and defined the three principal features as being: 2 1. Support: that property of the denture-bearing tissues which resists movement of the denture towards these tissues. 2. Retention: the resistance to displacement of the denture base away from the ridge (this might more appropriately be termed the peridenture tissues). 3. Stability: the resistance of the dentures to horizontal or rotational forces (perforce, this is a paradigm of muscle and occlusal harmony or ‘balance’). While all three of the above have implications on function, there are, additionally, several other areas which need to be considered: Appearance: while aesthetic dentistry has developed into an apparent subspecialty, this invariably falls into the domain of Operative Dentistry and the art of complete dentures has received scant attention since the days of Frush and Fischer3 (1956–1959). More recent reviews, by Smith and McCord4 and Critchlow et al,5 mention the need to involve the patient in formulating the appearance, even as far as allowing the patient to take the try-in home for approval (if he/she so desires). Unfortunately, no hard and fast rules apply and, in 2012, Cooper et al6 demonstrated significant differences between aesthetic perceptions among dentists, technicians and patients and also recommended that the ‘individual variability in patient response should be taken into account during treatment planning’ of complete dentures. Miscellaneous: this covers a variety April 2014
of factors such as allergy, xerostomia, atypical pain and stomatitis/angular cheilitis and TMJ Pain Dysfunction syndrome; although some of these affect function directly, there may be other symptoms which affect success of the dentures indirectly. Intrinsically, there are objective normative means by which denture problems may be diagnosed and also indirect means via anamnestic symptoms related to the clinician. For simplicity, objective normative means will be confined to support, retention and stability. Guidelines to deductions from anamneses will also be presented in tabular form.
Figure 2. This shows a typical ‘flabby’ ridge (arrowed) which presents support problems that have an impact on (upper) denture stability.
Theoretical recognition of complete denture problems Recognition of support problems
It is not the purpose of this article to carry out a resumé of the oral and facial anatomy relevant to complete denture prescription; nevertheless, it could be argued that this facet should be the easiest for the practitioner to identify. The absence of well-defined ridges means that, in theory, there is less denture-bearing tissue to carry the functional loads and this should highlight problems of support. Careful examination of the denture-bearing areas of both arches is therefore required but this does not mean a reliance on visual scanning. This will give little meaningful information on the ability of the denture-bearing tissues to withstand pressure7 (although it may draw the clinician’s attention to potential problems (Figure 2). Further assessment, for example by digital pressure over the dental-bearing areas, is therefore essential to identify where problems are (Figure 3). This will help the clinician to plan which impression material to use (vide infra) in addition to helping her/him to prescribe appropriate relief if required, eg over a torus or bony prominence (Figure 4). Recognition of retention problems
Retention of complete dentures is principally achieved via a peripheral seal; anything which
Figure 3. This shows areas of blanched tissue which indicate potential support problems which may be detected on palpation.
Figure 4. This shows the presence of a torus and also a spur of bone near the (left) canine area.
Figure 5. The presence of a muscle attachment on the ridge (arrowed) means that a peripheral seal is impossible. Stability will also be compromised.
DentalUpdate 251 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 30, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
DentureProsthodontics
prevents/impairs the potential for a peripheral seal therefore should be identifiable as a potential problem in the successful prescription of complete dentures. High muscle attachments, which are attached to the crest of a ridge, therefore will not only affect stability of a denture, but will make the achievement of a peripheral seal impossible (Figure 5). Similarly, the presence of a palatal fissure in the postdam area will present problems which will require modification of the master cast (vide infra) (Figure 6). In the same way that digital pressure is recommended in the identification of support problems, it is recommended that the clinician determines the relative displaceability of the tissues of the post dam, as there tends to be more glandular and connective tissue laterally than there is centrally (Figure 7). Although it has been stated that the principal factor in retention is peripheral seal, proximity of fit of the denture base to the tissues is also of importance, as is surface tension; factors influencing these may also therefore affect the retention of a complete denture. This will be dealt with later.
Recognition of stability problems
As was described earlier, stability of complete dentures, if achieved, is a paradigm of muscle balance and occlusal balance. The achievement of successful stability is, in the opinion of the authors, the single-most difficult thing for a clinician to achieve. While careful impression techniques may ensure a good peripheral seal, eccentricities of muscle form may displace a proficiently made denture. On the other hand, patients with neuro-muscular diseases/ conditions may have uncontrollable tremors which make it almost impossible to achieve acceptable muscle balance. While not all occlusal problems may be overcome, each clinician should be able to identify where occlusal tables are too long (Figure 8) and too broad (Figure 9). In addition, where prosthodontic guidelines are disregarded and inappropriate occlusal planes are prescribed, the result can be instability
252 DentalUpdate
caused by clinical displacement of the mandibular denture in accordance with the principles of an inclined plane (Figure 10). It is perhaps prudent here to indicate that, while the authors accept that it is highly unlikely that clinicians will be able to prescribe balanced articulation clinically, the minimal requirement, prosthodontically speaking, for complete dentures is balanced occlusion in Retruded Contact Position (RCP). As instability occurs when spaces occur between dentures, then the concept of balanced articulation was introduced as a means of improving stability. This should be achievable on all cases on an articulator. Sadly, semiadjustable articulators do not equate to the ginglymo-diarthrodial TMJ apparatus of patients and true balanced articulation is probably achieved only rarely. This, however, should not mean that the clinician does not aspire to achieve it! In addition to the above, good common sense and careful historytaking might alert the clinician to the potential for denture-wearing problems. Figure 11 shows a patient who obviously wears spectacles. The pressure of the spectacles on the keratinized tissues on the bridge of the nose would lead one to be sceptical about the ability of the (non–keratinized) tissues overlying the residual ridges to withstand robust oral function; this is also a useful guide to the biological age of the patient. The mention of function does raise the important question of what functions are being sought. If we include appearance as a function (strictly speaking it is not), then there are four principal functions of complete dentures: 1. Speaking; 2. Eating (chewing and clenching); 3. Swallowing; 4. Appearance. Although the diagnosis of these problems in these areas will be dealt with later, it is important to determine the functional needs of a patient before commencing treatment. Speech problems may not always be treatable via replacement dentures and not all foods may be tackled as with a natural dentition; nevertheless, it would be sensible to know how a patient
Figure 6. The presence of a palatal fissure (arrowed) means that a peripheral seal is impossible. The master cast will require to be modified.
Figure 7. The post dam area exhibits differing areas of thickness which ought to be so identified on the master cast. This is the responsibility of the clinician.
Figure 8. The occlusal plane here is too long as the second molar is encroaching on the ascending portion of the ridge; this overextension will induce a protrusive slide on closure by dint of an inclined plane effect.
April 2014 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 131.172.036.029 on September 30, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
DentureProsthodontics
Figure 9. The occlusal plane here is too broad and the presence of lingual undercuts (arrowed) will induce instability.
Figure 10. The occlusal plane here drops posteriorly. This would impart a protrusive slide from RCP.
eats. By giving a patient a biscuit and observing how he/she eats; a guide to posterior tooth form may be gleaned. If mandibular movements are vertical, then it may be quite acceptable to prescribe flat-cusped teeth. If, however, ruminatory movements take place, then cusped teeth will be required to prevent destabilizing spacing between dentures. In conclusion, although it is recommended that the clinician is aware of the philosophical basis of complete denture prosthodontics, such problems rarely fall into one category and care has to be taken to take into account what the clinician sees but also what he/she palpates and hears. For that reason, the next section in this article will be on diagnosis of symptoms reported by the patient (anamnestic reports). The symptoms will relate to commonly presenting symptoms such as: Looseness: this is typically the mandibular denture but may also be the maxillary denture, especially if copious easing of undercut areas has been performed, or in cases where considerable residual ridge resorption has occurred. Pain: again this is commonly associated with atrophic mandibular ridges but may be a feature of undercut ridges, retained roots, tori or induced support problems (eg surface imperfections on newlyprescribed dentures). Lack of appropriate freeway space is also classically described. Problems eating: this may be a consequence of problems of support, retention and stability and needs careful assessment.
Speech problems: relate principally to appropriate freeway space and also labio-dental sounds; the appropriate positioning of the maxillary teeth is critical. Miscellaneous problems: these range from problems of appearance to social problems to problems of more obscure origin, eg allergy. For simplicity, these complaints will be presented in tabular form (Table 1). As is normal in clinical practice, however, diagnosis is just part of the problem. The next problem is how to manage the problem (more often it is more than one problem) and this article has given a brief introduction to most of the common ones and readers are referred to a standard textbook of Prosthodontics7 for more detailed coverage of the matter.
April 2014
Conclusion This manuscript has been written in an attempt to facilitate diagnosis of complete denture. Reference has been made4,5,6 to the need to take the patient’s views into account before commencing (as well as during) the provision of dentures. A recent article, however,8 raises the question of the need for practitioners to keep abreast of the literature as this critical systematic review of the literature indicated that, while some patients may benefit from traditional elaborate techniques and impression materials, for many patients, simple techniques have been demonstrated to serve the needs of many edentulous patients.
Figure 11. Note the inflamed nature of the tissues under the nose rests of the spectacles. This may indicate that the biological age of the patient is greater than the chronological age and, therefore, consideration should be given to the denture-supporting tissues.
References 1. Appelbaum M. Plans of occlusion. Dent Clin N Am 1984; 28: 273–276. 2. Jacobsen TE, Krol AJ. A contemporary review of the factors involved in complete denture retention, stability and support. J Prosthet Dent 1983; 49: 5–15; 165– 172; 306–313. 3. Frush JP, Fisher RD. Complete dentures: the dynesthetic interpretation of the dentogenic concept. J Prosthet Dent 1958; 8: 558–581. 4. Smith PW, McCord JF. What do patients expect from their complete dentures? J Dent 2004; 32: 158–170. 5. Critchlow SB, Ellis JS, Field JC. Reducing the risk of failure in complete denture patients. Dent Update 2012; 39: 427–436. 6. Cooper GE, Tredwin NT, Cooper NT, Petrie A, Gill DS. The influence of maxillary central incisor heightto-width ratio on perceived smile aesthetics. Br Dent J 2012; 212: 589–599. 7. McCord JF, Smith PW, Grey NJA. Treatment of the Edentulous Patient. London: Elsevier Books, 2004. 8. Carlsson GE, Örtorp A, Omar R. What is the evidence base for the efficacies of different complete denture impression procedures? A critical review. J Dent 2013; 41: 17–23. DentalUpdate 255
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Table 1. (1–5) Identification of denture problems from symptoms reported by patient (pre-construction of C/C). 1. Looseness of Dentures Descriptor
Likely Cause
All the time, lower only
May be under- or over-extended. Occlusal surface may be too large. May have high muscle attachments, ie retention and stability problems. May require template dentures.
All the time, both
As per above, but loose maxillary denture may also have a support problem (eg flabby anterior ridge).
On eating – lower only
Occlusal problem most likely – may be related to position of maxillary anterior teeth.
On eating – both
Unlikely to be solely occlusal with the upper – probably muscle balance problem.
After a time (2 hours post insertion)
Likely to be related to tissue contact and possibly salivary flow. Is patient on diuretic medication or is he/she diabetic?
‘When I purse my lips’
Likely to be a consequence of lack of appropriate border moulding.
‘When I talk’
Stability problem. Could be problems associated either with over-extension of the denture base or the occlusion.
2. Pain Descriptor
Likely Cause
On insertion
May be a support problem, eg retained root, undercut, torus or a pearl of PMMA on tissue surface of denture.
On insertion and removal
Undercut(s)
On eating
May be support or stability (over/under-extension) or occlusal problem. May be neural, eg pressure on mental nerve(s).
On yawning
Posterior buccal flange is impinging on coronoid process(es).
As day progresses
This is pathognomonic of insufficient freeway space (FWS).
All the time
Likely to be support problem such as atrophic mandibular arch.
Even with C/C out
Do not start treatment. Should have this investigated by a consultant in oral medicine.
3. ‘Can’t eat’ Descriptor
Likely Cause
‘Painful to eat’
Most likely reason is support, directly as in an atrophic ridge but could be under- extension of denture base. Occlusal causes also likely.
‘Dentures move’
Muscle imbalance and/or occlusal imbalance likely.
‘No room to eat’
Likely cause is inappropriate freeway space.
‘Teeth lock’
Inappropriate selection of posterior teeth. May also be poor positioning of anterior teeth, creating a locked occlusion.
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4. ‘Can’t speak clearly’ Descriptor
Likely Cause
‘Dentures too big’
Periphery perhaps over-extended. Perhaps too big a change from previous denture.
‘Dentures move too much’
Check for over/under-extension of lower denture.
‘Sounds muffled’
Check for sufficient freeway space/closest speaking space. Also check for appropriate restoration of upper lip.
5. ‘Don’t like them’ Descriptor
Likely Cause
‘Don’t like the look of them’
May happen even after several trial visits. If the dental team has worked accurately, may be a good time to exit!
‘Don’t like the colour’
Sometimes bleaching of the bases can occur when dentures are placed in bleach or boiling water.
‘My family don’t like them’
This highlights the importance of determining what the needs and expectations are. Again a good reason where indicated, to prescribe a template technique.
‘Experiencing burning sensation’ May be an allergic response or Burning Mouth Syndrome – refer to consultant in oral medicine. ‘Don’t like the overlap’ Patients may not realize that wear of older dentures occurs and that overjets (anterior and buccal) are reduced. Clinicians should explain what they are attempting to do by way of rehabilitation. ‘You’ve given me fewer teeth than my old dentures’
Sometimes, and for perfectly good reasons, a clinician will not prescribe 2 premolars and 2 molars in each posterior quadrant. Patients should be told why this is being done – they will certainly be aware of the difference!
Table 1. (1–5) Identification of denture problems from symptoms reported by patient (pre-construction of C/C).
April 2014
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