DENTURE TROUBLESHOOTING

 

 

Overextension of Denture Borders

Slight overextension is preferred to slight underextension.

Remember, however, overextension is prejudicial to denture retention.

To examine the lower denture for overextension:

If the denture lifts, consider 3 possiblities:

  • To test buccal and labial flanges of the lower denture for retention, cheeks and lips are drawn outward. Keep index finger of the other hand on occlusal surface of the teeth on the same side. If denture lifts, border may be overextended.

    Test buccal and labial flanges of the upper denture for retention the same way except hold index finger of the opposite hand in contact with palatal vault

    Wharton’s (submaxillary duct)

  •  

    Faulty Vertical Dimension

     

    Speech Problems

    It takes patients from 2 – 3 weeks to accustom themselves to dentures, so it is difficult to judge this early on, but some things to think about are:

     

    Physiologic Failures

     

    Mucosal Irritations

     

    Sialorrhea (hypersalivation)

     

    Xerostomia

     

    Stomatopyrosis (burning mouth)

     

     

    Action of the Denture as a Foreign Body

     

     

    Contraindications to a Denture Reline

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    From: Perspectives in Prosthodontics

  • DENTURE REFERENCE

    (Dr. Kenneth Barrack, Medical University of South Carolina)

     

  • Signs/Symptoms Causes Solutions

     

     

    Fullness under nose

     

    Depressed philtrum and/or nasolabial sulcus

    Upper lip sunken in

     

    Shows too much of the teeth

     

    Artificial look

     

     

     

     

     

     

    Whistle on "S" sound

    Lisp on "S" sound

    "Th" and "T" sounds indistinct

    "T" sounds like "Th"

     

    "F" and "V" sounds indistinct

     

     

    Sore Spots

    • In vestibule
    • On posterior limit of maxillary denture base
    • Single sore spot over ridge

     

     

    • Generalized soreness over ridge

     

     

     

    • Soreness under labial flange of mandibular denture

    Burning Sensation

    • Anterior hard palate & anterior ridge area
    • Premolar area to molar tuberosity
    • Lower anterior ridge

    Tongue and cheek biting

     

     

     

    Fiery redness of all tissues contacted by denture, including tongue and cheeks

    Redness of bearing tissues

    Pain in TMJ

     

     

     

     

    Instability/ Retention

    • When not occluding

     

     

    • When incising food

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    • When occluding in centric occlusion

     

     

     

     

     

     

     

     

     

    Interference

    • Swallowing

     

     

     

     

     

     

     

     

     

     

     

     

     

    • Gagging

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

    • Clicking

     

     

    • Deafness
    • Muscles of mastication become fatigued

    General feeling dentures are not right, but with absence of pain (patient has high pain tolerance)

     

    ESTHETICS OF DENTURES

    Labial flange of maxillary denture base too long or too thick

    Labial flange of maxillary denture base too short or too thin

    Maxillary anterior teeth too far lingual

    Vertical dimension too great

    Incisal plane too low

    Cuspids and laterals too prominent

    Technique setup, the alignment of the teeth are too regular

    All teeth same shade

    Lack of grinding incisal edges and angles

    Lack of individualizing gingival contours and color of denture base

     

    PHONETICS OF DENTURES

    Too narrow an air space on the anterior part of the palate

    Too broad an air space on the anterior part of the palate

    Inadequate interocclusal distance

    Maxillary anterior teeth too far lingual

    Improper position of maxillary anterior teeth either vertically or horizontally

     

    COMFORT OF DENTURES

    Overextended borders

    Posterior palatal seal too deep

    Sharp posterior palatal seal

    Overextensions

    Malocclusion in that area

    Inaccurate denture base (esp 1Ú stress bearing areas)

     

    Bubbles in acrylic resin

    Vertical dimensions too great

    Inaccurate denture base

    Centric occlusion not in harmony with centric relation; drives lower denture forward

    Excessive overbite

    Patient’s habit, wants to masticate in protrusive

    Overextended labial flange

    Pressure on anterior palatine foramen

    Pressure on posterior palatine foramen

    Pressure on mental foramen

    Posterior teeth edge to edge (minimal reduction of buccal aspect of teeth)

     

    Overclosure

    Posterior teeth too far lingual or buccal

    Denture base allergy

     

     

     

     

    Ill-fitting denture

    A vitaminosis

    VDO too small

    Centric occlusion not in harmony with centric relation

    Arthritis

     

    Function of Dentures

    Overextension of borders and posterior limit

    Underextended borders

    Loss of posterior palatal seal

    • Posterior palatal seal on hard palate
    • Posterior limit not in hamular notches
    • Insufficient posterior palatal seal

    Dehydration of tissues due to medications or alcohol

    "Flabby" tissues displaced when making impressions

    Loss of posterior palatal seal (same as above)

    Anterior teeth placed too far labially

    Poor denture foundation ("flabby" anterior tissues)

    Improper incising habits

     

    Malocclusion

    • Premature individual tooth contacts
    • High occlusion on one side of arch
    • High occlusion in bicuspid areas
    • Maxillary denture "riding" on median hard palate
    • "Flabby"tissues over the ridge
    • Teeth set too far bucally
    • Centric occlusion not coincident with centric relation

    Maxillary

    • Denture base overextension in posterior
    • Denture base too thick in posterior

    Mandibular

    • Denture base overextension in the lingual
    • Denture base too thick in lingual posterior flanges

    Overclosure of the VDO

    Posterior teeth too far lingual, crowds tongue

    Too great a VDO

    Immediately upon insertion

    • Maxillary
    • Overextension
    • Too thick posterior border
    • Mandibular
    • Distolingual flange too long

    Delayed gagging (2 wks – 2 mo post)

    • Incomplete border seal allowing saliva under denture
    • Lack of denture stability and/or loose denture
    • Malocclusion causing denture to loosen, allowing saliva under denture
    • Undetermined, uncontrollable or neuromuscular malocclusion causing denture to loosen, allowing saliva under denture
    • VDO too great
    • Unstable mandibular (borders overextended)
    • VDO too small
    • VDO too small
    • VDO too great

     

    Malocclusion

    Centric occlusion not coincident with centric relation

    Incorrect VDO

    Lack of confidence in retention

     

     

     

    A,D

     

    J

     

    G

     

  • G

    G

    G

    O

    O

    O

    O

     

  • G
  • G

    G

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    A

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    D

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    C

    A

    A,R

    F

    P

    B,G

     

     

    B,G

    B,G

    A

    A

    A

    A

    G

  • E,Q
  • G

     

  • M,Q

     

     

     

  • J,P

    H

    E

    B,C,G

    I

     

     

  • A

     

    A

     

     

    K

     

    J

     

    K

     

    H,M,N

     

    L,P

     

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    G,O

     

    L

     

    G

     

    B,C

     

    B

     

    B,F

    A

     

    L

    G

    B,C

     

     

     

    A

     

    D

     

     

    A

     

    D

     

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    G

     

    F

     

     

     

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    D

     

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    N

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

  • SOLUTIONS

     

    1. PIP and disclosing wax to identify over-extensions, and/or tissue impingement and adjust accordingly. Determine whether problem is due to excessive length or excessive pressure spot (ie mylohyoid ridge)
    2. Remount to identify occlusal discrepancies
    3. Selective grinding to eliminate occlusal discrepancies
    4. Feel for sharp edges, thin out borders, then adjust and polish
    5. Add acrylic resin to occlusal surfaces to increase VDO
    6. Remount and grind occlusal surfaces to decrease VDO
    7. Remove teeth from denture base, reposition in wax, re-evaluate and reprocess
    8. Nutritional analysis
    9. Rheumatology consult to rule out arthritis in TMJ
    10. Add to borders with compound or wax and reprocess to correct under-extensions
    11. Add posterior palatal seal area and reprocess to correct
    12. Reduce flabby tissue surgically or alter impressioning technique
    13. Review medical history for medications that may cause xerostomia or refer for medical evaluation
    14. Use denture adhesive to augment retention and delay/retard saliva flow under denture base
    15. Communicate with patient and laboratory technician concerning the characterization of artificial tooth arrangement while at the wax try-in step of denture fabrication to try to meet the patient’s expectations
    16. Re-impression/remake denture
    17. Appropriate referrals
    18. Repair with hard reline material

     

     

     

     

     

     

  • The Complete Denture Remount Procedure

    Contributed by Dr. Ana Arnold

    (from Leary, JM, Diaz-Arnold, AM, Aquilino, SA. The complete-denture remount procedure. Quintessence International 1988;19(9)623-629.

     

    Purpose: Correction of denture occlusion under controlled conditions no matter what the cause of the occlusal disharmony.

    Reasons:

    • Reduces patient participation
    • Done on solid base
    • Dry field
    • Clear visibility
    • Corrections made away from patient

    Procedure to remount a denture begins at the time the processing of the denture is complete. It can be broken into four phases: two laboratory and two that involve patient manipulation. The sequence would be initial laboratory correction, patient interocclusal records, laboratory correction, and finally patient evaluation and finalization of denture occlusion. The first laboratory phase may not be done by you, the dentist, and can be done by the laboratory technician, depending on your laboratory directions and philosophy.

    The basic procedures are as follows:

    • Preliminary laboratory occlusal adjustment
    • Patient chairside tissue surface and peripheral extension evaluation and adjustment
    • Laboratory occlusal adjustment utilizing interocclusal records to mount complete dentures
    • Denture insertion and post insertion care

     

    Preliminary laboratory occlusal adjustment involves occlusal adjustments resulting from processing error that occurs in the laboratory. Adjustments are done in the labs before delivery to the dentist.

     

     

    Patient participation involves the evaluation and necessary adjustment done by the dentist on the tissue surface and periphery of the complete denture which results in a properly fitting prosthesis. At this time interocclusal records, using the patients new and properly adjusted maxillary and mandibular dentures are made for remounting these complete dentures.

     

    Laboratory occlusal adjustment is the procedure of denture adjustment done at the laboratory bench after remounting the prosthesis on the articulator

     

    Denture insertion is the final delivery of the denture. It includes intraoral inspection for accuracy of laboratory occlusal adjustment and review of home care instructions for the prosthesis and the patient’s mouth. These instructions are sent home with the patient.

    More detailed breakdown of this remount procedure is as follows:

    Procedure

    1. Preliminary laboratory occlusal adjustment
    1. Patient participation
    1. Denture insert
  • The following is a step by step laboratory occlusal adjustment that will result in elimination of occlusal errors of anatomic teeth. A different procedure is used with monoplane teeth set flat.
    • Adjustment is accomplished by selective grinding permitting both tooth form and occlusion to be retained.
    • Articulating paper/ribbon of minimum thickness is used, thicker paper gives inaccurate markings and deceptive results.
    • Centric relation deflective contacts are adjusted first.
    • Complete dentures cannot be loose on the remount casts. It may be necessary to sticky wax the denture to the casts to prevent movement.
    • Place articulating paper between complete denture teeth and lightly tap together. Both sides can be done at same time by fastening paper together in from with a paper clip.
    • Basic rule: Grind fossas and deflective inclines and not cusp tips.
    • Repeat marking and grinding until posterior teeth have contact in centric occlusion.
    • During centric occlusion marking and grinding, incisal guide pin is raised 1 mm out of contact to compensate for the thickness of the wax interocclusal record.
    • REMEMBER: After centric occlusion has been perfected the centric cusps must not be shortened.
    • REMEMBER: The maxillary lingual cusps and the mandibular buccal cusps are usually centric cusps.
    • After centric occlusion, deflective contacts are eliminated. The incisal guide pin is placed in contact with the incisal guide table and kept in contact during elimination of eccentric deflective movements, working and balancing.
    • Place articulating paper between teeth on both sides of the arch and move articulator into lateral movement. I f the pin raises form the incisal table, reduce the appropriate marking.
    • Reduce the appropriate non-functional cusp inclines on the working side first – lingual incline of maxillary buccal cusps or buccal incline of mandibular lingual cusps.
    • Reduce the appropriate cusp inclines on the balancing side. The lingual incline of mandibular buccal cusps are reduced before the buccal inclines of the maxillary lingual cusps.
    • Marking and grinding is continued in lateral movement until the incisal pin stays flat and contact is made on as many posterior teeth as possible. Contact on all posterior teeth is ideal
    • REMEMBER: Grinding to correct occlusion in lateral movement is usually limited to non centric cusp inclines. These include the lingual inclines of the upper buccal cusps and the buccal inclines of the lower lingual cusps on the working side. The lingual inclines of the lower buccal cusp on the the balancing side are reduced before the buccal inclines of the upper lingual cusps.
    • After correction of right and left lateral movement, deflective contacts in protrusive are addressed.
    • Relief is accomplished for protrusive interference on the distal inclines of maxillary cusps and mesial inclines of mandibular cusps.
    • Light posterior contact is desirable in protrusive movement as long as the incisal guide pin stays on the incisal guide table.
    • Anterior teeth should just clear without interference. This is usually addressed during the trial arrangement, but adjustment may be necessary
    • Elimination of occlusal errors with rational teeth set to a flat occlusal plane is accomplished on the lower arch. The maxillary teeth are sanded flat with "220 wet or dry" sandpaper on a flat surface. This arch is then maintained while adjustment are made on the mandibular teeth.
    • Finalization of the adjustment can be accomplished with milling past. All ground teeth should then be light polished to provide smooth movements.
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  • REFERENCES:

    Barrack, K. DENTUREREFERENCE©. Perspectives in Prosthodontics, American College of Prosthodontics 1997.

    Jumbelic, R., Nassif, J. General Considerations Prior to Relining of Complete Dentures. J Prosthet Dent 1984;51(2):158-163.

    Landa, JS: Trouble Shooting In Complete Denture Prosthesis. Part 1. Oral Mucosa and Border Extension. J Prosthet Dent 1959;9(6):980-987.

    Landa, JS: Trouble Shooting In Complete Denture Prosthesis. Part 4. Proper Adjustment Procedures. J Prosthet Dent 1960;10(3):490-495.

    Landa, JS: Trouble Shooting In Complete Denture Prosthesis. Part 7. Mucosal Irritations. J Prosthet Dent 1960;10:1022-1028.

    Landa, JS: Trouble Shooting In Complete Denture Prosthesis. Part 9. Salivation, Stomatopyrosis, and Glossopyrosis. J. Prosthet Dent 1961;11:244-246.

    Leary, JM, Diaz-Arnold, AM, Aquilino, SA. The complete-denture remount procedure. Quintess Int. 1988;19(9)623-629.

    Morstad, AT, Petersen, AD. Postinsertion denture problems. J. Prosthet Dent. 1968;19(2):126-132.

    Van der Waal, I. The Burning Mouth Syndrome. (ed 1) Munksgard, Copenhagen 1990.