Post insertion complaints / orthodontic continuing education


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Post insertion complaints / orthodontic continuing education

  2. 2. Most complaints will fall under one of the following headings though frequently a patient will have more than one complaint: 1. Pain. 2. Appearance. 3. Inefficiency. 4. Poor retention. 5. Instability. 6. Chattering teeth. 7. Nausea. 8. Discomfort. 9. Altered speech. 10. Biting the cheek and tongue­ 11. Food under the denture.
  3. 3. I. PAIN (a) Overextension of the Periphery It is due to incorrect moulding of the impression or incorrect outlining of the denture on the model and is visible in the mouth as an area of hyperaemia, an angry red line or an ulcer, depending upon how continuously the denture has been worn, or how gross the overextension. Treatment: Mark with an indelible pencil on the denture the exact position and extent of the area or use easing paste and reduce the periphery at that spot. If the denture is an old one, the overextension may be due to alveolar resorption and the slow, chronic irritation may have caused a local hyperplasia. In this case cut the denture away freely and when the hyper­ plasia has absorbed, or been removed surgically, construct a new denture
  4. 4. (b) Poor Fit
  5. 5. (c) Insufficient Relief
  6. 6. (d) Incorrect Centric Occlusion This may be anyone of the following faults, or a combination of them. (i) Wrong Anteroposterior Relationship
  7. 7. (ii) Uneven Pressure
  8. 8. (iii) Over Open
  9. 9. (iv) Over-closed
  10. 10. (e) Cuspal Interference
  11. 11. (f) Teeth off the Ridge
  12. 12. (g) Retained Root or Unerupted Tooth
  13. 13. (h) V-shaped Ridge
  14. 14. (i) Mental Foramen
  15. 15. (j) Irregular Absorption (k) Pathological Conditions
  16. 16. (l) Allergy Treatment: New dentures must be constructed in another material.
  17. 17. (m) Rough Fitting Surface Treatment. Remove the offending roughness from the denture.
  18. 18. (n) Infection with Monilia albicans Treatment is to polish the fitting surface of the denture and instruct the patient to apply daily to the fitting surface for 10 days a fungicide such as Nystatin ointment or Fuchsonium. The patient should also be instructed to remove the denture at night without fail and place it in a dilute solution of hypo­chlorite such as Milton.
  19. 19. (o) Swallowing and Sore Throat Treatment: The patient will usually know which denture is at fault and examination of the regions described will show a slight redness. Reduction of the overextension is all that is required.
  20. 20. (p) Undercuts Treatment: It may be possible to insert this side of the denture first quite painlessly, and then the opposite side removing it in reverses order. If this manoeuvring is not successful the fitting surface must be cut way until the denture can be inserted comfortably but the periphery must not be reduced in height.
  21. 21. 2. APPEARANCE In spite of the greatest care on the part of the operator to obtain the patients full approval of his appearance at the “try-in” stage, there will always be some patients who are dissatisfied with their appearance when wearing the finished dentures. The number of patients who are dissatisfied with their appearance with the final dentures can be much reduced if the operator insists on a relation or a friend being present at the try-in stage. The following examples of complaints about appearance are by no means comprehensive but will be found to cover the main
  22. 22. (a)Nose, and chin Approximating This complaint may be made of new dentures, or of old ones, and is due to a so-called closed bite, which term is synonymous with excessive free-way space. Treatment. As previously described for over closure.
  23. 23. (b) Cheeks and Lips Falling In
  24. 24. (c) Angular Cheilitis or Soreness of the Corners of the Mouth As descried previously this is frequently the result of loss of vertical dimension and muscle tone and the corners of the mouth fall in and become bathed in saliva and develops fissures. Frequently however, as with traumatic damage to the palate, a secondary infection with Monilia albicans supervenes, especially if such an infection already exists in the mouth. The vertical dimension should be restored (but never opened) and the upper denture 'plumped' to help restore the muscle tone.
  25. 25. (d) Colour, Shape and Position of Anterior Teeth Colour: This complaint is almost invariably that the teeth are too dark or too yellow, but before changing them it must be explained to the patient that natural teeth darken with age and that very light-shaded teeth look more artificial than darker ones. Treatment: Comply if possible with the patient's request for lighter teeth, usually by a compromise between the shade chosen by the operator and that chosen by the patient. Shape: Few people are sufficiently observant to be able to describe the shape of their, lost teeth and are likely to say vaguely, when referring to their dentures, that they don't look right. Artificial teeth usually look larger than natural teeth of identical size, probably because their mesial and distal surfaces are not so rounded, and so the eye is able to focus on their width more accurately, '
  26. 26. Treatment: Remove the teeth complained of and replace them with others mounted in wax, until by a process of trial and error mutually suitable ones are obtained, which are then permanently attached. Position: the complaint under consideration is that the teeth are too far back in the mouth, or are too far forward, more often the former. Stability will be jeopardized much more by encroaching on the tongue, than by setting the teeth in the neutral zone where pressures of tongue and lip are equalized. Treatment: New dentures will almost certainly have to be made. If only the anterior teeth of the existing denture are moved forward, larger ones will be required if proximal contact is to be maintained and this is contra-indicated if the teeth originally chosen were correct; if the teeth are to be moved back the converse is equally true.
  27. 27. (e) Amount of Tooth Showing
  28. 28. 3. INEFFICIENCY (a)inability to Eat Anything
  29. 29. (b) Inability to Eat Meat This is a complaint which may be made of new-dentures, never old ones, It may be due to' (i) Flattening of the cusps of the posterior teeth by over­ enthusiastic spot-grinding to correct an unbalanced denture. (ii) The Use of Cusp less Posterior Teeth. (iii) Over closure. (iv) The Use of Acrylic Posterior (v) Unbalanced Articulation (vi) Cuspal Interference preventing free lateral movements, under which heading is included, too great an overjet for the degree of overbite, or an incorrect incisive angle. (vii) Inexperience on the part of a patient wearing his first full dentures Treatment: Having discovered which of these faults is the cause of the complaint, the remedy is sufficiently obvious to require no further
  30. 30. (c) Dentures Dislodged by Eating
  31. 31. (iv) Insufficient Tongue Space
  32. 32. (v) Periphery Overextended. -
  33. 33. (vi) Inexperience.
  34. 34. 4. POOR RETENTION (a)When opening the Mouth Patients more often complain that the lower denture lifts than that the upper one drops. If this lifting only occurs when the mouth is widely opened, as in yawning, it should be explained that this is normal. The following are the usual causes: (i)Overextension
  35. 35. (ii) Tight Lips . (iii) Tongue Cramped
  36. 36. (iv) Underextension
  37. 37. (v) Lack of Peripheral Seal (vi) Lack of saliva
  38. 38. (b) When Coughing or Sneezing
  39. 39. 5. INSTABILITY This question has already been discussed in relation to its two main causes: (a) When Eating: Under the heading of inefficiency. (b) When Talking: (c) The Defensive Tongue:
  40. 40. 6. CLATTERING TEETH The noise appears to be considerable to: the patient and it is, in fact, frequently audible to his fellow diners. There are two main causes for this complaint of which the first mentioned is the most common. (a) Too Great a Vertical Height . This will cause the teeth to come into contact sooner than expected and therefore noisily. Treatment: Reduce the height. (b) Gross Cuspal Interference Complaints from this cause are rarely met without the accompanying complaint of instability, but in either case it is easily' distinguished from too great a vertical height. Treatment: This is as already described under the heading of pain.
  41. 41. 7. NAUSEA Although this subject has been discussed from the point of view of impression taking, there are some essential differences when considering nausea in relation to wearing a full upper, denture. The cause of the sickness is the same in both cases, light or intermittent contact on the soft palate or back of the tongue, and the patient's complaint is almost invariably 'that the upper denture goes too far back and makes me feel sick'. The causes are: (a)Denture Slightly Overextended Rare, but, if it does exist, the movements of the soft palate will 'cause it to make intermittent contact with the denture. Easily diagnosed by observing the relation of the posterior border to the vibrating line. Treatment: Remove the excess and re-post-dam if necessary
  42. 42. ( b ) Denture Underextended If the posterior palatal border of the upper denture does not extend, at least very slightly, beyond the termination of the hard palate It can' rarely compress the soft tissues sufficiently to maintain close contact with them under all normal conditions, and this will often cause nausea for the following reasons: (i) Intermittent Contact The denture moves owing to an inadequate air seal. (ii) A Palpable Edge The edge is-detected by the dorsum of the tongue, owing to its being insufficiently embedded in the mucous membrane. Treatment: Extend the denture almost to the vibrating line and post-dam adequately.
  43. 43. (c) Thick Posterior Border This is a very common cause of nausea resulting from the dorsum of the tongue being irritated by the thick edge. The palatal edge of the upper denture should be thin, and slightly embedded in the compressed mucous membrane, so that the tongue is unable to detect any definite junction of denture and mucosa. Treatment: Thin down the posterior border of the denture.
  44. 44. 8. DISCOMFORT Patients sometimes complain that new dentures are not comfortable but can give no specific cause for complaint. These cases are difficult to diagnose since they are not accompanied by pain, and retention appears to be satisfactory, but as the patient has nearly always previously worn dentures a careful comparison of the new with the old will generally give a clue to the cause. The causes may be: (a) Cramped Tongue Space
  45. 45. (b) Altered Vertical Height (c) Altered Occlusal Plane
  46. 46. 9. ALTERED SPEECH When full dentures are first worn there is always some temporary alteration in" speech owing to the thickness of the denture covering the palate, necessitating slightly altered positions of the tongue. Commonly this is only a temporary inconvenience, most rapidly overcome by reading aloud; when there is an altered position of the upper incisors, a change in their palatal shape, or any reduction of tongue space, adaptation may be very difficult even with perseverance. Treatment: The dentures must be re-made.
  47. 47. 10. BITING THE CHEEK AND TONGUE (1) Cheek Biting Two common causes for this condition exist: (i) Insufficient Overjet The normal occlusal relationship of the posterior teeth is with the buccal cusps of the upper teeth outside those of the lower teeth; this arrangement normally prevents the cheeks getting caught between the teeth and bitten. If for any reason this arrangement has been altered, or if a patient has very lax cheeks, cheek biting may occur. Treatment: Increase the buccal overjet and plump the denture; in some cases it maybe necessary to remove the last molar teeth or grind the buccal surfaces of the lower posterior teeth so that the lingual cusps only will make contact with the upper teeth
  48. 48. (ii) Reduced Vertical Height If the vertical occlusal dimension is grossly reduced, the resultant bunching of the cheeks allows of their being caught between the occlusal surfaces of the teeth as they occlude. Treatment: Restore the vertical dimension or, if this is impossible, grind off the buccal cusps of the lower teeth. (2)Biting the Tongue This is almost invariably due to a decrease in the tongue space occurring when fitting new dentures for patients already wearing dentures.
  49. 49. 11. FOOD UNDER THE DENTURE This complaint is usually made by patients wearing dentures for the first time and who have not yet learnt how best to control the food. Undoubtedly a perfect peripheral seal will prevent 'the ingress of food beneath the denture but perfection is rarely attained and, owing to alveolar absorption, never maintained. Scraping a groove in the model, along and near the entire periphery of the denture, is sometimes carried out but this food- line, as it is termed, usually causes some inflamma­tion and ulceration until it is finally established as a groove in the mucous membrane; it is rarely completely successful. Treatment: This usually consists of covering the maximum possible area and obtaining an adequate peripheral seal; thereafter, only perseverance by the patient can bring about any 'improvement.
  50. 50. THE SIX COMMONEST CAUSES OF DENTURES FAILING ARE: (I) Incorrect antero-posterior relationship of the mandible to the maxilla. (2) Uneven and locked occlusion - this is always present unless a careful check record has been carried out. (3) Open vertical dimension - not necessarily gross but sufficient to deprive the patient of a freeway space. (4) A cramped tongue. (5) Poor retention - due to incorrect outline usually under­extension of the periphery. (6) Failure to copy existing dentures when making new ones for an experienced denture wearer.
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