10- Post Insertion Problems and Complaints -.pptx

Inform patient of possible problems.
 Un-informed patient:
Sense of pain.
Sense of loss (waste of time and money).
Sense of deceit.

Within 3 to 7 days 3 to 4 months for difficult
patients 12 month interval
for most
Periodic Recall appointments
Examination to detect potential problems
Patient should point to problem
Corrected in early stage.
Eliminate pain or discomfort
Patients should be checked
within 24 hours

Diagnosis Causes Treatment
Managed by
Listen, examine & treat
Visual and digital examination of oral cavity.
Adjustment to eliminate any problem.

Causes are attributed to
Patient's
dissatisfaction
Denture
settling
Denture errors
Most of the complaints associated with complete dentures are actual
and not psychological, contrary to the belief of most clinicians.

Patient's dissatisfaction are attributed to
Denture
problems
Types of patient
Indifferent
Philosophical Hysterical
Exacting

Adaptive, Psychological Problem
Prevention: Interview
 Philosophical: Rational, sensible, organized and overcomes conflicts
(Expectations are real)
 Exacting: Methodical, precise and accurate; places severe demands (Must
reach an understanding before starting treatment)
 Indifferent: Apathetic, uninterested, uncooperative and lacks motivation;
blames dentist for poor health; pays no attention to instructions (Unfavorable
prognosis)
 Hysterical: Emotionally unstable, excitable, apprehensive (Psychiatric help
may be required)
House Classification of Patients

Denture problems
Old denture
Loose fit
New denture
Over extension Over closure
(Low VD)

The majority of the patients with new
denture may face one or more of the
following problems (Common complaints):
Pain Poor
appearance
Poor
masticatory
efficiency
Speech
difficulties
Poor
denture fit
Nausea
and
gagging
Clattering
or noisy
teeth
Cheek, lip
and tongue
biting
Food under
the denture
Mucosal
irritation
Discomfort
Uncommon
complaints

Loss of
taste
sensation
Halitosis
Burning
Sensation
Pain in
TMJ
Ear ache
Deafness
Drooling at
the corner
of the
mouth
Inability
to keep the
denture
clean
Dry Mouth Whistling
Excessive
Bulk
Tingling
of the
lower lip
Rough &
sharp
surfaces
Inability
to tolerate
dentures
Inability to
chew with
equal vigor
on both side.
Saliva
under the
dentures
Uncommon complaints:

Chewing
only
Occlusion
Gets worse
throughout
day
Occlusion
When first
insert
dentures
Denture
Base
Pressure
on first
molars
Denture
Base
History of Chief Complaint.. When?

1. Improper extension of the
periphery
2. Severe Undercuts
3. Insufficient relief
4. Incorrect occlusion, and
teeth off the ridge
5. Poor fit
6. Irregular and knife edge
ridge.
7. Rough fitting surface
8. Difficulty in swallowing and
Sore throat
9. Retained roots, unerupted
tooth or sharp bony spicules
10.Denture Stomatitis
• Infection with Candida Albicans
• Papillary Hyperplasia
11.Allergy

Questions to ask when assessing
oral pain
When obtaining a pain history:
Site – Where is the pain?
Onset – When did it start?
Character – Can you describe the pain?

Ridge VD
Denture
Borders
•Over-extension
Basal Seat
Uneven
pressure
Occlusion
Cuspal
interference
Poor fit
Mental Foramen
Pressure area
Improper impression
Warpage of denture base
Improper cast
CO#CR
Teeth off ridge
Roughness
Allergy DD Patch test
Remaining
Root
undercut
•Under-extension
(distolingual area)
•Rough border.
•Sharp border

 Over extension Interfere with muscle movement
 Under extension Break the seal, Mylohyoid ridge
 Improper trimming Thick or thin (Sharp) border
Borders

The most common cause of pain
Insufficient opening. Irritation caused by extended labial flange

Overextension of
labial flange on the
upper jaw. Irritation
areas: Cut in
vestibule

Labial and buccal frena
Should be thin and deep, not
broad.
Round internal and external
angles.

Over extension of denture
flange produces
TISSUE IRRITATION

In the form of
Ulceration
Hyperaemia Cut in vestibule

Never adjust without
locating exact position
of the problem,
Use P. I. paste

Never adjust without locating exact position
of the problem, Use P. I. paste

Irritation area due to deeply
prepared postdam area on the upper
denture.
The patient is feeling pain as soon
as the denture is inserted and this
pain becomes more acute when
chewing force is applied and there
is a deeply or sharply prepared
postdam area in the upper denture.

Identification of over extended denture flange
by means of pressure indicating paste(P.I.P.) or
a thin layer of alginate

Overextension of
labial flange on
the lower jaw
Irritation area:
Ulcer

A denture border short of the mylohyoid ridge
digs into the residual ridge and causes pain.
If shortened, the denture border will impinge
again upon the ridge.
Mylohyoid muscle

Border molding of the mylohyoid
ridge area should be performed
4-6 mm below this ridge.
Later the impression surface of
the denture on the mylohyoid
ridge area is relieved.
Mylohyoid muscle

Proper recording gives typical S–form
of the lingual flange

PIP Sequence
Dry denture surface.
Thin even coat of PIP with stiff brush
onto the surface of the denture.
Seat the denture with pressure in the
first molar region.
Remove immediately, Inspect and
adjust bearing surface as necessary.
Adjusting the denture base.
How to Read PIP?
• Streaks - no contact (N)
• No Paste - Impingement (I)
• Paste, no streaks - normal
contact (C)
N
C
I

Pressure indicating paste is used to determine
the prominent mylohyoid ridge.
Thin layer of alginate can be used instead of
PIP.

The complaint might be delayed:
 Here it is due to ridge resorption and often it is
accompanied by hyperplasia. In this case the cut
back denture should be lined with tissue conditioner.
When the hyperplastic region has been reduced a new
denture should be constructed.

Overextension of the periphery
New denture
Old denture
Occlusal view of the
edentulous mandible
Epulis fissuratum

Epulis fissuratum is a benign hyperplasia of
fibrous connective tissue which develops as a reactive lesion to
chronic mechanical irritation produced by the flange of a poorly
fitting denture. More simply, Epulis fissuratum is where excess
folds of firm tissue form inside the mouth, as a result of rubbing
on the edge of dentures that do not fit well. It is a harmless
condition and does not represent oral cancer. Treatment is by
simple surgical removal of the lesion, and also by adjustment of
the denture or provision of a new denture (Recovery Program).
It is a closely related condition to inflammatory papillary
hyperplasia, but the appearance and location differs.
Wikipedia

1. Tuberosities Undercut
• Often used by dentist to aid in denture retention.
• Associated with redness and ulceration.

Maxillary Tuberosity *
Palpate for undercuts if extreme, denture
might not seat.

Maxillary Tuberosity *
If enlarged: the posterior occlusal plane may
be placed too low, no enough space to set all
molars
Making the tuberosity area thinner
on the denture.

 Hamular Notches
 Commonly sharp flange
 Sometimes long
 Use PIP
Pain on insertion and removal.
Red and painful undercut area (ulcerated).
Irritation area caused by thick and overextended
maxillary tuberosity area of the denture.

Treatment:
• If moderate: Fitting Surface
cut away with no reduction of
periphery.
• If enlarged: Alveoloplasty +
New buccal or labial flange.
• Undercut on one side
insert in one side then rotate.

Unilateral undercut
Undercut on one side, inserted in one side
then rotate (change path of insertion of the
denture).
Treatment:

Presence of undercuts on the anterior
region of upper and lower jaws.

If the ridge is severely undercut,
the flange cannot be placed to
the depth of the vestibule,
otherwise the denture will not
seat or ulceration will occur
3. Disto-lingual Severe Tissue Undercuts

Areas to be relieved of the denture:
 Prominent bony areas (Median palatine raphe, Bony
tori (maxillary or mandibular), buccal canine region.
 Sensitive areas
Treatment:
 Apply pressure indicating paste to demarcate the area on the
fitting surface of the denture Relief

Poor base adaptation.
Fulcrum on bony.
structures.
Test hypothesis: PIP.

A denture border short of the mylohyoid ridge digs into
the residual ridge and causes pain. If shortened, the
denture border will impinge again upon the ridge.
Insufficient relief will cause pain during insertion and
removal due to insufficient relief of undercut area

Correct Amount
with Streaks
Insufficient
Amount
Too Much
Streaks

Insufficient relief Burning sensation

 Incisive canal – located in the anterior midline, transmits the
nasopalatine nerve; a terminal branch of the maxillary nerve (CN V3), it
runs from the nasal cavity, through the incisive canal and supplies the
tissues of the anterior part of the hard palate.
 Greater palatine foramen – located medial to the third molar tooth,
transmits the greater palatine nerve and vessels
 Lesser palatine foramina – located in the pyramidal process of the
palatine bone, transmits the lesser palatine nerve.

Mental foramen
 With resorption, it becomes over the
crest of ridge.
 Pressure from denture may elicit
numbness, localized or referred
pain.
Treatment:
Relief

Causes of Occlusal Errors
• Errors in impressions.
• Ill-fitting trial denture bases.
• Inaccurate jaw relation records.
• Errors during transfer of the records to articulator.
• Incorrect arrangement of teeth.
• Dimensional changes during curing.
• Processing faults.

Site .. Where is the pain?
. Is the pain in a specific area or widespread?
Onset.. When did it start?
• How long has the pain been continuing,
• Does the pain disappear after the removal of the
dentures?
• Is there continuous pain during the wearing of
the dentures, or is the pain increasing only at
certain times, for example, while eating?
Character.. Can you describe the pain?

Chewing only
Occlusion
Gets worse
throughout day
Occlusion
When first
insert dentures
Denture Base
Pain on
Pressure on
first molars
Denture
Base

 Undercut areas.
 Irregularities on the tissue surface.
 Overextensions.
 Pressure areas.
 Errors in occlusion.

1. Gets worse with chewing and during the day.
2. No pain when press firmly on 1st molars.
3. Denture dislodges or shifts when patient occludes
(tilting, twisting, tipping, sliding).
4. Patient complains of pain beneath denture bases by
biting. Ulcer or sore spots on sides of ridges.

1. If pain upon pressing firmly on 1st molars, adjust
denture base first until no pain.
2. Use finger pressure, Do NOT use occlusion to apply
pressure >> Occlusion could introduce tipping
forces.
3. Chew Test: Denture dislodges or shifts when patient
occludes (tilting, twisting, tipping, sliding).
What are the Methods of Detecting Occlusal Errors?

Chew Test:
 Chew on cotton ball on both side.
 Identify teeth that cause problem when chewing.
 Use articulating paper in excursions on those
teeth to remove tipping contacts:
 Heavy contacts
 Contacts buccal to the ridge.
 Contacts on inclines.

Incorrect Occlusion
VD CO # CR Uneven
Pressure and
Cuspal
interference
Improper tooth Position
White sore area
on the site of
pressure
VD
(Neurological
pain)
VD
(white
patch)
Contacts on
inclined portion
of ridge
Heavy anterior
interferences
Teeth off ridge

Incorrect Occlusion due to improper
tooth Position
Teeth off ridge
Cramped
tongue
Contacts on
inclined portion
of ridge
Heavy anterior
interferences
Upper buccal
sulcus of
working side
Tight lip
Vertical height
of mandibular
posterior Teeth.

1.Incorrect vertical dimension
 Low vertical dimension
 High vertical dimension
2. Incorrect Tooth Position
 Heavy anterior interferences
 Teeth off the ridge.
Labially placed mandibular anterior teeth.
Setting of upper posterior teeth far buccally.
Setting of lower posterior teeth too far lingually.
 Avoid Contacts on inclined portion of ridge.
 Vertical height of mandibular posterior Teeth.
3. Occlusal discrepancies
• Wrong anteroposterior relationship (Incorrect centric occlusion)
• Uneven pressure
• Severe disclusion of posterior teeth in excursions (lack of balance).
• Cuspal Interference.

High vertical dimension
Low vertical dimension
Solutions ???

Error during registration
stage. Or,
Incomplete closure of the
denture flasks.
Obliterated free-way space

Poor processing techniques.
 Poor laboratory technique
can result in the
movement of individual
teeth or in an increase in
occlusal vertical
dimension of the denture.

• Failure to close the flasks completely during
processing (Incomplete closure of flask causes
tooth movement).
• Too much pressure in closing flasks
• Shrinking of acrylic, processing changes

 Pain gets worse during day.
 Muscle/joint pain.
 Small white patches + painful areas.
 Pain returns within few days of
immediate relief over patches.
 Pain on crest of lower ridge.
 Dentures “click”, clatter, and
Distorted appearance. Obliterated free-way space

 Distorted appearance: Elongated appearance of face and
inharmonious facial proportions.
 Discomfort to patient: Obliterated free-way space lead to inability
to find comfortable resting position.
 Loss of biting power.
 Pain and muscular fatigue: The lips are unnaturally separated and
have a strained appearance. the stretching of facial muscles
causing pain.
 Clicking of teeth: Teeth are liable to contact causing noisy sounds
during speech and mastication.
 Interference with speech.
 Increased risk of trauma & pain of the basal seat
areas of denture, due to clenching of teeth.
 Generalized hyperemia and soreness of the residual ridge.
 Rapid bone resorption.
 Difficulty in swallowing and gagging sensation.
 Loss of stability of dentures.

Establishing the occlusal vertical dimension in
centric:
Occlusal VD is maintained by
occlusion of palatal upper
cusp and buccal lower cusp
(in normal occlusion).
( Supporting cusps)

 Minor reduction of the
supporting cusps
without causing anterior
interferences.
Establishing the occlusal vertical dimension in
centric:

Cheek Biting
 Either results from wrong jaw
relation records.
 Or from the alveolar ridge resorption
and/or acrylic teeth attrition.
 This condition is often a delayed not
immediate.
 Indefinite location of pain.
 May be associated with
temporomandibular joint dysfunction.
Angular Chelitis

 Indefinite pain location
 Lack of chewing power
 Angular (commissural) Chelitis
 Esthetic complaints:
 Chin prominent
 Poor lip support
 Cheek biting/ tongue biting/ lip biting
 Pain in temporomandibular joint and
sore muscles.
 Costen’s syndrome.
Cheek Biting
Cheek Biting
Angular Chelitis

 Inflammation of the angles of mouth.
 Attributed to excessive interocclusal
distance.
 It usually develops when occlusal
plane of the lower teeth is too high.
 This prevents the regular action of the cheek from eliminating the
saliva from the lower buccal vestibule, so saliva will exit through
the corners of mouth indicating spread of infection to the angles of
mouth.
 Advisable to construct new dentures.

Described by james. B. Costen in 1934.
He claimed that the symptoms forming his
syndrome were produced by over-closure of
the mandible >> Retruded condyles press on
the tympanic nerve, and that "opening the
bite" would clear up these symptoms.

The symptoms can be summarized as follows:
Otological symptoms: Tinnitus. Otalgia (ear pain),Hearing loss, Ear fullness or
stuffiness in the ear, Noises in the ear: Humming, ringing, crackling sounds,
Vertigo and Dizziness.
Facial pain.
Headache and neck pain: e.g. pain in the occipital region (the back of the head), or
the forehead or other types of facial pain including migraine, tension headache
or myofascial pain. Pain typical of "sinus disease."
Burning sensations and pain in the tongue (glossodynia), throat and side of the nose
and eye, as well as a metallic taste. (Burning mouth syndromes)
TMJ symptoms and pain: Tenderness and pain to palpation of the temporomandibular
joint and the muscles of mastication. Limited range of mandibular
movement, which may cause difficulty in eating, Noises from the joint during
mandibular movement, Joint noises may be described as clicking popping, or
crepitus (grating).

 Prolonged over closure
 Mild Deafness, tinnitus, blurring of vision
 Tenderness over the TMJ
 Dryness of mouth
 Neuralgic symptoms – burning sensation
of tongue, throat, nose and headache.
These symptoms may be resulted from
…………………………….??????

A. Chorda Tympani
B. Nerve to Mylohyoid
C. Inferior Alveolar Nerve
D. Lingual Nerve
E. Mandibular Nerve
These symptoms may be resulted from
pressure of the retruded condyle on
the auriculo-tympanic nerve (A)

Treatment:
1. Use of occlusal pivots to stabilize the occlusion,
followed by
2. Add tooth coloured self curing resin on the posterior
occlusal surfaces of the mandibular denture to
increase VDO gradually.

When the patients closes the mouth with the mandible
guided to the centric relation position, the occlusal
surfaces of maxillary posterior teeth are recorded in
the resin. Trim the resin to reestablish the contours of
the teeth.
Treatment:

1.Incorrect vertical dimension
 Low vertical dimension or High vertical dimension
2. Incorrect Tooth Position
Heavy anterior interferences
Teeth off the ridge.
Labially placed mandibular anterior teeth.
Setting of upper posterior teeth far buccally.
Setting of lower posterior teeth too far lingually.
Avoid Contacts on inclined portion of ridge.
Vertical height of mandibular posterior Teeth.
3. Occlusal discrepancies
• Wrong anteroposterior relationship (Incorrect centric occlusion)
• Uneven pressure or Severe disclusion of posterior teeth in excursions
(lack of balance).
• Cuspal Interference.

Heavy anterior interferences
Teeth off the ridge.
 Labially placed mandibular anterior teeth.
 Setting of upper posterior teeth far buccally.
 Setting of lower posterior teeth too far lingually.
Setting of Teeth on inclined portion of ridge.
Vertical height of mandibular posterior Teeth.

REMEMBER >> RULES
Whatever the concept
Try-in ???

 The horizontal overlap between upper and lower
anterior teeth is automatically decided by the
relation between the upper and lower residual ridges.
The horizontal overlap should be consistent throughout the
anterior region. At this stage it should be about 1.5 mm.

Flabby ridge(mobile or extremely resilient
alveolar ridge):
Is due replacement of bone by fibrous tissue.
Seen in anterior part of maxilla, as a sequelae of
excessive load of residual ridge and unstable
occlusal conditions.

Perpetually Loose Maxillary Denture
• Can cause loosening at posterior.
• Tuberosity mucosa grows into space.
• Space develops under midline of
denture base.

Tuberosity
Tilting Growth Loss of retention

Inclined
Residual Ridge
Lip
 Incisors placed too far labially
 Denture displaces lingually.
 Inclined ridge provides no resistance.
a. Labially placed mandibular anterior teeth.

Placement of upper and lower incisors excessively
labially
The stability of the denture is disturbed.
For the new denture, the lower anterior teeth should
be arranged as their position before the extraction of
the teeth.
Excessive labial placing of the lower anterior teeth,
to provide a normal overjet for patients with skeletal
class II, leads to the movement of lower denture
when the patient opens his/her mouth or laughs.

 Pain in upper buccal sulci and
tuberosities.
 Upper teeth are often too far
buccally (to meet occlusion in
cases of skeletal class III).
b. Setting of upper post. teeth far buccally
 During function, upper denture will tilt, digging the
periphery into the mucosa on the working side, and
pulling it down the tuberosity on the opposite side.

 Occlusal contact not centered
over ridge
 Tilting forces cause
displacement, abrasion,
ulceration.
 Worse if xerostomia,
malnourished, debilitated or
poor adaptability.
With Clinical Exam:

Patient demonstrates
problem by biting
where pain occurs
•Ulcer or sore spots on sides of ridges
Clinical Examination
Pain Upper buccal sulci and maxillary tuberosities.

Treatment:
Remove the last four posterior
teeth and reset and reduce the
bulk of acryl over the tuberosities
and reset.
New dentures

• Cramped tongue
• Instable denture
• Pain and discomfort
• Inefficient mastication
c. Setting of lower post. teeth too far lingually

Tilting/jiggling
• No teeth set over ascending portion of
ramus>> lateral forces>> instable denture.

• Avoids ascending portion of ridge.
• Drop 2nd premolar if necessary.
• Ensures adequate occlusal table (maintains 2
molars).

 Check centric position
(articulating paper)
Even, stable contacts
both sides.
Stop patient upon initial
contact.

Mismatch of ICP and RCP.
 Interdigitation of teeth locks the dentures together,
while the patient will not feel comfortable in that
situation
 Trials to Retrude the mandible will rub the denture
against the mucosa. This will cause pain and
looseness.

Incompatible centric
occlusion and centric
relation, lower denture moves
forward (anteriorly) and
irritation areas occur on the
anterior lingual part of the
lower jaw.

It is a relatively flat area having a length of 0.5-1mm,
created between centric relation and maximum
intercuspal position on the occlusal surfaces of the teeth,
gives the mandible freedom to close in Centric or slightly
anterior to it without any interference.
Freedom of centric (Long centric)

“LONG” CENTRIC No Anterior Contacts
The coincidence of Centric Occlusion & Centric Relation (CO = CR),
when there is freedom for the mandible to move slightly forwards from
that occlusion in the same sagittal and horizontal plane (Freedom in
Centric Occlusion). No anterior Interference, no change in VDO.

Nonequivalent contacts due to inadequate centric
occlusion. View of the dentures inside the mouth and
outside the mouth.
 Moderately wide, hyperemic (red), diffuse
and painful area.

 Mild error: chair side occlusal spot
grinding.
 Moderate errors: Clinical remount and
Selective grinding of teeth.
 Gross errors either replace posterior teeth
or remake denture.

Error in setting artificial teeth, or / Lack of occlusal
balance. resulting in the tilting of dentures.

a) Inaccurate centric occlusion (early contacts on the
right side) >> Irritation area over the right crest.
b) Correction of inadequate occlusion according to the
severity of the case.
1.Localized Pain: Pain is confined to the crest of
the ridge on one side.

Traumatic ulcer or sore spots
as a result of unbalanced
occlusion
2. Localized Pain: Pain is related to buccal aspect of the
ridge on one side and lingual aspect of the ridge on the
other side as the problem causes tilting of the denture (it
is mainly the lower).

• Lesser degrees of errors can be detected by a
celluloid strip or articulating paper on either side
with the patient closing just to hold it without
reaching the tilting point of the denture bases
• If more it is detected with a wax knife.
Diagnosis:

Uneven pressure:
Errors can be detected by a wax knife on either
side with the patient closing in centric.

Treatment:
 Slight error: chair side occlusal grinding.
 Moderate errors: clinical remount.
 Severe errors: remake denture or replace
posterior teeth.

The presence of premature contacts on the occlusion
cause an increase of the forces over the crests in certain
areas. Inflammatory changes can be easily noted visually
and are observed in these areas. Correction of inadequate
occlusion by: grinding in centric relation
After
Before.
Re-establishment of C.O.

A Dragging action will be exerted on both dentures during
lateral and protrusive movements with teeth in contact if
cusped posterior teeth are used or if excessive incisal
guidance angle has been used.
Dragging will cause pain
With Well Fitting Retentive Dentures Or
Instability with poorly retained dentures.
Pain is widely distributed, and only experienced on eating.
Sore areas on buccal or lingual surfaces of the ridges or on
the ridge crest.

(a) Existence of premature
contact in the premolar
region.
(b) Irritation or
hyperemic areas on
the ridge crests.
1. Pain in the Premolar Region

a. Overextended flanges in
the anterior area of the
denture.
2. Pain at the Peripheral Regions of the Denture
Pain in the anterior lingual margin of the lower jaw.
There are two reasons for pain in the lingual margin
of the lower jaw:
The denture flange areas
should be shortened

b. The presence of premature contact in the posterior region
. As a result of the premature contact, the lower denture
comes forward, causing pain in the lingual margin.
Grinding is made, thereby determining the premature
contact areas.

(a) A posterior premature contact, resulting in forward
movement of the lower denture (dotted arrow), produces
inflammation of the mucosa on the lingual aspect of the
alveolar ridge in the anterior region.
(b) Lateral displacement of the lower denture produces inflammation
of the mucosa in areas closely related to the occlusal error.

 This is mostly seen in the lower jaw, which has less
supportive area.
 After being determined, the premature contacts arising from
the occlusion are grinded until they are balanced.
3. Moderately wide, red, and painful diffuse area

Irritation of the Crest of the Ridge
Localized Lesion Generalized Lesion Hyperkeratotic Ridge
Occlusal Prematurity Lesion –same side as error

 Severe disclusion of posterior teeth in
excursions (lack of balance).

a. Three-point contact in lateral movement.
b. Three-point contact in protrusive movement

(a) Lack of balance on the posterior teeth in
protrusive movement.
(b, c) Providing balance on the posterior region
in protrusive movement.

Mild: Chair side grinding or clinical remount.
Gross: New dentures with balanced occlusion.
Treatment

The sequence of steps should be as follows
Restore the vertical dimension
Re-establishment of C.O.
Correction of working side occlusal errors.
Correction of balancing side errors.
Correction of protrusive relation.

p
B
a. If the cusp is high in centric and eccentric relation,
reduce cusp.
b. If the cusp is high in centric but not eccentric,
deepen fossa.
Re-establishment of Centric occlusion:

 Correction of occlusion done by reducing buccal incline of upper
Lingual cusp and Lingual incline of lower buccal cusp or deepening
their corresponding fossae.
p
B
Re-establishment of Centric occlusion:
 Do not grind the cusp tips unless it is high in every excursion, but rather
reduce the fossa or inclined plane of the cusp.

DO NOT Reduce maxillary lingual cusps.
DO NOT Reduce mandibular buccal cusps.
These cusps are essential to maintain the
recorded vertical dimension
DO NOT Deepen the fossae.

“LUBL rule on the
balancing side
"Bull rule on the
working side "
Correction of
protrusive
interferences
Re-establishment of eccentric occlusion:

Briefly
 Occlusal VD is maintained by occlusion of palatal upper cusp and
buccal lower cusp (in normal occlusion).
 Reduce cusps: If the cusp is high in centric and eccentric relation.
 Deepen fossa: If the cusp is high in centric but not eccentric.
Re-establishment of C.O.
BULL rule in:
 Working side interferences.
LUBL rule in:
 Non-working side interferences.
DUML rule in:
 Protrusive interferences.

• Patients can have multiple problems.
Examples:
• Denture base with sharp edge that doesn’t cause
problems until occlusion causes tiling of denture.
• OVD problem with an occlusal interference – makes
symptoms worse.
• Use history and exam to identify etiology.

Don’t Adjust Occlusion Intraorally
• Contact on inclines can cause
denture movement.
• May cause pain, or reflex.
• May make interference difficult to
mark.

Why is it difficult to detect occlusal errors in the
mouth?
 Negative attitude (assume an error exists and try to find
it)
What is the ideal occlusal contact?
At first contact, even maximum intercuspation at CR
without denture shifting or instability & without pain.

Adjusting Occlusion
 Reduces adjustment time.
 Saves time removing & replacing dentures.
Remount denture on an articulator
 Eliminates denture movements.
 Can visualize interferences easily.
 Centric relation & protrusive records.
 Mark centric & excursive contacts, adjust.

Mounting the lower cast with
new CJRR.
Make sure the denture bases
are not contacting posteriorly.
Clinical Remounting Procedure

 Looseness of dentures or poor fit usually
results due to lack of stability and/or
retention of the denture.
 Denture movement over the mucosa will
cause pain and areas of inflammation might
be present.

Treatment:
According to the cause.
Relining using tissue conditioner of old
denture or
Construct a new denture.

Related symptoms
Normal
 Open wide (Yawing)>>
Coronoid process
 Cough& sneezing
 New denture
 Saliva.
Abnormal
- Speaking
- Eating
- Pain

Principle
Always have the patient
demonstrate how a denture loosens
Denture Looseness

Denture base (fit & contour)
Occlusion
Poor anatomy
Poor denture fit

Borders
Fitting surface
Polished surface
Denture base (fit & contour)

 Improper border extension.
 Posterior peripheral Seal is not successfully made.
 Insufficient relief:
 Rocking, tilting dentures (poor retention).
 Burning sensation, Numbness.
 Shape of the polished surface.
 Sharp nodules of acryl on the fitting surface
(discomfort).
 Faulty impression / poor processing techniques.
 Dry Mouth (Xerostomia)

Typical History
Loose/discomfort immediately on
insertion
Denture Looseness
Denture Base:

• Pull upward and outward on canine.
• Add compound or wax.
1. Lack of post dam/ Retrozygomal seal

•PIP streaks
•Looks short of
vestibule
•Often displaces easily
2. Short flange

 PIP burn through
 Retentive until
speaking, eating.
 Watch when seating denture.
 Flange touches vestibular depth.
3. Long flange

The denture base must be contoured to permit the
modulus to function freely, to avoid displacement of the
denture.
The distobuccal corner of the
mandibular denture: The buccal
flange must converge medially to
avoid displacement due to
contraction of the masseter muscle.
Masseteric Muscle influencing area

Buccal
Attachments
To Hyoid
Mylohyoid Ridge
Cross section through
Mandibular ridge
in 2nd Molar region
Avoid Impinging on the Mylohyoid Ridge
A problem if
prominent or sharp
Retromylohyoid Overextension

A denture border short of the mylohyoid ridge digs into
the residual ridge and causes pain. If shortened, the
denture border will impinge again upon the ridge.

 Sore throat.
 Denture moves when
swallow.
 From retromolar pad, flange
should go straight down or
angle forward, never
backward.

If flange is too thick
 Seal may be maintained at rest.
 Pulls during function – drops.
If flange is short or long
 Displacement as lips or cheeks move.
 Allows air to break vestibular seal.
4- Thick flange

Mandibular lingual flange too thick
Tongue
Flange bulges into tongue space, lifts denture
during function. Flange is not too long.
“Eyes in Your Fingers”
Blanchard, JPD 2:36

Raphe from area of hamular
notch
Very tight in some patients.
Easily displaceable, but raphe
can displace denture during
wide opening.
5. Pterygomandibular Raphe

 Hard palate
 Zygoma
 External oblique ridge
 Before retromolar pad
 No seal, discomfort
 Eventual resorption
Dry Mucosa
6- Periphery terminates on
bony structures

Principle
Denture peripheries always terminate
on displaceable soft tissues
Retromolar pads, Vestibular tissues,
Vibrating line (non-movable soft
palate), Hamular notches

 Thick flange in retrozygomal
area.
 Coronoid gets closer to
tuberosity as patient opens
or moves jaw to side.
 Dislodges maxillary denture.
Polished surface:
7. Coronoid Interference

The buccal space or REZYOMATIC SPACE
Coronoid Process Area

Pain at disto-buccal area (tuberosity area) of the
upper denture on opening due to:
Extremely thick buccal Flange and constraining
coronoid process.
Treatment
Use PIP, relief and repolish

Areas to be relieved of the denture:
 Prominent bony areas (Median palatine
raphe, Bony tori (maxillary or mandibular).
 Sensitive areas
Treatment:
 Apply pressure indicating paste to demarcate the
area on the fitting surface of the denture Relief
8. Insufficient relief
Fitting surface:
Discussed before

Denture Looseness
1. Denture base (fit & contour)
2. Occlusion
3. Poor anatomy

Loose Maxillary Denture
• Heavy anterior interferences can cause loosening
at posterior
 Incisors placed too far labially Denture displaces
lingually.
Tilting/jiggling caused by:
• Contacts not centered over ridge
• Contacts on inclined portion of ridge
 Check centric position (articulating paper)
Occlusion

Typical History
Adequate stability initially
Gets worse with time

 Pain on eating
 Pain / Ulceration lingual to lower anterior ridge
 Pain / ulceration labial aspect of lower ridge and
incisive papilla on upper ridge
 Excessive vertical dimension
 Cheek / lip biting
 Tongue biting
Discomfort and pain
Related to Occlusal Surface Discussed before

Mild error: chair side occlusal spot
grinding.
Moderate errors: Clinical
remount.
Severe errors either remake denture
or replace posterior teeth.

Denture Looseness
Occlusion
Denture base (fit & contour)
Poor anatomy

Denture Looseness
Poor Anatomy
More involved/precise impression & jaw
relation procedures
If can’t identify problem, Refer.

Cleft Palate or Prominent. Midline
Fissure, Soft Palate
 In some patients midline soft palate fissure
 Can“tent”during function
 Allows air to leak under denture.

Normal size and function.
 Lateral borders rest at level of
mandibular occlusal plane while
dorsum is raised above it.
 Apex rests at or slightly below
the incisal edges of mandibular
anteriors.
Macroglossia
Tongue Position and function

How to Manage Large Tongue?
Lower the occlusal plane
Use narrower teeth
Increase the intermolar distance
Grind off the lingual cusps
Avoid setting a second molar

 Retruded tongue position
deprives patient of border
seal of lingual flange in
sublingual crescent and
also may produce
dislodging forces on distal
regions of lingual flange.

Frenal Attachments
 Fold of mucosa found at different
locations in the sulcus region of
upper & lower ridge
 Class I: sulcal or low attachment
 Class II: midway between sulcus
& crest of ridge.
• Class III: crestal attachment (frenectomy)

Floor of the Mouth
 If floor of the mouth (FOM) is near the
level of the ridge crest, retention &
stability of denture is less.
• Hyperactive FOM reduces retention
& stability.
• If great ridge resorption, FOM in
sublingual and mylohyoid regions
spills on the ridge Patency of
submandibular ducts.

The Soft Palate
(Palatal Throat Form)
House’s classification
 Class I: the soft palate is
almost horizontal curving
gently downwards
 Class II: the soft palate turns downward at about 45 angle
from the hard palate
 Class III: the palate turns downward sharply at about 70
angle to the hard palate.

Bony Prominences
Midpalatal raphe
Sharp ridge crest
Sharp mylohyoid ridge
Prominent genial tubercles
Bony fragments & fractured root pieces
Tori
Discussed before

Maxillary Tuberosity
If enlarged: the posterior occlusal plane may be
placed too low no enough space to set all molars.
If extreme: denture might not seat
The contour of a cross section of a residual ridge
that would prevent the placement of a denture or
other prosthesis

The Hard Palate (Vault)
 Class I: U shaped, most favorable for retention & stability.
 Class II: V shaped: Not very favorable
 Class III: Flat or shallow vault: Not very favorable,
accompanied by resorbed ridges, poor resistance to lateral
forces

(House’s classification), they are classified into:
Class I. Square: is the best form to
prevent rotational movements.
Class II. Tapering associated with high
arched palate, less retention
& stability.
Class III. Ovoid (less common).
Arch Form

Cross-section, resorption, sharpness,
spines, flabbiness, irregularities
should be evaluated.
Ridge Form and Contour
• Undercuts and Maxillary tuberosity, Mylohyoid
Ridge, Slope of Retromolar Pad, Lingual Pouch

It varies between upper & lower arches & from one
area of the arch to another arch. It can be divided
into:
 Normal ridge (I, II).
 Knife-edge ridge (narrow V-shaped class III)
 Flat ridge (resorbed ridge class IV)
 Irregular or undercut ridge (bulbous class V).
Ridge Form and Contour

Maxillo-Mandibular Relationship
Ridge relations
1. Residual ridge size.
2. Buccolingual relation (normal or cross bite).
3. Anteroposterior relations and denture stability.
4. interridge space.

Saliva Consistency
 Thin serous: provides an insufficient film for
denture retention.
 Thick mucus: thick ropy saliva tends to displace
denture.
 Mixed Amount: Normal: ideal for denture retention
 Excessive: make denture const. messy.
 Reduced: reduced retention and increased
soreness; salivary substitutes may be prescribed

Individuals with xerostomia often complain of
 Problems with eating, speaking, swallowing and
wearing dentures.
 The tongue sticking to the palate.
 Often complain of taste disorders (dysgeusia),
 A painful tongue (glossodynia)
 An increased need to drink water, especially at night.
Xerostomia

Some common problems associated with
xerostomia include:
• A constant sore throat,
• Burning sensation,
• Difficulty speaking and wallowing,
• Hoarseness and/or dry mouth
• Oral candidiasis is one of the most common
oral infections seen in association with
xerostomia.

Drugs Causing Xerostomia
 Diuretics
 Antihistamines
 Atropine
 Anticholinergic
 Antihypertensive
 Antiparkinson (Norflex)
 Corticosteroids

Oral and Facial Musculature
 The polished surfaces are properly shaped,
 The teeth are positioned in the neutral zone.
 The denture bases are properly extended to cover
the maximum area possible.
 Occlusal plane levelled below the maximum
convexity of the tongue.
Muscular control is an important aspect of successful
complete denture therapy. providing that:

Principle
Always have the patient rate
improvement (100%) after adjustment.
If below 90%, more
diagnosis/adjustment is required
Denture Looseness
and PAIN

Pressure during mastication causes pain .
Treatment: Relief over the sharp irregular ridge.
Alveolectomy followed by relining the denture

 Often the lower ridge. The denture squeezes the
mucosa against the sharp bony ridge.
 Pain may be accompanied with burning sensation.
Worst after meals.
Treatment:
Relief over the sharp irregular ridge.
Alveolectomy followed by relining
the denture. or simply: relief over
the sharp irregular ridge.

 This results in rough area on the crest of ridge with
sharp spicules of bone.
 Pain will be elicited when the intervening mucosa
is pressurized.
 Similar to pain due to narrow resorbed ridge, but
pain is localized.

Treatment:
Relief over the sharp irregular ridge
Surgical smoothing of the affected area
followed by relining
the denture.

Common causes of pain arising from the
impression surface of a denture are
indicated by numbers
(1) Surface roughness associated with
sharp projections and acrylic nodules;
(2) Sharp edge of relief chamber;
(3) Overextension into bony undercuts.
Sharp nodules of acryl on the fitting surface.

Rough contact or fitting surface
 Small pimples or blebs of acrylic
over the fitting surface due to
inaccuracies of the surface of
the cast.
Treatment:
 Remove roughness by acrylic
bur.

 Over-extension or under-extension of the Upper denture:
Slightly Under-extension causes intermittent contact with the
tissues.
 Thick posterior border: Irritates dorsum of the tongue.
 Pressing in the hamular notch area or the postdam region.
 Protrusive imbalance: This will cause the upper denture to
dislodge posteriorly and tickle tissues there.
 Over- extension of the disto-lingual area of the lower denture, in
the lingual pouch.
There will be an area of slight redness or ulceration.

– The Medial Pteregygoid
– The Superior Constrictor Muscles
– The mylohyoid muscle
– Palatoglossus muscle
Distolingual area
compressing the
tissues
•Proper recording gives
typical S–form of the lingual
flange.

Anatomical structures affecting lingual border of
the mandible
1. The Genioglossus muscle
2. The mylohyoid muscle.
3. Sublingual gland.
4. The Superior Constrictor Muscles.
5. Pterygomandibular raphe
6. Palatoglossus muscle
7. The Medial Pteregygoid.

Treatment:
Reduction of the over extension.
Pulled S –form of the
lingual flange.

Treatment
Upper denture slightly over-
extended or under-extended:
Remove over-extension and
readapt post dam.

Pain results from direct pressure on
an area already tender.
Treatment:
Extraction of the root or tooth,
followed by relief over the area. OR
relining of the denture.

Treatment:
Treating the condition
+
Rare.

(Smoker's Palate) is a lesion on the
roof of the mouth. The concentrated
heat stream of smoke from. tobacco
products causes Nicotinic Stomatitis.

Contact Allergy to Denture Resins

 It is difficult for some patients to formulate a decision
regarding aesthetics at the try-in stage.
 The presence of a friend, spouse or relative at the try-in stage
will help the patient make such a decision and accept it.
 The patient might accept the trial denture and still remain
unsatisfied with the finished denture.
 Final esthetics can be assessed only 4-6 weeks after the
insertion of the denture due to adaptation of lips and muscles.

 Nose and chin approximating
 Cheeks and lips falling in
 Angular cheilitis or soreness of the corners of the
mouth
 Colour, shape, size and position of anterior teeth.
 General dissatisfaction---- who?---female middle age
--- need kindness and patience.

1- Nose –chin approximation
Due to closed bite.
Treatment:
As reduced bite.

 Nose and chin approximating (Closed or high bite)

As the occlusal vertical dimension is too small, the vermilion
border appears thin and wrinkles occur around the lips.
The chin is apparently protruded.

Frontal and b, profile views of patient demonstrating overclosure and collapse of
nasolabial features due to VDO that is reduced.

Plumping: Unsupported lip and cheek.
Due to lack of tone of facial muscles.
Due to labial and buccal resorption in max. ridge.
Teeth have been set too far lingually or
Having insufficient width of the buccal and labial
flanges.
2. Cheeks and lips falling in

Sunken lips and cheeks
Treatment: Building up of the upper denture.

Corner of Mouth
3. Angular cheilitis or soreness of the
corners of the mouth

• Loss of muscular tone and decreased
VD
• Saliva bathed in the fissure
secondary infection .
Treatment: Restoration of VD.
3. Angular cheilitis or soreness of the
corners of the mouth

4. Colour:
5. Shape and Size:
Too large or too small
Teeth: too dark or too yellow
Acrylic resin.
Treatment: Replace teeth or new denture.

6. Arrangement and position:
Even or irregular
Too far forward or backward
Cheeks & lip falling- in
Treatment: Replace teeth or new denture.

Irregular Occ. plan
Cheeks& lip falling- in

Anterior teeth have been set too far out into labial sulcus. A, resulting incompetence
of the resting lips. B, and excessively full lip appearance, C.

Anterior teeth have been set too far in into labial sulcus. A, resulting depressing the lips.

Colour, shape and position of anterior teeth.
Remember: there is upper labial resorption, Making the teeth too far lingually).

Shape, Shade and Position of
teeth

7. Amount of tooth showing:
Treatment: New denture with corrected occlusal
plane.
Smile view of the patient and amount of tooth showing:

8- General dissatisfaction
with teeth
• Appearance
• Women
• Middle Aged
• Menopause.

Appearance and Shape
Complaint: “ They don’t look right”.
Treatment: remove teeth, mount other
new teeth of different shape in wax until
suitable ones are obtained.

A. Mastication
Inability to Eat Anything
Inability to Eat Meat
Dentures dislodged by eating
B. Phonetics (speech difficulties)

Dislodgement during eating
Borders
New denture
Anything
•Cuspal
interference
•Unbalanced
articulation
•Flat teeth
Meat
Improper tongue Space
Cuspal interference
unbalanced articulation
Tooth off ridge,
V.D.
Occlusion
Basal seat
Eating
experience
Overextension
Unstable
denture

Cuspless teeth
Improper tongue space
Denture dislodged by eating
1. Usually, new denture wearer.
2. Certain food stuffs are more difficult to consume.
3. Habit of eating on anterior teeth only
4. Overextended flange
5. Instable denture
6. Using Non-Cusped teeth
7. Lack of interdigitation of posterior teeth.
8. Unbalanced occlusion and articulation
9. Cuspal interference
10.Teeth outside the ridge
11.Cramped tongue: Restricted tongue space
Occlusion
Border
Base
General
problems

• Improper position of anterior teeth:
• Encroachment on tongue space:
• Poor denture retention.
• Excessive salivation.
• Vertical dimension →P, B, F, V

Anterior Teeth:
Improper Labio-lingual positioning and Vertical
overlap → "S" sound → (Whistling or lisping).
 Encroachment on tongue space:
a- Posterior teeth placed too far lingually.
b- Too great Bucco-lingual width of posterior teeth.
c- Excessive thickness of the lingual flange.
d- Poor palatal contour (Rugae area)→"S" sound→P.I.P.

The Linguo-alveolar S, Z, and, C (soft), sounds:
Linguo-alveolar consonants:
The S, Z and C sounds (sibilants): the formation of a narrow midline groove of the
tongue through which air is directed against the incisal edge of the teeth; the
lateral margins of the tongue contact the teeth and gingivae and the blade of the
tongue nearly touches the alveolar ridge. The palatopharyngeal valve is closed so
that the air stream for these continuants can be emitted orally

•The upper and lower incisors should
approach each other end-to-end, but
they should not touch that indicate a
possible error in the amount of
horizontal overlap of the anterior
teeth.
•Always check on the total length of the
upper and lower teeth (including their
vertical overlap)

Lisping:
 Too small anterior air space
 Too much overlap
 Teeth are set too far palataly
 Palatal contour too constricted
 Bulky Rugae Area
 Insufficient tongue space
 Improper occlusal plane

Whistling:
 Too large air space on the anterior part of the palate.
Indistinct TH and T Sounds
 Inadequate interocclusal space
T sounds like TH:
 Upper anterior teeth too far lingually
F and V sounds indistinct:
 Improper position of the upper anterior teeth either
vertically or horizontally.

Lisping
Bulky Rugae
Altered speech
Can be enhanced by exercise, otherwise remake.

Anterior Tooth Setup
 Check symmetry with
reference lines.
 Anterior teeth don’t
contact in centric
position.
 Grazing contacts in
excursions.
Overjet = 2mm
Overbite = 0mm

No Anterior
Contact in Centric
Correct
Insufficient
Excessive

• Check for one half tooth offset between maxillary &
mandibular teeth
• Ensures posterior teeth have normal cusp to fossa
relationship for lingualized occlusion

Canine Offset
Correct
Insufficient
Improper offset
results in a space or
half tooth
replacement

Phonetic Assessment
 Maxillary centrals should
lightly touch vermilion border
of lower lip for ‘F’, ‘V’ sounds
 ‘S’ sounds - incisal edges
should approximate each other

If the channel formed
between the hard palate and
the tongue is too narrow and
deep
Whistling
Lisping “Sh” sound
if the depth of the channel is
further decreased or
obstructed
Lisping and whistling are opposite phenomena
If this channel is too shallow
(broad and thin)
Lisping(th or etts)

In the production of the fricatives f, v, and ph sounds,
the lower lip is brought into contact with the incisal edges of the
maxillary anterior teeth. The lip may curt over the labial surface
of the maxillary teeth to a height of 1-2 mm.
Labio-dental Consonants:

Effects of labiodental consonants in
denture construction
• Upper anterior teeth too long or too far posterior
or too far anterior.
 Position of the maxillary and mandibular
anterior teeth
 Vertical dimension: Increasing or decreasing
of the V.D. affects the pronunciation of the
labio dental sounds.

Phonetic Assessment
 Maxillary centrals should
lightly touch vermilion
border of lower lip for ‘F’,
‘V’ sounds
‘S’ sounds - incisal edges should
approximate each other

Looseness of dentures or poor fit
usually results due to lack of
retention and/or stability of the
denture

Loose Dentures
Symptoms
Difficult
Speech and
mastication
Denture
falling
Food
entrapment
Pain
Causes
Decreased
retentive
forces
Increased
displacing
forces
Support
problems

Denture becomes loose when the
displacing forces acting on the
denture are greater than the
retaining forces.

Reduced retentive force
Lack of posterior palatal
seal
Under extension of
borders
Xerostomia
Excessive relief
Increased displacing force
Over extension of the
border depth and width
Occlusal Errors
Inadequate
supporting structure

The retentive Denture could
be stable or not.
But un-retentive denture
never be stable. Why???

 Overextension
 Under-extension
 Tight lips will push the lower denture backwards and
upwards
 Cramped Tongue Restricted tongue space
 Lack of peripheral seal (adding tracing compound,
then reline).
 When coughing or sneezing

 Un-retentive denture
 Insufficient relief
 Incorrect centric occlusion
 Cuspal interference
 Unbalanced articulation
 Teeth off the ridge
 Insufficient tongue space
 Technical discrepancies
 When eating
 When talking

1. Heavy anterior interferences
2. Contacts on inclined portion of ridge
3. Uneven pressure
4. Decrease or increase of V.D.
5. Occlusal discrepancies. CO # CR.
6. Setting the teeth off the ridge
Labially placed mandibular anterior teeth.
Buccally and Lingually placed posterior teeth.

Simplified cross-section to illustrate the seal arising from compliant tissue, flow restriction in
narrow spaces, and the effect of surface tension in a well-fitting denture

Class I, II and III soft palate: (a) Hard palate, (b) soft palate, (c) palatal
extension of denture

Poor Denture fit
A. Flat ridge
B. Flabby ridge
C. Fibrous displaceable
tissues
D. Bony Prominence
Retention, stability or Support XXX
Inadequate supporting structure

Poor retention of Lower denture
Less
surface area
Bathed in
saliva
Strong
movements of
the tongue
Relieved

Treatment:
 According to the cause.
 Relining of old denture XX
 Or Construct a new denture.
Poor Denture fit

An involuntary series of uncoordinated spasmatic movements
of the swallowing muscles due to stimulation of the swallowing
receptors situated in the posterior pharyngeal wall .
Causes:
1. Systemic disorders .
2. Psychological factors.
3. Physiologic factors.

Psychological gagging is the most
difficult to treat since it is out of the
dentist's control. In such cases, an
implant supported palate-less denture
may have to be constructed or a
hypnotist may need to be consulted.

 Loose dentures
 Poor occlusion
 Thick distal termination in upper dentures
 Palatal placement of upper posteriors
 Low occlusal plane
 Overextended retromylohyoid area
 Underextended denture borders
 Psychogenic

Managements
Pre-prosthetic managements.
The use of medications.
During clinical procedures.

During clinical procedures
1. Seat the patient in upright position .
2. Tell the patient that little difficulty will be encountered.
3. Ask the patient to breathe deeply.
4. Direct the patient attention to other subject.
5. Start with the lower impression first.
6. Select the proper impression material, with fast setting
time.
7. Use proper amount of the impression material.
8. Seating the posterior part of the upper tray first .

9. Use local surface anesthesia .
10. Bead the posterior border of the tray.
11. Mix the impression material out of the sight of the patient.
12.Never say the word GAG.
13.Encourage physical and mental relaxation.
14.Speak loudly and clearly to the patient.
15.Ask the patient to rinse with astringent before the procedure.
16.With impression procedures tilt the patient head forward.

Treatment
 Upper denture slightly over-extended or under-extended:
Remove over-extension and readapt post dam. under-
extension causes intermittent contact with the tissues.
 Thick posterior border: Irritates dorsum of the tongue.
 Protrusive imbalance: This will cause upper denture to
dislodge posteriorly and tickle tissues there.

(Clicking of teeth)
1. Increased vertical dimension
2. Porcelain teeth
3. Movement of lower denture.
4. Increased incisor overlap
5. Loose dentures
6. Cuspal interferences and lack of balance

Cheek and lip biting could be due to:
1. Lack of horizontal overlap: Premolar and molar teeth
that occlude edge to edge… grinding the buccal cusps
of the mandibular posterior teeth.
2. Reduced VDO, cheeks tend to
collapse into the occlusal area
3. Incorrectly positioned occlusal plane.
4. Monoplane teeth.

 Monoplane
 Heavy Bite
 No Horizontal
Overlap

a. Lack of horizontal overlap on
the left posterior region of the
lower denture.
b. Existence of cheek biting.
c. Providing adequate horizontal
overlap in the posterior area by
changing the position of teeth.

The horizontal
overlap prevents
biting of cheek &
lips
Horizontal overlap
Beumer J, DDS, MS and Michael Hamada DDS: 16. Occlusal Schemes - Lingualized Occlusion
Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry UCLA School of
Dentistry.

(a) Low vertical dimension.
(b) Patient bites cheek even
though there is sufficient
overjet on posterior
teeth.
(c, d) Chronic cheek biting

a.Inadequate teeth arrangement, cheeks are supported by
the denture base.
b.Cheeks go between the teeth in cross bite.
c.The solution is to make the upper denture base thicker.

 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.

Food Collection
1. Only during the initial period of adaptation
to the prostheses.
2. Under-extended border.
3. No peripheral seal.
4. Unfitted denture.
5. Improper flange thickness.

If the denture border is underextended in the buccal shelf area.
Therefore, it will not be able to occupy the buccal pouch.
A space will occur between the denture border and the lower muscle
bundle of the buccinator, resulting in food accumulation.
The fibers of the buccinator run anteroposteriorly so that the force
dislodging the denture during mastication is minimal..

Causes
Pressure by denture
Over extension
Movement of denture
Improper occlusion

Types
Generalized localized
Acute chronic

Bruxism
Increased
VD
CO#CR
Oral
hygiene
Allergy Xerostomia
Eccentric
occlusal
interference

Examination
Xerostomia
24 h rest
Oral hygiene
Recurred
Another
denture
Allergy
Fluid
TTT
Bruxism Remove denture at night
Tranquilizer
Food debris Patient instruction
Wear facets

Denture shifting
anteriorly
Increased VD
CO#CR
No contact on the
other side
Eccentric occlusal
interference
Clicking of teeth
Another
denture
Grinding
Grinding

Occlusion
• Occlusal
interferences
•Over extension
Border
• Ridge
• Spicules
& remaining roots.
• Denture Pressure (PIP)
Basal Seat
•Unpolished
• Tooth off ridge

Treatment
Remove the cause Tissue rest

 All the previous complaints cause discomfort.
 Cramped tongue space.
 Tingling or Numbing sensation.
 Altered vertical dimension
 Altered occlusal plane
 Altered position of the upper incisors and thick
palate.
 Unemployed ridge: difficult to wear lower denture.
High Plane of Occlusion

Loss of
taste
sensation
Halitosis
Burning
Sensation
Pain in
TMJ
Ear ache
Deafness
Drooling at
the corner of
the mouth
Inability
to keep the
denture
clean
Dry Mouth Whistling
Excessive
Bulk
Tingling
of the
lower lip
Rough &
sharp
surfaces
Inability to
tolerate
dentures
Inability to
chew with
equal vigor on
both side.
Saliva
under the
dentures
Uncommon complaints:
Sharry.J.J Complete denture Prosthodontics, 3rd edition, chapter 17, p. 358
According to Sharry

Acrylic Resin
Explain to the Patient
Metal base.
Patient
instruction
Bacterial growth
Diagnosis: black area with
bright light
Oral Hygiene
Hidden porosity
• Consuming very hot or very cold food will also help to stimulate the
remaining taste buds. Patients should be encouraged to flavor their
food.

• Food may become lodged underneath dentures and can be
the root of any potential bad breath.
• The plaque caused by the lingering food can form a layer
around dentures, creating an unpleasant smell.
• Failing to clean dentures every day due to a build-up of
bacteria,
• Wearing your dentures all the time.
• Soaking dentures in peroxide

 Common sites are:
1. Anterior hard palate and anterior alveolar ridge areas ( upper
denture bearing tissues) due to pressure on anterior palatine
foramen.
2. Bicuspid area to molar tuberosity due to pressure on
posterior palatine foramen.
3. Tongue.
 Uncommon sites are:
The lips and lower denture bearing tissues.

1. Dentures may place stress on
some of the muscles or
tissues of the mouth (Incisive
papilla, Thin wiry ridge).
2. Inadequate tongue space.
Unrelieved Incisive papilla
and Thin wiry ridge

Blood dyscrasia
3. None acceptable vertical and/or horizontal
relation.
4. Presence of candidal infection.
5. Allergy to denture material.

6. None acceptable retention and/or
stability.
7. Inadequate denture extension.
8. Diabetic patients
9. Under- cured denture

10.Psychological problems such as emotional
stress
11.Anxiety and depression
12.Hormonal deficiencies in post-menopausal
women.
13.Neurological abnormalities.

Tongue biting could be due to:
1. Reduced VDO.
2. Arrangement of teeth lingually
limits the tongue space > Cramped
tongue.
3. Too low occlusal plane.
4. Irregular areas on the teeth or the
lingual surfaces of the dentures
base.

a. Arrangement of teeth lingually limits the tongue space.
b. Irritation area on the tongue caused by insufficient tongue space.
If the area of the tongue is restricted, there might be pain related to
cramps, and if the teeth are placed excessively to the lingual, the
tongue could be bitten. There is intense burning sensation on the
tongue.

 The joints are complex
structures consisting of
tendons, muscles, and
bone.
 Injury to any part of these structures can cause
the symptoms associated with TMJ disorders.

1. Low VDO: Costen’s syndrome.
2. High VDO: Insufficient interocclusal distance.
Due to inaccurate jaw relation records.
3. Incompatibility of centric occlusion and centric relation
and Occlusal discrepancies.
4. Poor fitting complete dentures > > can lead to jaw disc
displacement, which can increase the risk of TMJ
disorders.
TMJ pain is generally caused by

 Clicking or Popping when moving the jaw.
 Problems moving the jaw or inability to move the
jaw normally.
 Pain in the jaw that can occur with motion or rest
 Headaches and neck pain.
 Ringing in the ears, dizziness, vertigo, or ear pain.
The most common symptoms include:

TMJ can be difficult to diagnose
Because these symptoms can be vague and some
of them, such as headaches or problems with the
ears, may seem unrelated to the jaw or denture.

 Even dentures that are perfectly made
can lead to problems if not worn at night,
or if they are not replaced as needed.
 Just like ill-fitting shoes, poorly fitted
dentures aren’t going to become more
comfortable over time.

Inflammation of the angles of mouth.
 Attributed to excessive
interocclusal distance.
 Too high occlusal plane of the
lower teeth.
Lead to commissural Chelitis=

This prevents the regular action of the
cheek from eliminating the saliva from
the lower buccal vestibule, so saliva
will exit through the corners of mouth
indicating spread of infection to the
angles of mouth. Advisable to
construct new dentures.

 Inadequate finishing of denture especially
interdentally.
 Use of hard abrasives.
 Failure to clean dentures regularly.
 Incorrect use of denture cleansers.
 Reduced manual dexterity of the elderly (or
ill) patient.

Some common problems associated with xerostomia include:
1. A constant sore throat,
2. Burning sensation,
3. Difficulty speaking and wallowing.
4. Hoarseness and/or dry nasal
5. Oral candidiasis is one of the most common oral infections
seen in association with xerostomia.

6. Individuals with xerostomia often complain of problems
with eating, speaking, swallowing and wearing dentures.
7. Denture wearers may have problems with denture
retention, denture sores and the tongue sticking to the
palate.
8. Patients with xerostomia often
complain of taste disorders
(dysgeusia), a painful tongue
(glossodynia)
9. An increased need to drink water, especially at night.

High vault palate.
Rare condition ??? why
 Fullness under the nose due to too
long or too thick labial flange.

‫يبلى‬ ‫ال‬ ‫البر‬
..
‫ينسى‬ ‫ال‬ ‫الذنب‬ ‫و‬
..
‫يموت‬ ‫ال‬ ‫الديان‬ ‫و‬
...
‫شئت‬ ‫ما‬ ‫فاعمل‬
...
‫تدين‬ ‫كما‬
‫تدان‬

Loose fit Over extension
over closure due to
(Low VD)
Anterior sulcus Epilus Fissuratum
Hard palate Papillary hyperplasia
Ridge Flabby ridge
Ridge Resorption
Denture Settling
Teeth Wear
Anterior Resorption
TMJ Disturbances
Lead to
*Chief complaint of old denture
-Discomfort - Discoloration
- Abraded Denture Base.

Mouth with old dentures:
sagging face
Mouth with new dentures: notice the lift to
the face and lips

Loose fit Pressure area & Over
extension over closure
(Low VD)
•Tissue
conditioning
material
•Relining
•Rebasing
•Remake
Occlusal Pivot:
Increase VDO in lower 2nd
premolar & lower 1st molar
by adding acrylic resin on
their occlusal surface.
Relieved
Hyper plastic tissue
•Tissue rest
•Tissue
conditioning
•Surgery

Angular cheilitis or soreness of the corners of the mouth

The primary cause of this condition is over extension of
denture border which may be the result of sinking of the
denture.

Epulis Fissuratum
Ill fitting and over
extended denture

The labial flange of the denture produces A low grade irritation in the
surrounding soft tissues, resulting in development of epulis fissuratum,
and cause an associated overgrowth of fibrous tissue covering the
maxillary tuberosities.

The rehabilitation of abused oral tissue is to
improve its health and regain its original form
before making a new denture:
I- Remove the cause
II- Recovery program

Remove the cause
 Removal of the denture from the patient's
mouth for few days, with an appropriate recovery
program to allow the inflammation to subside and to allow
the tissues to regain its normal healthy form before making
new impressions.
 Or, an alternative line of treatment is accomplished by
denture correction and then, starting the recovery
program.

1. Finger Massage of the soft tissues two or three
times a day to stimulate the blood supply and aid
recovery.
2. Mouth wash: Instruct the patient to dissolve one-half
teaspoon of table salt in a half glass of warm water
and rinse vigorously.
3. Tissue rest: Remove old dentures from the mouth for
at least 8 hours every 24 hours for few days before
making new impressions to allow the inflammation to
subside.
Recovery Program

1. Detect and remove any pressure areas or sore spots
using pressure-indicating paste.
2. Relining the old dentures with soft tissue
conditioning materials to aid recovery before
constructing new dentures
3. Correction of occlusal disharmonies by clinical
remounting and Restoring (VDO) the occlusal
vertical dimension
4.Elimination of any contact between natural anterior
teeth and opposing artificial teeth.
Denture Correction

Tissue conditioning material application

Add tooth coloured self curing resin
on the posterior occlusal surfaces
of the mandibular denture
When the patients closes the mouth with the
mandible guided to the centric occlusal position,
the occlusal surfaces of maxillary posterior
teeth are recorded in the resin. Trim the resin to
reestablish the contours of the teeth.

Autopolymerizing acrylic resin has been added to mandibular posterior
denture teeth a- to reestablish esthetic , b, c- physiologically acceptable VDO.

If the condition persists then the
treatment may be either:
1.Prosthetic approach to the flabby
tissue, OR
2. Surgical removal of the flabby
tissue.

Original appearance with upper and lower prosthesis in place
demonstrating inadequate facial support and improper plane of occlusion.

At the conclusion there are six commonest
causes of dentures failing are:
Incorrect anteroposterior relation ship of the mandible
to the maxilla.
Uneven occlusion or unbalanced occlusion.
High and low vertical dimension.
A cramped tongue.
Poor retention.
An inexperienced denture wearer.

References:
1. Boucher, C. O., Hieckey, J. C. and Zarb, G. A.: Prosthodontic treatment for edentulous patients. 2nd ed., C. V. Mosby Co. St.Louis, 2000.
2. Eissman, M.R.: Dental laboratory procedures, complete denture, C.V. Mosby company, St. Louis, Toronto, London, 2000.
3. El Mahdy, A. S.: Complete Denture Prosthesis. Anglo-Egyptian book shop, Cairo, Egypt. 1968.
4. Hassaballa, M. A.: Clinical complete denture prosthodontics. 1st edition. Academic Publishing and Press, Riyadh, Saudi Arabia, 2004.
5. Iwao Hayakawa: Principles and Practices of Complete Dentures creating the mental image of a denture, Tokyo Medical and Dental University, Tokyo,
Japan. Quintessence Publishing Co., Ltd. 1999.
6. Iwao Hayakawa: research profile on BiomedExperts,The Journal of prosthetic dentistry 2007;98(2):141-9. 2007.
7. Iwao Hayakawa: Principles and practices of complete dentures: creating the mental image of a denture, rapidshare.com, 27 Dec 2009.
8. Kaddah, A. F.: OCCLUSION IN PROSTHODONTICS, Varieties, Aberrations & Management. Dar El-Etehad. First Co. First ed. Cairo Egypt. 98/7071, 1998.
9. Tamer El-Gendy: Introduction to complete denture, Didactic and Laboratory Manual, Course Director: Tamer El-Gendy BDS, MS. Assistant Professor.
COLLEGE OF DENTISTRY, THE OHIO STATE UNIVERSITY.2000.
10. Winkler, S.: Essentials of complete denture prosthodontics. 2nd ed., PSG Publishing. Co. Inc., 2005.
11. Zarb, G. A., Bolender, C. L., Hickey, J.C. and Carlsson G. E.: Boucher’s Prosthodontic Treatment for Edentulous Patients, ed. 12th . St. Louis Mosby, 2000.
 Internet Sites:
- Full denture relining using Tokuso Rebase, By Dr. David J. Sultanov, DMD, Pittsburgh, PA. Information provided by J. Morita USA. The British Dental Journal
is published by Nature Publishing Group for the British Dental Association.© 2002 British Dental Association
- http://www.dentistry.bham.ac.uk/ecourse/pros/casetreat_w3.asp
- http://www.tpub.com/content/medical/14274/css/14274.
- The School of Dentistry, Birmingham UK
- Treatment options for edentulous spaces. Dr David C. Attrill d.c.attrill@bham.ac.uk
Lectures and PowerPoint® presentation slides:
- Full denture relining using Tokuso Rebase By Dr. David J. Sultanov, DMD, Pittsburgh, PA. Information provided by J. Morita USA
- Lectures Posted by dental products .net. Originally published in the April 2001 Dental Products Report. Copyright 1999-2005 Advanstar Dental
Communications.
- Lectures Produced in the United States of America. ISBN 0-7216-9770-4
- Related Links: About Tokuso® Rebase; Rationale for relining; Tips for success.

Kahn, Michael A. Basic Oral and Maxillofacial Pathology. Volume 1. 2001.
Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2. ed.). Philadelphia: W.B. Saunders. pp. 440–442. ISBN 978-0721690032.
^ Jump up to:a b Thomas, GA (1993). "Denture-induced fibrous inflammatory hyperplasia (epulis fissuratum): research aspects". Australian Prosthodontic Journal. 7: 49–
53. PMID 8695194.
^ Jump up to:a b Cawson RA, Odell EW (2002). Cawson's essentials of oral pathology and oral medicine (7. ed.). Edinburgh: Churchill Livingstone. pp. 275–276. ISBN 978-
0443071065.
^ James, William D.; Berger, Timothy G. (2006). Andrews' Diseases of the Skin: Clinical Dermatology. Saunders Elsevier. ISBN 978-0-7216-2921-6.
^ Barnes L (2009). Surgical pathology of the head and neck, vol. 1 (3rd ed.). New York: Informa Healthcare. pp. 220–221. ISBN 978-0849390234.
^ Jump up to:a b c d e f g Scully C (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone.
p. 352. ISBN 9780443068188.
^ Dorfman J, The Center for Special Dentistry. http://www.nycdentist.com/dental-photo-detail/2446/215/Oral-Pathology-Dental-Medicine-diagnosis-treatment-cyst
^ Laskaris, George (2003). Colour Atlas of Oral Diseases. Thieme. p. 216. ISBN 9781588901385.
^ Jump up to:a b c d de Arruda Paes-Junior, Tarcisio José; Cavalcanti, Sâmia Carolina Mota; Nascimento, D. F.; Saavedra Gde, S.; Kimpara, E. T.; Borges, A. L.; Niccoli-Filho,
W.; Komori, P. C. (1 January 2011). "CO2 Laser Surgery and Prosthetic Management for the Treatment of Epulis Fissuratum". ISRN Dentistry. 2011:
282361. doi:10.5402/2011/282361. PMC 3170081. PMID 21991461.
^ Naderi, NJ; Eshghyar, N; Esfehanian, H (May 2012). "Reactive lesions of the oral cavity: A retrospective study on 2068 cases". Dental Research Journal. 9 (3): 251–
5. PMC 3469888. PMID 23087727.
Pocket Dentistry: Recall Procedures, Fastest Clinical Dentistry Insight Engine, WordPress theme by UFO themes, Jan 19, 2015 | Posted by mrzezo in Prosthodontics.
Yasemin K. Özkan : Complete Denture Prosthodontics, Post Insertion Problems in Complete Dentures, pp 145
-
195
References

Cause Diagnosis Treatment
1. Lack of peripheral seal - Pulling down the anterior teeth (examines the anterior labial
flange)
- Pull out on incisors (examines the posterior palatal seal).
- Pull out on canines (examines the tuberosity region).
Proper border molding followed by relining or rebasing
the denture.
2. Under extension of the border in depth Tracing compound added will remain beyond the border. Remoulding the denture in mouth.
Change to acrylic resin either:
Directly by self cure resin or tissue conditioning
material.
3. Under extension of the border in width By tracing compound.
Lack of contact between polished surface and cheeks
especially in tuberosity area.
Remoulding by allowing the patient to move mandible
from side to side.
4. Posterior palatal seal:
a. Over extension on movable tissues.
b. Under extension on non displaceable
tissues.
Clinical examination:
a. Broken seal by speech
b. Under extended border.
a. Reduce border, add post dam and reline.
b. Extend with tracing compound, mold, wash
impression, make post dam on cast and then reline.
5. Poor fit due to:
Deficient impression.
Damaged cast
Warped denture.
Grinding tissue surface.
Clinically, gap is seen between denture base and tissues.
Pressure indicating paste reveals uniformity in thickness.
Relining or rebasing.
6. Excessive relief Pressure indicating paste reveals excessive thickness in this
area.
Relining or rebasing. After forming proper thickness for
relief..
7. Xerostomia Patient complains of dry mouth and reduced taste.
Clinically, presence of sticky dry mouth.
The patient is advised to use artificial saliva, frequent
fluid intake, chew gums.
Denture with additional retentive means is preferred.
8. Decreased neuromuscular control due to:
Facial palsy
Mandibular molars placed too far lingually.
Convex polished surface.
High mandibular occlusal plane.
Clinically evident through improper speech and
mastication.
Patient is advised to use denture fixatives until he
develops denture skills.
Correction of errors in the occlusal plane.
Poor fit due to decrease in retaining forces.

Cause Diagnosis Treatment
1. Over extension in depth Direct vision
Elevation of mandibular denture when mouth opens
slowly.
Reduce over extension and re-polish the denture.
2. Over extension in width
a. In lingual flange
b. Mandibular labial flange
c. Maxillary labial flange
d. Tuberosity area
Patient complains of bulk and food entrapment.
Denture will lift by tongue
Mentalis muscle lifts the denture.
Denture is displaced by maxillary lip
Cheek soreness and denture displacement.
Reduce over extension and re-polish the denture.
3. Recoil of supporting tissues. Denture falls when teeth are not in contact
History of impression made without tissue rest from
old denture.
Muco compressive impression technique was used.
Reline or rebase using minimum pressure
impression technique.
4. Occlusal errors
a. Uneven occlusal contact
b. Disharmony between centric occlusion and
centric relation.
c. Lack of freedom in intercuspal position.
d. Lack of occlusal balance in eccentric
positions.
e. v. Excessive anterior vertical overlap.
Ask patient to close slowly in centric until teeth
touch..
Presence of occlusal errors may be masked by:
a. Displacement of the mucosa.
b. Tilting of dentures.
Achieve even contact or harmonious jaw relation by:
Chair side tooth grinding.
Remounting.
Remake dentures.
Poor fit due to increase in displacing forces.

10- Post Insertion Problems and Complaints -.pptx

10- Post Insertion Problems and Complaints -.pptx

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