1. 7. Complete Dentures for Irradiated
Patients
John Beumer III DDS, MS
Distinguished Professor Emeritus
Division of Advanced Prosthodontics, Biomaterials and Hospital
Dentistry, UCLA
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2. Table of Contents
 Risk of bone necrosis
 Use of silicone soft liners
 Placement of dentures – timing
 Dentures and pre-existing bone necrosis
 Morbidity – ORN secondary to denture use
 Soft tissue necrosis and dentures
 Prosthodontic procedures
 History and examination
 Impressions
 VDO and CR
 Occlusal forms
 Delivery and post-insertion care

3. Prosthetic Management
Edentulous Patients
Can edentulous patients be permitted to
wear dentures after completion of high
dose radiotherapy for oral cancer?
Yes!! Almost all patients will be able to use complete
dentures with little or no risk of precipitating an
osteoradionecrosis if certain precautions are taken.

4. Can existing dentures be reinserted
after completion of RT?
Dentures can reinserted following completion of RT and the
resolution of mucositis in most patients. One factor to consider
is the percentage of the bearing surface within the gross tumor
volume because these tissues will receive a very high dose.
 For most patients with soft palate or nasopharyngeal neoplasms, the dose
delivered to the denture bearing surfaces of the mandible is not clinically
significant whether or not CRT or IMRT is employed
 Experienced complete denture wearers usually have developed the necessary
neuromuscular coordination necessary for successful function with dentures and
are less likely to exhibit tongue or cheek biting.

5. Can existing dentures be reinserted
after completion of RT?
 However when tumors of the oral tongue and floor of mouth are irradiated
with CRT or IMRT, large portions of the mandibular bearing surface may be
within the gross tumor volume and exposed to high doses and this should
be taken into consideration.
 Therefore, in some patients it may not be appropriate for the patient to
continue to wear their existing dentures
 The following risk factors affect the decision:
 The condition of the bearing surface mucosa
 Boney contours of the alveolar ridge
 Compliance of the patient
 ChemoRT magnifies the risk of complications associated with denture use

6. What factors determine the risk of bone
necrosis from denture use?
 Dose and volume delivered to the mandibular
denture bearing surfaces
 Boney contours of the mandibular denture bearing
surfaces
 Quality of the denture bearing mucosa in the
mandible
 Neuromuscular control of the patient
 Past experience with dentures

7. Prosthetic Management
Edentulous Patients
What is the risk of bone necrosis from denture use?
Two Groups to Consider
 Patients edentulous prior to radiation therapy with
experience with dentures.
 Patients undergoing preradiation or postradiation
extraction with dentures fitted after completion of
radiation.
The former are at low risk of ORN from the of use dentures while
the latter have some risk although it is minimal.

8. Source: Beumer J et al, J Prosthet Dent, 1976
Patients Edentulous Prior to Therapy
• Number of patients 92
• Full lower dentures in the field 87
• Full upper dentures in the field 72
• Previous experience with removable prostheses (pts) 84
• Time interval, therapy to delivery (mths)
• Average 15.4
• Range 2-112
• Followup after delivery (mths)
• Average 20.9
• Range 6-114
• Osteoradionecrosis secondary to dentures 0
• Soft tissue necroses (patients) 6

9. Source: Beumer J et al, J Prosthet Dent, 1976
Denture use in patients dentulous prior to therapy requiring
extractions in the radiation fields
 Number of patients 36
 Full lower dentures 31
 Full upper dentures 30
 Soft tissue necrosis 0
 Previous experience with RPD’s 18
Dentures for patients with pretreatment extractions
 Patients 23
 Osteos secondary to dentures (pts) 2
 Time interval, therapy to delivery (ave, mths) 22.2
 Followup after delivery (months)
 Average 19.2
 Range 3-92

10. Dentures for patients with post radiation
extractions
Patients 16
Osteos secondary to dentures (pts) 3
Time interval, therapy to delivery (ave, mths) 26.1
Time interval, extraction to delivery (months )
 Average 11.8
 Range 2-45
Source: Beumer J et al, J Prosthet Dent, 1976

11. Silicone Liners
Contraindicated because:
 Silicones exhibit decreased wetability. This, combined with reduced
salivary flow results in increased friction at the denture-mucosa
interface during function.
 The silicones deteriorate rapidly secondary to fungus infestation.
 It is very difficult to adjust.
Eight of 25 patients fitted with silicone liners developed
soft tissue necrosis (Daley and Drane, 1972)

12. Placement of Dentures - Timing
Patients edentulous prior to the tumor diagnosis who
are experienced denture wearers
 New dentures can be made or existing dentures reinserted as soon as
the mucositis has resolved.
 If the tumor site lies within the area of a denture extension area or the
bearing surfaces, the denture should be checked with pressure
indicating paste (PIP) and disclosing wax prior to reinsertion.
Patients dentulous prior to undergoing preradiation
or postradiation extractions
 Denture bearing surfaces should be carefully examined for contour
irregularity, telangiectasia, and scar before proceeding with denture
fabrication.
 Some such patients qualify immediately, others may never be good
candidates for mandibular dentures.

13. Denture use and preexisting osteoradionecrosis
Permitted in selected patients
 When the bone exposure is
confined within the zone of
attached keratinized mucosa
(circle).
 When the denture can be
generously relieved at and around
the area of bone exposure.
Not permitted
 When the bone exposure is
extends beyond the zone of
attached keratinized mucosa or
shows signs of worsening (arrow).
 In noncompliant patients.

14. Morbidity
Osteoradionecrosis Secondary to Dentures
Most ORN’s secondary to denture irritation resolve with
conservative treatment and generally do not require surgical
resection and/or hyperbaric oxygen.
 Daley and Drane (l972) – Four out of five healed with
conservative measures.
 Beumer et al (l984) – Seven of eight resolved with
conservative treatment.
 Why so successful?
Post radiation the periosteum is the
primary blood supply
Most ORN’s in edentulous patients
present short of the mucogingival junction.
The gingival fibers help secure the
periosteum to the underlying bone
preventing spread of the exposure.

15. Soft tissue necrosis and dentures
 In some patients edema of the tongue and buccal mucosa is prominent
and tongue and cheek biting is not uncommon. Occlusal trauma may lead
to a soft tissue necrosis, particularly in patients whose tongue lesions
were treated with brachytherapy.
This patient was treated with combination external beam and brachytherapy. The
dose delivered to the lateral tongue was in excess of 8000 cGy. Occlusal
trauma led to a soft tissue necrosis.
Exam often reveals in such cases that the denture teeth are excessively worn with
insufficient horizontal over lap.
In such patients dentures should be remade paying particular attention to the
horizontal overlap of the posterior teeth.

16. Positioning posterior denture teeth – Irradiated patients
In arranging posterior teeth careful attention should be directed toward
attaining proper buccal horizontal overlap. Some clinicians use only 3
posterior teeth, in order to avoid trauma to the posterior buccal mucosa.
 By properly centering the
lingual cusps of the
maxillary teeth over the
central grooves of the
mandibular teeth the
horizontal overlap should be
ideal and should be
sufficient to prevent biting of
the cheek and corner of the
mouth.
 Note that only 3 posterior Horizontal
teeth have been used in this
setup overlap

17. Soft tissue necrosis and dentures
 Treatment consists of establishing the diagnosis, removal of the
lower denture and close followup. In severe cases some
clinicians believe that a course of HBO will accelerate healing.
 Pentoxifylline, a fibrinolyitic agent which enhances blood flow in
ischemic tissues, has also been proposed as a means to
facilitate mucosalization (Dion et al, 1989).

18. Prosthodontic Procedures
History and exam findings of unique importance
 Radiotherapy data
 Condition of oral mucous membranes
 Contours of the bony bearing surfaces, presence of bony
undercuts
 Salivary flow rates
 Trismus
 Scarring at the tumor site

19. History
Radiotherapy data
 Modality
 CRT vs IMRT
 Dose to denture bearing surfaces
Previous denture use
 History of successful use of complete dentures prior
to therapy is an accurate indicator of future success
Psychosocial issues
The patient’s attitude towards himself/herself and the disease is of prime
importance. Many are emotionally distraught over the uncertainty regarding cure
and the morbidity inflicted by their radiation treatment. These attitudes should be
anticipated and psychosocial counseling provided when appropriate . An
uncooperative, poorly motivated patient, is a poor candidate for postradiation
denture service.

20. History of Denture Use
 Edentulous patients with a history of multiple complaints and
difficulties associated with their dentures prior to radiation treatment
may indicate an added risk factor for complications with dentures
post radiation.
 This possibility must be discussed frankly with the patient prior to
prosthetic treatment. In addition the patient must be well informed
of the risks associated with the use of dentures.
 Since most complaints are associated with mandibular complete
dentures, rarely will these patients be pleased with their new
mandibular denture.

21. Exam findings
Condition of oral mucous membranes
 Telangiectasia, mucosal atrophy and bearing surface
boney contours
This patient presents with both telangiectasia of the bearing surface
mucosa and irregular boney bearing surfaces.
In such instances the denture bearing surface epithelium may be only
5-6 cell layers thick.

22. Exam findings
Telangiectasia and mucosal atrophy - mandible
These two patients were treated with CRT with opposed
mandibular fields and the dose to the mandibular body was 70
Gy.
 Exam revealed mucosal atrophy and telangiectasia on the
denture foundation surfaces.
 Both patients are poor candidates for mandibular dentures
because of the high risk of mucosal perforation and
osteoradionecrosis. However, a maxillary denture can be worn
with little or no risk to the patient.

23. Exam Findings
Telangiectasia and mucosal atrophy - Maxilla
A B
These two patients were treated with CRT via posterior lateral facial fields.
Both exhibit telangiectasia and mucosal atrophy but not on the bearing
surfaces.
In patient “A” the fields terminated anteriorly at the junction of the hard and
soft palate. Little of the mandibular bearing surfaces were in the
radiation field.
field
In patient “B” the telangiectasia and scarring was confined to the tumor site
and did not extend to the mandibular denture bearing surfaces.
Based on these and other factors both patients were considered candidates
for maxillary and mandibular complete dentures.

24. Exam Findings
Telangiectasia and mucosal atrophy - Maxilla
 In this patient the maxilla was exposed to in excess of 68 Gy.
 Note the telangiectasia of the palatal mucosa, the buccal mucosa and the
residual portion of the soft palate.
 A maxillary prosthesis in indicated because the risk of osteoradionecrosis
(ORN) is insignificant but if such changes were noted on the bearing
surfaces of the mandible a complete denture would be contraindicated
because of the risk of mucosal perforation and ORN.

25. Exam Findings –Bony Contours
Contours of the bony bearing surfaces and presence of
bony undercuts
 Irregular contours on the mandibular bearing surface may contraindicate
the fabrication of a lower denture if these surfaces are within the gross
tumor volume and the dosage is high (above 65 Gy).
During function the mandibular denture slips and slides over the mucosa
during function and prior to closure the tongue seats the denture on
the bearing surfaces. If the denture is not properly seated when the
closure occurs mucosal injury can result.

26. Exam Findings –Bony Contours
Contours of the bony bearing surfaces and presence of
bony undercuts
 Irregular contours on the mandibular bearing surface may contraindicate
the fabrication of a lower denture if these surfaces are within the gross
tumor volume and the dosage is high (above 65 Gy).
This patient would be a poor candidate for a lower denture. He was treated
with CRT with opposed mandibular fields for a lateral tongue lesion. The
dose delivered was 66 Gy. The irregular bearing surfaces combined with
significant reduction in salivary flow would predispose this patient to mucosal
perforations and osteoradionecrosis.

27. Exam Findings –Bony Contours
Contours of the bony bearing surfaces and presence
of bony undercuts
If the gross tumor volume was high and posterior, limiting the dose to these
irregular bony surfaces to less than 5500 cGy, dentures could be worn safely
and the ridge irregularities expected to remodel.

28. Exam Findings Posterior - Palatal Seal Area
 If the posterior palatine salivary glands are heavily irradiated
the palatine glands and the adjacent tissues become fibrotic
 As a result the posterior palatal seal area becomes less
displaceable and combined with reduced salivary flow
peripheral seal becomes more difficult to attain

29. Exam findings – Salivary flow rates
Consequences of reduced flow rates:
 Compromise tolerance of dentures particularly the
mandibular denture
 Compromised peripheral seal of the maxillary denture
 Increases the risk of tissue irritation particularly in the
mandible because:
 Its reduced bearing surfaces as compared to the maxilla
 The mandibular denture slips and slides over the bearing surface
during function.

30. Exam findings - Trismus
 Most commonly seen in patients with tumors of the soft palate,
tonsil and nasopharynx where the muscles of mastication
receive high dose levels (about 10-50% in such patients)
 Made significantly worse by concomitant chemotherapy
 Trismusmay require the reduction of the vertical dimension of
occlusion in order to facilitate entrance of the bolus

31. Exam Findings - Scarring
Scarring at the tumor site within the denture
foundation area or at the periphery of the denture
This patient is a good candidate for complete dentures but care
must be taken to avoid overextension of the denture adjacent to
the scar associated with the tumor site. A mucosal perforation in
this area would probably lead to an osteoradionecrosis.

32. Compliance
 Does the patient continue to abuse tobacco and alcohol?
 Will he/she leave out the dentures at night?
 Can you rely on the patient calling you when he/she develops a
sore area?
 Do they understand the risk of bone necrosis?
If the patient does not understand the importance of the
above or is noncompliant, upper dentures may be worn
but use of lower dentures should be discouraged.
discouraged

33. Exam Findings
Any condition which compromises the prosthetic prognosis in
nonirradiated patients assumes added significance in irradiated
patients.
 The clinician should examine the denture foundation area thoroughly for
undercuts, tori, high tissue attachments, enlarged maxillary tuberosities, flabby
and redundant tissue, lack of attached gingiva, retruded tongue position,
unfavorable floor of mouth contours and abnormal jaw relationships.
 For example, mandibular ridges such as these with severe bilateral undercuts or
excessive ridge resorption with little attached keratinized mucosa are poor
candidates for complete denture service following radiation therapy.

34. Prosthodontic Procedures
Impressions
Border molding
 Border mold with a low fusing compound* with custom
trays
 Develop maximum extensions but avoid overextension
at the tumor site
 Do not attempt to displace the floor of the mouth to
obtain peripheral seal
*Bite compound, G.C. Dental Industrial Corp. Chicago, Tokyo

35. Prosthodontic Procedures
Impressions
Border molding
 Efforts to develop the lingual flange should be directed toward
gaining stability rather than retention.
 Edema of the tongue and floor of mouth, which is particularly
prominent if the patient has undergone a radical neck dissection,
will occasionally be sufficiently extensive to compromise tongue
space, compromise floor of mouth posture and limit the extent of the
lingual flange.
*Bite compound, G.C. Dental Industrial Corp. Chicago, Tokyo

36. Prosthodontic Procedures
Impressions
Wash materials
 Polysulfide
 Thermoplastic wax
 If wax is used to refine the impression, an occlusal index engaging the
opposing denture must be incorporated within the tray

37. Facebow transfer record
A facebow transfer record
is used to mount the
maxillary cast on the
articulator.

38. Establishing VDR and VDO
VDO
 Determined in the usual fashion
 The VDO is closed only in patients with severe
trismus so as to facilitate easy entrance of the
bolus

39. Centric relation records are
made in the usual manner.

40. Occlusal forms
 It is not possible with the information at hand to make
assumptions relative to the efficacy of any particular occlusal
scheme available in the construction of complete dentures for
irradiated patients.
 In our review of 128 patients (Beumer et al, 1976) both
anatomic teeth and non anatomic forms with full balance were
employed. On a theoretical basis, however, I have come to
favor lingualized or monoplane occlusal schemes with
balance facilitated with posteriorly situated balancing ramps.
 The literature seems to indicate that less horizontal force is
generated with a nonanatomic occlusal scheme (Frechette,
1955; Kydd, 1956; Sharry et al., 1960; Swoope and Kydd,
1966) and this assumption, if true, would be of obvious
advantage to irradiated patients.

41. Occlusal forms
Lingualized with Nonanatomic with
bilateral balance balancing ramps
Selection based on the usual criteria
 Coordination of the patient
 Bony contours of the ridges
 Tongue position and floor of mouth posture
 Jaw relations
Tooth selection is not based on the fact
that the patient has been irradiated.

42. Lingualized Occlusion
Indications for use Advantages
 High esthetic demands  Good esthetics
 Severe mandibular ridge  Freedom of non-anatomic
atrophy teeth
 Displaceable supporting  Potential for bilateral
tissues balance
 Malocclusion  Centralizes vertical forces
 Previous successful  Minimizes tipping forces
denture with Lingualized  Facilitates bolus
Occlusion penetration (mortar and
pestle effect)

43. Delivery and Post-Insertion Care
 Pressure indicating paste
 Disclosing wax
 Clinical remount
 24 and 48 hour followup
 Leave dentures out at night
 Educate the patient
 Risk
 Morbidity

44. Adjusting the Denture Base with pressure
indicating paste (PIP)
PIP the mandibular denture
 Use smooth even brush
strokes
 Carefully insert denture so as
to avoid wiping off PIP in
undercut areas
 Adjust as necessary
Pay particular attention to the
mylohyoid region for mucosal
perforations in this region can
lead to an osteoradionecrosis.

45. Adjusting the denture borders with disclosing wax
 Examples of commonly overextended areas
 Pay particular attention to the site of the tumor particularly
if it is located on the denture border
These flanges are too thick
These flanges are too long

46. Clinical Remount
Purpose
To Correct for the fact that:
 Adjusted denture bases seat more
accurately than record bases
 Accommodate for errors made during
the making of centric relation records
“Measure twice, cut once”
once

47. Clinical Remount
Seat the posterior palatal seal
 Placetwo cotton rolls between the posterior
teeth and have the patient bite down for 5
minutes.

48. Clinical Remount
Make centric relation record and prove the record
Carry to mouth and have the patient close in centric
relation just short of tooth contact. While making the
record, instruct the patient to retrude and elevate the
tongue. This will ensure that the condyles are properly
seated while making the record.

49. Clinical Remount
Remove the record. Chill in cold water and trim so that only
the cusp tip indentations remain. Trim the buccal side so
that the seating of the dentures can be visually checked.

50. Clinical Remount
Return the record to the mouth and recheck the record.
Contact should be equal and simultaneous bilaterally. If not
repeat the record. Observe the maxillary denture as the patient
closes. If the denture moves during closure repeat the record.

51. Clinical Remount
Using remount casts the dentures are remounted on the
articulator. Make sure to lock the condyles in centric while
remounting the dentures. The maxillary remount cast had been
mounted prior to removing the maxillary denture from the
master cast.

52. Clinical Remount
Begin by equilibrating in centric relation. If your original
Centric Relation record was correct, little or no
adjustment will be necessary.

53. Clinical Remount
Make a protrusive record. Instruct the
patient to bring their mandible forward
8-10 mm when making the record.

54. Clinical Remount
Protrusive record
 Transfer the record to the articulator. Hold the upper
member of the articulator down into the record and
adjust the condylar inclination.

55. Clinical Remount – Lingualized Occlusion
Balancing Working
side side
Mandibular
movement
Check excursions. If necessary, adjust the occlusion
to restore bilateral balance.

56. Delivery Instructions and Followup
The care after delivery of dentures is critical and requires an
understanding patient to avoid untoward complications.
 The patient is given an instruction sheet detailing possible problems and precautions.
Instructions concerning removal of the dentures if soreness develops, the necessity
for periodic return visits, and the initial limited use of the prosthesis for mastication
are provided.
 Complete dentures should never be worn while sleeping.
 During the first week, 24 hour, and 48 hour recall appointments are recommended
regardless of how well the patient is tolerating his/her dentures.
 At the end of the adjustment period, the patient is required to return four times during
the first year. If the patient continues to present without complications, the interval
between visits may be lengthened during succeeding years.

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58. References
 Beumer J, Curtis T, Morrish R. (1976) Radiation complications in edentulous patients.
J Prosthet Dent 36:193-203.
 Griern M, Robinson J., Barnhart G. (1964) The uses of a soft denture base material in
management of the postradiation denture problems. Radiology 82:320-1.
 Daly T, Drane J. (1972) Management of dental problems in irradiated patients.
Houston, Texas (Publication of the University of Texas).
 Rahn A, Matalon V, Drane J. (1968) Prosthetic evaluation of patients who have
received irradiation to the head and neck regions. J Prosth Dent 19:174-9.
 Krajicek D. (1969) Oral radiation in prosthodontics. J Amer Dent Assoc. 78:320-22.
 King R, Elzay R, Prints. (1968) Effects of ionizing radiation in the human oral cavity
and oropharynx. Radiology 91:990.
 Frechette A. (1955) Masticatory forces associated with the use of various types of
artificial teeth. J Prosthet Dent 5:252-67.
 Kydd W. (1956) Complete denture base deformation with varied occlusal tooth form. J
Prosthet Dent 6:714-18.
 Sharry J, Askew H, Hoyer H. (1960) Influence of artificial tooth forms on bone
deformation beneath complete dentures. J Dent Res 39:253.
 Swoope C, Kydd W. (1966) The effect of cusp form and occlusal surface
area on denture base deformation. J Prosthet Dent 16:34-43

59. The End