Complete denture troubleshooting final/endodontic courses

Troubleshooting in
Complete denture
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

• Introduction
• Fabrication of complete dentures is dependent
on technical, biological, and psychologic
interplay between the clinician and the patient.
• Paramount to the patient are such factors as
esthetics, comfort, and masticatory ability.
Patient satisfaction is critical determinant in
the success or failure of complete denture
therapy.
• The problem with complete dentures is that they
are foreign bodies. Though they are compatible
with oral environment they require learning for
tissue accommodation.
• Tissue response varies from individual to
individual and from time to time in the same
individual. www.indiandentalacademy.
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• Factors of general health, resistance to disease, pain
threshold, diabetes, hyper tension, habits such as smoking,
medication of long duration, anemia, wasting and old age
alter tissue response and create problems associated with
denture use.
• Majority of the problems associated with denture are real
and not psychosomatic or psychologic.
• A careful scrutiny based on a thorough knowledge of
normal and abnormal tissue response as well as of the
fundamentals of complete denture prosthesis is essential in
treating the problems connected with complete denture use.
• Many essentially satisfactory dentures are ruined by hasty
indiscriminate alteration by grinding the denture base and
teeth. www.indiandentalacademy.
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• The majority of patients with complete dentures
are apparently well satisfied.
• According to Yoshizumi, Langer, Sheppard
satisfaction and comfort rate in good quality
complete dentures varied between 69% - 85%.
• Unfortunately a small percentage of patients
persistently seek adjustments. The sequence of
denture adjustments, reline, remake can develop
into a cycle with some individuals.
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Why should there be a problem in
adjusting to complete dentures
• 1. It can be said that complete denture treatment is an
unnatural treatment of oral tissues left over after loss of
teeth.
• 2. The oral tissues are exposed to the presence of a
foreign body which sandwiches the oral mucosa against
the hard bone.
• 3. It may be understood that the oral tissues have not
evolved to accept the ravages of such large foreign
bodies. It is therefore natural that an initial copious flow
of saliva is a proof of rejection of the oral tissues of
invading agency.
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• 4. If however the tissues are compelled to accept them,
rationally speaking prosthesis have to be formulated
keeping in mind the tissue biology and the mechanical
needs of retention and stability.
• 5.The dentures are simply placed on tissues without
anchors and the patient is expected to acquire neuromotor
skills in holding them. In this exercise the dentures are
expected to remain seated during various functional
excursions.
• 6.The neuromuscular attainment of skill is more easily
said than done since the learning potential of patients
vary at every age level and hence in advanced age the
patients face a situation of tight rope walk.
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• 7. It is to be reckoned that the denture bearing area
present varying degrees of different morphology and
altered physiology.
• 8. In fact the dentures reveal a lot of skidding effect
adding to the problem of sensitive oral mucosa.
• 9. Similarly food habits manifest diversity to a point that
patient needing to use the dentures successfully, has to
accept the changes in life style.
• 10. Emotional disturbances and more so in advancing age
are yet another manifestation that causes irritation of
tissues and the resulting tissue loss.
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• Classification
• According to J.S. Landa ( jpd 1959)
• A. Tissue Injury
• B. Impaired function
• C. Miscellaneous
• According to William.R.laney
• A. problems associated with impression surface
• B. problems associated with occlusal surface
• C. problems associated with polished surface
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TISSUE INJURY
• Involving supporting and stabilizing areas
• Tissue Injury in Contact with Denture
Periphery
• Tissue Injury in Contact with Polished
Surface of Teeth
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• INVOLVING SUPPORTING AND STABILIZING
AREAS
Symptoms
• Patients with injuries of these areas will usually have
symptoms like localized tender or painful spot on
denture bearing surface like crest and slope of ridge,
palate.
• Several areas of pain over residual ridge and palate
where in the location of pain shifts after each
adjustment.
• Burning sensation over the residual ridge,sides of the
tongue or all over the mouth.
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• Inadequacies from Dentist
• Lack of appreciation to remove bony spicules and
sharp protuberances either during extraction of
teeth or later by alveolectomy. Absence of relief
provided for such sharp bony spicules.
• Pearls or sharp ridges of acrylic on the fitting
surface of denture.
• Inadequate impression technique, insufficient
care during jaw relations, use of large posterior
teeth, set in wide arch out side the ridge crest.
• Porous surface of the cast.
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• Inadequacies from patient
• Patient’s who have undergone recent extractions,
with thin and atrophied mucosal tissue.
• Sharp ridge crest, mental foramen on the ridge
crest, absence of cortical bone.
• Low pain thresh hold, vigorous mastication of
food, bruxism.
• Poor denture foundation, poor health of soft tissues.
Systemic disease lowers tissue resistance to
occlusal load.
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• Psychologic disturbances, old age,
sedentary life.
• Lack of Rest: Some patients do not
remove their dentures and hence do not
allow rest to the tissues. The constant
pressure of the dentures retards the
normal blood supply.
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• Lesions:
• 1. Punched out areas
• 2. Whitish areas
• 3. Hyperemic and painful areas
• 4. Localized or generalized areas of inflammation
• 5. Hypertrophy
• Punched out lesions and the surrounding hyperaemic
mucosa are usually the result of imperfections in denture base,
trauma from food particles when the dentures were not in the
mouth.
• Lesions particularly of the crest are whitish due to the
presence of excess Keratin (whitish  may also be due to
ischaema  improper impression technique).
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• Lesions that are hyperaemic and painful are
encountered over the mylohyoid ridges, the cuspid
eminences, the alveolar tubercles and areas of
exostosis. It is usually seen when undercuts are present
in the lateral aspect of maxillary tuberosities. It is
produced by the flanges of the denture during the
placement and removal of denture from the mouth or
from excessive friction when the denture moves during
function.
• Hyperaemic, painful and detached areas of
epithelium that develop on the slopes of residual ridge
are usually the result of disharmony of occlusion when
the teeth are making unbalanced contacts in eccentric
jaw positions.
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• Localized or generalized areas of inflammation
• · Poor oral hygiene can result in inflammatory reactions; e.g.
in Xerostomia
• · A complete denture opposing natural teeth or a partial
denture may cause localized hyperaemia and edema.
• · An unbalanced diet and avitaminosis contribute to
inflammatory conditions in all age groups. Alcoholism and senility
may lead to malnutrition, which is reflected in the inability of the
oral mucosa to resist the pressure of dentures.
• · Systemic debilitating diseases contribute to poor tissue tone
and poor tissue resistance of dentures. E.g. Hypertension, diabetes.
• Allergic reactions of the supporting tissues to denture base
materials.
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• Hypertrophy:
• An abnormal increase in size of the stress bearing oral
mucosa is unusual. In the midpalatal suture area,
particularly when a relief is placed in the tissue side of the
denture base, hypertrophy of the mucosa does occur.
Small nodules which are defined as ‘papilloma-like
hypertrophy’ develop throughout the area.
• The incisive papilla is another area that becomes enlarged,
hyperaemic and painful if it is not relieved in the dentures.
When the cause is not removed the tissue becomes
pendulous.
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• Problems involving bone:
• Residual alveolar ridge is the major bony support for the denture
base to resist torquing and horizontal forces.
• Isolated spinous processes may develop on the surface of the bone.
The soft tissue covering is caught between the hard denture base
and the spine of bone with resulting discomfort and pain.
• Bone growth on the surface and exostosis results in a thinning of
the over lying mucosa. These areas of bony growth act as fulcrums
and pressure points.
• Sharp and prominent mylohyoid ridge acts like a knife edge and
also creates an undercut area.
• Bone sore mouth a rarely encountered condition in senile patients
shows no soft tissue damage but expresses a feeling of constant
soreness and desire to remove the dentures.
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• Treatment
• Provide appropriate relief on the fitting surface of
denture.
• Locate nodules with finger or snagging dry cotton
wool fibers.
• Use disclosing material to adjust in region of wipe
off. Exercise care as excessive removal may
reduce retention. Clinician should only insert and
remove the denture at this time and patient should
not bite at this time as this may confuse an
occlusal fault with support problems.
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• TISSUE INJURY IN CONTACT WITH
DENTURE PERIPHERY:
• These lesions are mostly encountered in following areas
and in the order named:
• - Frenum attachments
• - Retromylohyoid space
• - Retromolar pad
• - Massetric notch
• - Hamular notch
• - Vestibular fornix
• - Floor of the mouth
• - Soft palate
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• Symptoms include
• Pain in the buccal or labial vestibule and or
lingual sulcus, frenum attachments, sub
mandibular or tonsillar regions during swallowing
• cut/abrasion in alveolar mucosa immediately
adjacent to the denture.
• gagging, retching, nausea, vomiting
• both dentures are loose and get dislodged on
opening the mouth, on slightest speech.
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• Scant regard for anatomical and functional limits
of denture extension.
• Excess pressure during impression
• lack of adequate border molding
• trial dentures sealed on cast with excessive wax.
• Faulty judgment of palatal extension
• faulty placement of PPS
• lingual flanges of lower dentures over extended.
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• Inadequacies from Patient
• Low resistance to pressure on the soft tissue of the
mouth.
• Hyper sensitive patient
• prominent gagging reflex
• narrow oropharyngeal space and large tongue.
• Comparatively non resilient soft tissues
• dry mouth
• uneven sulcus depth.
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•
• Hyperplasia Border faults
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• Lesions seen are
• - Slit like fissures
• - Ulcers
• - Hypertrophy
• Hypertrophy at the junction of tightly and loosely
attached mucosa is caused by initial trauma which may
be a result of disharmony of occlusion in the eccentric
positions.
• This is especially true when the forces of occlusion are
directed towards the anterior residual ridges in biting.
The bone loss results in a loose denture and a loose
denture produces more trauma.
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• Hypertrophy in the labial flange area often occurs
following the insertion of an immediate complete
denture when the occlusion and denture base have
not been altered to meet the changes taking place
in the basal seat.
• Slit like lesion in vestibule should not be
confused with herpetic or apthous lesion, which
has a yellow base with an inflammatory halo.
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• Treatment
• Localized reduction of the over extended flange
• adequate relief for free movement of the frenum
during function.
• Rounding off the sharp margins and polish the
flange.
• For gagging and retching – correct over
extension, correct post dam, increase stability and
retention, permit longer adaptation time by short
periods of use of dentures at intervals.
• Use anti sialogogues, topical astringents,
anesthetics.
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• TISSUE INJURY IN CONTACT WITH OCCLUSAL
SURFACE OF TEETH
• Areas involved are lips, cheeks and tongue.
•
symptoms are
• Cheek/lip biting
• Tongue biting
• Irritation of mucosa
• Head ache and fatigue on wearing dentures for some
time. No localized pain in the mouth. Craving to remove
dentures.
• Denture getting dislodged while chewing, lifting on
opposite side while chewing on one side, poor stability.
• Inability to chew, decreased chewing efficiency.www.indiandentalacademy.
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• Overjet of posterior teeth inadequate, too large
anterior overjet causing lip trapping
• teeth set in a narrow arch causing tongue
cramping
• heels of denture in contact.
• Lack of regard for physiologic rest position of
mandible.
• Enthusiasm to improve esthetics by increased
vertical dimension(characterized by increasing
pain as day progresses)
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• Lack of equalization of pressures during
impression making.
• Inadequate relief provided to hard unyielding
areas.
• Faulty jaw relations recorded. Use of simple
hinge articulator. Over enthusiasm for giving
maximum inter locking occlusion for efficient
mastication.
• Indiscriminate grinding of posterior teeth during
occlusal adjustment.
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• Inadequacies from Patient
• Loss of excess fat, sunken in cheeks. Loose
cheeks and lips.
• Delicate temperament, hyper sensitivity, irritable,
general debility.
• Addiction to drugs like aspirin, tranquilizers.
• Thick displaceable soft tissues on the sides and on
the crest of the ridge with unyielding mucosa in
the median raphae.
• Uneven residual ridge. Inter arch relation at rest
unfavorable.
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• Treatment
• If vertical dimension is altered and if the increase
is less than 1.5 m.m. grind the occlusal surfaces to
provide free way space. If it is increased by more
than 1.5 m.m. , re-register vertical dimension to
reset dentures at new vertical dimension.
• For lip biting grind lower incisors to provide a
more appropriate incisal guidance angle.
• In cases of tongue biting remove lower lingual
cusps or reset teeth.
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• The role of occlusal interferences.
• The occlusal interferences should be checked for
carefully. Interferences in occlusal contacts can be
checked by guiding the patient to occlusal contact in
centric relation. The initial contact of teeth is noted .
Usually patient comes with complaint of pain in denture
bearing or peripheral seal area. The usual complaints are
• Irritation on anterior lingual and lateral slopes of
mandibular ridges.
• Irritation in retromylohyoid region.
• Irritation on median raphae
• Irritation on labial mucosa.
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• Irritation on anterior lingual and lateral slopes
of mandibular ridges.
• Caused by centric relation and centric occlusion
not coinciding.
• Deflective occlusal contact on second molars.
• Unilateral deflective occlusal contacts in molars.
• Errors in occlusal contacts are observed by
guiding the patient to occlusal contact in centric
relation. Note the initial contact of the teeth and
simultaneous anterior and rotational movement of
mandibular denture.
• Treatment- occlusal corrections by remounting.www.indiandentalacademy.
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• Irritation in retromylohyoid region.
• Caused by anterior occlusal interference in protrusion..
• Deflective occlusal contact on the contralateral side.
• Deflective balancing occlusal contacts on second molars
of the ipsilateral side.
• Instructing the patient to bring their teeth in protrusive
contact check for protrusive interference, by moving their
teeth into right and left eccentric positions, contralateral
and ipsilateral deflective occlusal contacts may be
diagnosed.
• Remount the cast on articulator and remove the
interfering contacts.
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Irritation in median raphae
Caused by excessive incisal contact in centric relation
• . Also caused by loss of support from primary stress
bearing area and insufficient relief.
• If discomfort appears immediately it is due to excessive
contact. If discomfort appears after several days of
insertion it will be due to loss of support
from primary stress bearing areas.
• Also due to excessive incisal contact there will be
forward and upward movement of the maxillary denture.
• To correct this we have to equilibrate the anterior teeth.
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• ESTHETICS:
• Mental and emotional responses to the appearance of
dentures vary. What is acceptable to one person may be
unacceptable to another. Regardless of age or sex,
esthetics is an important factor in denture acceptance.
• Esthetic acceptance of a prosthesis provides a strong
mental support for the patient during adjustment period.
• Common problems
• 1. Dissatisfaction with appearance
• 2. Dissatisfaction with teeth colour
• 3. Dissatisfaction with teeth position
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• . Dissatisfaction with appearance: The
number of patients who are dissatisfied with
their appearance with final dentures can be
much reduced if the dentist insists on a
relative or a candid friend being present at the
trial stage, although it has to be stressed that
the appearance cannot be fully assessed until
four to six weeks after placement of finished
dentures.
• This is because, the lip and muscles have to
adapt to the dentures.
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• . Dissatisfaction with teeth colour: The
complaint is almost invariably that the teeth
are too dark or too yellow
• but before changing them it must be
explained to the patient that natural teeth
darken with age and that very light shaded
teeth look more artificial than darker ones.
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• . Dissatisfaction with teeth position: The
complaint may be that the upper incisal
edges are too low and therefore too much
tooth is showing.
• If there is a fault in the orientation of the
occlusal plane, the anterior teeth may be
removed and replaced at a higher level but
usually this is unsatisfactory as it spoils the
acrylic matrix and ruins the protrusive tooth
contacts.
• The best solution in such cases is to remake
the dentures.
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• PHONETICS:
• When complete dentures are first worn, there is always
some temporary alteration in speech owing to the
thickness of the denture covering the palate,
necessitating slightly altered positions of the tongue.
• Commonly this is only a temporary inconvenience, most
rapidly overcome by the patient reading aloud.
• However, some knowledge of phonetics in relation to
dentures is necessary, in order to correct speech defects
that may occur in denture wearers, and also to act as a
guide for the more accurate design of complete dentures.
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• Factors in denture design affecting speech
• The vowel sounds:
• These sounds are produced by a continuous air stream
passing through the oral cavity which is in the form of a
single chamber.
• All vowel sounds involve the tongue which has a
convex configuration.
• The tip of the tongue, in all the vowel sounds, lies on the
floor of the mouth either in contact with or close to the
lingual surfaces of the lower anterior teeth and gums.
• The application of this in denture construction is that the
lower anterior teeth should be set so that they do not
impede the tongue positioning for these sounds.
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• Consonant sounds:
• - Labial sounds – They are b, p and m formed
mainly by the lips
• - Labiodental sounds – They are f and v made
between the upper incisors when they contact the
posterior 1/3 of the lower lip.
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• Most important information to be sought
while the patient makes these sounds is the
relation ship of incisal edges to lower lip.
• If found defective reset upper anteriors either
higher or lower position.
• If incisal plane is set too high it results in
hissing sound.
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• Dental and alveolar sounds:
• Dental sounds such as ‘th’ are made with the tip of the
tongue extending slightly between the upper and lower
anterior teeth.
• This sound is closer to the alveolar than the tip of the
teeth.
• Careful observation of the amount of tongue that can be
seen can provide information regarding labiodental
position of anterior teeth.
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• The sibilants s, z, sh, ch and j are alveolar sounds because
the tongue and alveolus form the controlling valve.
• When these sounds are made, the upper and lower
incisors should approach each other end to end, but they
should not touch.
• An excessively thick palate will cause problem, but
adaptive response satisfactory.
• If patient is unable to adapt give metal base to reduce the
thickness.
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• The ‘S’ sound can be considered dental and alveolar
speech sounds because they are produced equally well
with two different tongue positions.
• Most people make the ‘S’ sound with the tip of the
tongue against alveolus in the area of rugae with small
space for escape of air between tongue and alveolus.
• Size and shape of this small space will determine the
quality of the sound.
• If the opening is too small, a whistle will result.
• If the opening is too broad, the ‘S’ sound will be
developed as an ‘Sh’.
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• Frequent cause of undesired whistles with denture
is a posterior dental arch form that is too narrow.
• A cramped tongue space, especially in the
premolar region forces the dorsal surface of the
tongue to form too small an opening for the
escape of air.
• The procedure for correction is to thicken the
center of the palate so that the tongue does not
have to extend up so far into the narrow palatal
vault.
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• Posterior palatal seal area: Errors of construction in this
region involves the vowels ‘u’ and ‘o’ and the
consonants ‘k’, ‘g’.
• A denture which has a thick base in the posterior seal
area or a posterior edge finished square instead of
chamfered, will probably irritate the dorsum of the
tongue, impeding speech and possibly producing a
feeling of nausea.
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• Treatment
• Reduce denture bulk.
• Improve teeth positions.
• Improve palatal vault curvature.
• Ensure adequate tongue space.
• Use metal base to improve resonance.
• Institute positive efforts in the practice of speech,
obtain assistance of speech therapist if necessary.
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• MASTICATION
• Inability to eat:
• This complaint is mainly confined to patients who are
wearing complete dentures for the first time, and are
impatient at the time spent in acquiring new habits of
eating.
• Careful attention by the operator to the psychological
approach to denture wearing, will eliminate his
complaint except in rare cases.
• Difficulty may be encountered with certain fibrous
foods and this is likely to be due to low-cusp or zero
cusp posterior teeth or lack of inter digitations of
posterior teeth.
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• Difficulty also arises due to lack of balanced occlusion
and open bite.
• This results from dentist’s lack of regard for efficient
occlusion of teeth, indiscriminate grinding of teeth
during occlusal adjustments and unrealistic
masticatory demands by patient.
• An overextended periphery may cause a denture to
dislodge. (This is because movements during eating
are more extensive than those employed when molding
the periphery of the impression. Intelligent observation
by the patient of the exact movements which cause the
instability will eventually enable the operator to locate
the over extension).
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• Treatment – reconstruct dentures with due
regards to balanced and efficient occlusion,
improve the ratio of masticatory load to area of
support.
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• Problem with Retention and Stability
• Patients more often complain that the lower
denture lifts than that the upper one drops.
• Causes
• Over extension
• Tight lips
• Under extension
• Lack of saliva
• dislodgement when coughing or sneezing,
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• Complaints
• Upper denture drops when patient yawns
• Lower denture raises when mouth is partly open
• Lower denture unseats with various tongue
movements
• Upper denture drops while patient is talking
• Dislodgement of dentures on taking fluids.
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• Checking lack of seal
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• Checking for stability
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• Over extension :
• It is due to incorrect molding of the impression or
incorrect outlining of the denture on the cast and is
visible in the mouth as an area of hyperaemia or an ulcer.
• With the help of pressure indicating paste the over
extension can be detected and corrected.
• Tight lips:
• It can be the most difficult problem if the mandibular
ridge is flat and atrophic. The inward pressure from the
lips will push the lower denture backwards up the
ascending ramus.
• Treatment: Remake the lower denture with the lower
anterior teeth set more lingually, with a labial concavity
on the denture. Surgical vestibuloplasty must be
considered. www.indiandentalacademy.
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• Tongue space
• If the lower posterior teeth are tilted or set lingually they
produce an undercut area into which the wide middle
third of the tongue will get locked.
• Movements of the tongue then lift the denture.
• Treatment: Reduce the width of the lower posterior teeth
by grinding off the lingual cusps.
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• Under extension:
• Maximum retention cannot be obtained without covering
the greatest possible denture bearing area.
• It can be corrected by proper border molding procedures
with low fusing compound and a conventional reline can
then be carried out.
• Lack of saliva: Serous saliva produces better cohesive
force than mucous saliva.
• Advice salivary substitutes in case of xerostomia.
•
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• When coughing or sneezing: occasionally a new denture
wearer will complain that his upper denture falls and his
lower denture lifts whenever he coughs or sneezes.
• Treatment: It must be explained to the patient that when
coughing or sneezing the soft palate rises suddenly and
the air pressure is considerably reduced so that the
peripheral seal of the upper denture is broken and it is
liable to fall
• the usual muscular movement will cause the lower
denture to lift.
• There is no way of preventing these movements of the
dentures, but covering the mouth with a hand or
handkerchief is an obvious suggestion
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• Upper denture drops when patient yawns:
• · During the act of yawning the mouth is opened to its fullest
extent, and the border tissues pull down against the borders of the
denture.
• If there is an area of irritation or the borders are overextended it
should be reduced.
• If there is no evidence of over extension, the patient should be
cautioned to refrain from opening the mouth too wide.
• · Distobuccal flange of the denture may be too thick so that
they interfere with the action of ramus. A side to side movement
of the jaw will loosen the denture. If this occurs, reduce the
thickness of the distaobuccal flanges.
• Denture is inadequate in posterior palatal seal. This leads to a poor
palatal seal and air is permitted to enter under the posterior border
of the denture.
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• · Buccal surfaces of the teeth are placed too
far towards the cheek. When this occurs, and the
mouth is opened the muscles of the cheek pull
against the buccal surfaces of teeth and tend to
unseat the denture.
• · Denture is overextended in the
pterygomaxillary notch. When this occurs, the
functional activity of the Pterygomandibular
raphae is interfered with and during jaw
movements the denture is unseated.
• ·
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• · Lower denture rises when the mouth is partly
open
• Lingual flanges are over extended in the
mylohyoid region.
• Lower posterior teeth are too far to the buccal.
• Overextension of the buccal flanges.
•
• Upper denture drops while patient is talking
• Poor border seal
• Improper frenum relief in the denture.
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• Dislodgement of dentures on taking fluids
• The patient should be told that when the dentures are
delivered it is possible for him or her to experience a
loosening of dentures while drinking.
• During swallowing, the soft palate rises and the
posterior palatal seal may be lost.
• The tongue and floor of the mouth are raised by the
tongue muscles. The mandible is prevented from
moving downwards by the suprahyoid muscles. So the
mandibular denture rises during swallowing.
• However, this will not persist when the tongue, lips and
cheeks learn to manipulate the dentures.
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• Gagging:
• One of the most bewildering problems encountered in
complete denture prosthodontics is that presented by the
patient referred to as “gagger”.
• Gagging is an involuntary retching reflex that may be
stimulated by something touching the posterior palatal
region.
• The retching may lead to actual vomiting and is
accompanied by lacrimation, salivation and flushing.
• These symptoms are usually triggered by tactile
stimulation of the soft palate by the maxillary denture,
but may also be caused by virtually any intraoral
procedure.
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• The maxillary denture of the gagging patient usually has
either of the two characteristic contours.
• It may have a posterior palatal margin that is so concave
that it almost terminates on the hard palate, or it may have
a palate which has a marked downward slope away from
the soft palate. In either case the dentures can exert only
minimal pressure against the soft palate.
• The most paradoxical feature found in almost every
gagging patient is although the soft palate is extremely
sensitive to the contact of the denture or any instrument,
the patient seldom gags on foods and liquids of his diet
which contact this same area during swallowing.
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• It can thus be seen that the picture presented by
the average gagger can be separated into –
• i) Acute
• ii) Chronic
• Shortening of palatal margin does not decrease the
tendency to gag but may actually increase it.
• Even in a non gagger light touch or pressure
against the soft palate can cause tickling sensation,
whereas firm pressure is much less apt to do so.
• And so, too, with the maxillary denture; it is
much more apt to cause a tickling sensation if it
exerts too little pressure against the soft palate
than if it exerts too much.www.indiandentalacademy.
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• So the consistent feature of the acute phase is a maxillary
denture which feels “too long” and causes gagging which
is not relieved by palate shortening.
• Chronic phase:
• In this phase the gaggers history resembles a simple
conditioned reflex in that the gagging becomes so
intimately associated with the denture that ultimately any
procedure involving the denture, or the oral cavity, can set
off the reflex. Even the thought of such contact may cause
gagging.
• The gag reflex can be markedly diminished if the
patient’s complete attention is diverted by having him
maintain a leg in an elevated position.www.indiandentalacademy.
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• Treatment:
• There are a number of methods of dealing with the
problem. It is important to give the patient a feeling of
confidence on the part of the dentist.
• Prior to the impression making, the patient should be
instructed to breathe through the nose slowly and audibly
and at the same time to rhythmically tap his right leg on
the floor. By doing so the patients attention would be
diverted enough to allow the making of mandibular
impression without incident.
• The palate may be sprayed with surface anesthetic or
ethylchloride prior to recording the impression. Posterior
third of the tongue which is often implicated in the
retching reflex can also be anesthetized.www.indiandentalacademy.
com

• It is wise to have the patients head upright and to record
the lower preliminary impression first, an impression
compound with minimal flow is recommended eg.
Medium fusing compound. Either silicone or heavy
bodied polysulphide is suitable for final impression.
• For registration of centric relation, virtually the entire
palatal surface of the maxillary trial base is removed in
order to reduce to an absolute minimum the area of
contact between rim and palatal tissue.
• In addition, a thin film of adhesive was sprinkled onto the
record base for retention, and an anesthetic was sprayed
onto the palate.
• Patient followed instructions regarding breathing and
foot tapping. www.indiandentalacademy.
com

• Prior to actual placing of new dentures, the patient was
prepared for a temporary period of discomfort, but was
assured that although initially uncomfortable, it would be
short lived.
• Lower denture should be placed first. The maxillary
denture should then be placed and the patient is requested
to close into centric occlusion. The patient should be
made to nose-breathe in a deep slow fashion. Although
initially very severe, the gagging will subside over a
period of (4-5) minutes.
• Hypnotherapy is also used as are various types of
behavior therapy. Barbiturates may be used to depress the
CNS, antihistamines to lower the feeling of sickness or
parasympathetic depressants to reduce the salivary flow
which increases at the outset of retching.
com

• Systemic factors resulting in discomfort.
• Burning tongue (glossopyrosis) and burning mouth
(stomatopyrosis) these symptoms are frequently seen in
complete denture patients. However complete dentures are
not always the etiologic factor.
• It is almost impossible to make a clear cut diagnosis of the
cause of stomatopyrosis. Severe burning mouth is most
frequently found in menopausal women between 40 and 60
yrs of age.
• Other causes:
• Deficiency : Vit B12
, Folate, Iron
• Infections : Staphylococcal, Candidiasis
• Psychogenic : Cancerophobia, depression
• Prosthetic : Occlusal faults, bony irregularities, allergy to denture
base material.
com

• Beefy red tongue possibly glossodynia also
caused by folate deficiency. Refer for medical
treatment.
• Tongue thrusting, empty mouth chewing, is often
seen in elders.
• May have psychological or neurological
problems.
• Treatment may be required, it should include
occlusal adjustment.
com

• Painless erythema of mucosa related to supporting
tissue of maxillary denture. May be accompanied
by angular chelitis.
• This has frictional element due to ill fitting denture
plus opportunistic candida infection.
• To manage it, best to leave dentures out until
condition clears, then repeat the dentures.
• If angular chelitis is present combination of anti
fungal and anti bacterial agents useful.
• Presence of herpetiform ulcers in mouth caused by
herpes simplex or herpes zoster. History and
distribution of lesions should coincide.www.indiandentalacademy.
com

• Treatment:
• - Occlusion should be balanced in all positions
• - Check for roughness on the tissue and polished
surface of the denture.
• - Treat the causative systemic diseases.
• - Reconstruct the dentures, if porous and
unhygienic
• - Change denture base material if necessary
• - A balanced diet rich in vitamins and essential
minerals should be prescribed.
• - Whenever indicated, hormones should be
administered
• - Psychotherapy can be instituted.www.indiandentalacademy.
com

• Food under the denture
• This compliant is usually made by patients
wearing dentures for the first time and who have
not yet leant how best to control the food.
• A perfect peripheral seal will prevent the ingress
of food beneath the denture, but perfection is not
always attained and owing to alveolar resorption,
never maintained.
• Treatment: Covering maximum possible area of
the edentulous foundation and obtaining an
adequate peripheral seal
•
com

• Clicking of teeth
• The main causes are:
• - Excessive vertical dimension of occlusion causes
the denture to contact during speech, particularly the
sibilant sounds, as the mandible moves vertically through
the speaking space.
• - Movement of the lower denture from whatever
cause is very liable to lead to clicking of teeth.
• - Excessive incisive guidance angle usually means that the
horizontal overjet is inadequate in relation to the vertical overlap.
This means that during speech, in which there is often a
pronounced horizontal movement of mandible the incisors contact
each other and cause clicking.
• - Porcelain teeth by nature of the material creates more impact
noise than acrylic.
com

Difficult Denture Birds
• By Alex Koper(1988)
• The difficult denture birds is defined as problem
denture patient with much experience as a
recipient of various kind of dental therapy.
• They are individuals who complain, have pain,
are hostile, tense, anxious, and unhappy people.
They often exhibit regressive behavior and
transfer many of their fear and frustrations to
their mouth and face bow.
com

• Whittling denture dove/ denture swellers
• These are passive songsters who fill the dentist with nothing but
praise until the dentures are completed.
• They can hardly wait to get the finished dentures home to the work
bench. At the slightest of discomfort they start smoothening or
evening up of dentures with sand paper of emery.
• Denture swellers collect self cure resin and then start adding self
cure material to suit their facial contour often leading to
destructive results.
com

• Bruxing booby
• After wearing down his natural teeth away he brings a
life time of experience and over developed masseter and
pterygoid muscle to the encounter with the denture. The
mutilation resulting due to his over loaded and abused
denture bearing tissues brings howls of pain and threats
of violence to the dentist.
com

• Gagging grackle
• The gagging grackle dares the dentist to make dentures that he cannot
get rid of him self.
• The novice gagger will upchuck during impression stage and alert the
dentist there by alerting the dentist soon. Occasionally he uses his
hand to remove the dentures.
• The experienced gagger learns that it is more fun to see how far one
can toss the dentures when they are complete. He hides the fact that
he cannot the denture in his mouth for more than 15 minutes.
com

• Birds of paradise
• Also called as warm bottomed warbler
• The members of this species are all female who are
completely satisfied with their dentures. They have other
problems which they think that only a dentist can solve.
Be sure to keep one assistant with dentist all times.
com

• No pay jay
• The no pay jay is an expert at getting some thing for as
little as possible. His way of life is based on the premise
that any one can pay for the dentures and use them, but
the real skill is in getting the dentures and not paying for
it. Most often they delay payment of all but a token
retainer. Request for payment is always accepted and
deferres for one reason or other. As soon as dentures are
placed, the trouble begins. Nothing is right, everything
turned out differently than what it looked at the time of
try-in.
com

• Sweet sue sparrow
• These are the most prolific breeders in difficult denture
bird family. They know that the cost of defense, the
aggravation involved, and the dentist’s time away from
practice often leads to unjustified settlements.
•
com

• Aphasic tern
• These patients have great trouble in
communicating with the dentist during treatment.
But as soon as the dentures are completed they
become voluble experts of explaining every detail
of countless problems.
com

• Pocket wearing wren
• He is fine happy male songster who just wants to be left
alone. He has only one set of dentures and never comes
in for adjustments because he hardly wears them. The
occupation of this species is important so that it allows
him to keep his dentures in his pocket and work.
com

• Conclusion
• A thorough knowledge of factors involved in
construction of complete dentures is essential
before attempting post insertion check up.
• With out having this knowledge any attempt made
to solve post insertion problems will lead to
haphazard reduction of prosthesis which will
compromise its purpose, also leading to repeated
patient visits and dissatisfaction of the patient.
• Also the role of patient in getting used to the
prosthesis should be clearly explained to him
rather than simply heeding to patient demands.www.indiandentalacademy.
com

• References
• Zarb- Bolender – Prosthodontic treatment for edentulous
patients- 12th
edition p 379-380.
• Heartwell- Rahn - Syllabus of complete dentures – 4th
edition p 407-423.
• Sheldon winkler- essentials of complete dentures- 2nd
edition p 202-217
• Joseph Landa – oral mucosa and border extensions- J
Prosthet Dent- 1959;9:978-987
• Joseph Landa- lesions of the oral mucosa and their
correction – J Prosthet Dent- 1960;10:42-46
• Joseph Landa – traumatic injuries – J Prosthet Dent –
1960;10:263-267
• Joseph Landa – proper adjustment procedures – j
Prosthet Dent – 1960;10:490-498www.indiandentalacademy.
com

• Joseph Landa – local and systemic involvement –
J Prosthet Dent 1960;10:682-687
• Joseph Landa – mucosal irritations – J Prosthet
Dent 1960;10:1033-1028
• Louis Block – common factors in complete
denture prosthetics – J Prosthet Dent 1953;3:736-
746
• Roland .D. fisher – six fundamental rules for
making full denture impression – J Prosthet Dent
1951;1:135-144
• C. A. kennedy – trouble shooting in full denture
constructions- J Prosthet Dent- 1953:3:660- 664
• www.indiandentalacademy.
com

• Alex cooper- maxillary complete denture
opposing natural teeth: problems and solutions- J
Prosthet Dent- 1987;57:704-07
• Alex cooper – difficult denture birds- new
sightings- J Prosthet Dent- 1988;60:70-74
• S.Jegannathan, J.A.Payne – common faults in
complete dentures: a review Quintessence
international 1993;24:483-87
• J.F.Mc cord, A.A.Grant – identification of
complete denture problems: a summary – British
Dental Journal 2000;189:128-134
• Mahesh verma – trouble shooting in complete
dentures – Fam dent 2001;1:37-44
com

• Dentures instability: It may be due to a faulty
impression technique, or when posterior teeth are
placed too far buccally or when there is no
equilibrium between resilient and non resilient
areas.
• Inadequate free way space: A generalized
hyperaemia of the crest and slopes of the ridges
accompanied by pain in the muscles attached to
the mandible, the production of hyper keratin and
a looseness of the dentures are often the result of
insufficient interocclusal distance
com

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