Sequelae of wearing complete dentures/ orthodontics training courses

Sequelae of wearing complete
dentures
www.indiandentalacademy.com

Contents
 Introduction
 Soft tissues consideration
 Denture stomatitis
 Commisural chelitis
 Flabby ridge
 Traumatic ulcers
 Denture irritation hyperplasia
 Clicking
 Gagging
 Burning mouth syndrome
 Residual ridge reduction
 Overdenture abutments:caries &periodontal disease
 Indirect sequelae
 Conclusion
 References

Introduction
 Placement of removable prosthesis in the oral cavity produces
profound changes of the oral environment that may have an
adverse effect on the integrity of oral tissues.
 Mucosal reactions could result from a mechanical irritation by the
dentures,an accumulation of microbial plaque on dentures or
occasionally a toxic or allergic reaction to denture base material.
 The continuous wearing of denture have a negative effect on
residual ridges form because of bone resorption.Furthermore
wearing dentures that function poorly and that impair masticatory
function could be a negative factor with regard to maintenance of
adequate muscle function and nutritional statuswww.indiandentalacademy.com

Interaction of prosthetic materials and oral
environment
 Surface properties of denture base affect plaque formation
on the prosthesis.Irregularities or microporosities promote
plaque accumulation.
 Different materials in oral cavity may give rise to
electrochemical corrosion . Corrosive galvanic currents is
seen in B.M.S , oral lichen planus & in altered taste
perception.

 Certain microorganism (yeast) are able to use methyl
methacrylate as a carbon source thereby causing
chemical degradation of denture resin.
 Local irritation of mucosa by dentures may increase
mucosal permeability to allergens or microbial antigen
thereby capable of eliciting an allergic response

Soft tissue considerations
 Soft tissues supporting the dentures can be divided
into 3 types
1. Mucosa with a tightly attached submucosa :
masticatory mucosa covering the crest and slopes
of residual ridges & anterior third of palate in
rugae area.They resist pressure and frictional
impact of dentures.

2. Mucosa with loosely attached submucosa : located
in vestibular fornix &soft palate distal to the
palatine bones.They form a seal with the borders of
dentures
3. Mucosa with differentiated submucosa : located in
posterior third of hard palate , except for palatine
raphae &in retromolar pad.

 The soft tissues that contact but do not support the
dentures may be classified into 2 types:
1. Lining mucosa : covering the cheeks, lips,
undersurface of tongue,floor of mouth.
2. Specialized mucosa : covers the dorsal surface of
tongue.

 Injuries to oral tissues occur principally in 3 areas:
1. Tissues that support and resists stress.
2. Tissues that act to form a seal with denture borders.
3. Tissues that contact the polished surfaces and the
teeth.

Stress bearing mucosa
 Signs and symptoms of traumatic injury to this area is
as follows :
1. Lesions occurring in the mucosa that covers the palate
and the crest of residual ridges are small,well
circumscribed and indurated.The presence of excessive
keratin often causes the area to be white.
2. Lesions that appear punched out & the surrounding
mucosa hyperemic are a result of imperfections of
denture base,trauma from food particles or an injury
produced when the dentures were not in mouth.

3. Lesions that are hyperemic & painful to the pressure of closure
are usually the result of pressure directed toward an area of
exostosis , spur of bone or a foreign body.
4. Severe irritation and detaching of overlying mucosa occurs
occasionally over mylohyoid ridge,cuspid eminences,alveolar
tubercles &areas of exostosis.caused by denture flanges during
insertion or removal of denture or from excessive friction during
function.
5. Hyperemic , painful and detached areas of epithelium that
develop on the slope of residual ridges due to occlusal
disharmony.

Basal seat mucosa
 2 problems associated are hypertrophy and inflammation.
 Inflammatory reactions covering the basal seat are the
result of the following:
1. Continuous wear of dentures
2. Generalized hyperemia of crest and slopes of the ridges
accompanied by pain in the muscles attached to
mandible,the production of hyperkeratin,looseness of
dentures as a result of insufficient inter occlusal distance

3. Presence of loosely attached submucosa results in
friction of underlying bone against the undersurface of
the mucosa when the dentures glide on mucosa thereby
producing inflammation.
4. Complete denture opposite natural dentition or partial
denture causes localized hyperemia and edema.
5. Poor oral hygiene
6. Unbalanced diet and avitaminosis
7. Endocrine gland disturbances,systemic diseases
8. Allergic reactions to denture base materialswww.indiandentalacademy.com

Transitional submucosa
 Hypertrophy occur in area of transitional submucosa
such as border extensions.results due to unpolished
or sharp borders.
 Lesions appear as slit like fissures,varying length
and depth ,painful and often become ulcerated.

Lining mucosa
 Abrasions appear on mucosa of cheeks and
lips are frequently the result of :
1. cheek biting.
2. Rough margins on the teeth.
3. Unpolished denture bases.

Specialized mucosa
 Ulcerations and other lesions appearing on the
margins and apex of tongue are results of:
1. Tongue biting often caused by improper placement
of teeth either in horizontal or vertical position.
2. An unpolished denture base or a too pronounced
rugae area.
3. Rough margins on teeth.

 Cause complaint
 Denture faults
 Impression surface
inaccurate fit p l
over extension p l
Flange width inadequate for facial seal p l
post dam absent l
roughness p
Cast damaged before processing p
extension into bony undercuts p
 Polished surface
Denture not in neutral zone l
Shape unfavorable for muscle control l
 Occlusal surface
Occlusion unbalanced p l
Cuspal interference p l
Occlusal plane too high l
Inadequate freeway space p
Occlusal table too wide p lwww.indiandentalacademy.com

 Patient factors
 Bruxism /parafunction p
 Low pain intolerance p
 Poor neuromuscular control
Slow rate of adaptation(elderly patients) l
Neuromuscular disorder(parkinsonism) l
 Mucosa
Flabby l
Atrophic p
 Bone
Sharp spicules p
Prominences:mylohyoid ridge,mental foramen p
Advanced resorption l
Pathology within bone p
 Saliva
Deficient or absent p l
 Systemic diseases
Iron deficiency anemia p

Direct sequelae
 Mucosal reactions
 Oral galvanic currents
 Altered taste perception
 Burning mouth syndrome
 Gagging
 Residual ridge reduction
 Periodontal disease & caries of abutments

Denture stomatitis
Newton’s classification
Type I:localized simple inflammation or pinpoint
hyperemia
Type II:An erythematus or generalized simple type seen as
more diffuse erythema involving a part or entire denture
covered mucosa
Type III:granular type involving central part of hard palate
and alveolar ridges

Etiology
 Type I is trauma induced whereas types II & III are caused by
presence of microbial plaque accumulation(bacteria or yeast) on the
fitting denture surface & the underlying mucosa
 The direct predisposing factor for candida associated denture
stomatitis is presence of dentures in oral cavity.
 Kulak Y,Arikan A(1993) found that there was a statistically
significant relationship between denture stomatitis and denture
hygiene,smoking habits,candidal formation and colonization.

 It is seen the major part of microorganisms of denture
plaque are also involved.In addition trauma could
stimulate turnover of palatal epithelial cells thereby
reducing the degree of keratinization and barrier
function of epithelium thus the penetration of fungal
and bacterial antigens takes place more easily

 Colonization of fitting denture surface
by candida species depends on :
Adherence of yeast cells
Interaction with oral commensal bacteria
Surface properties of acrylic resins
Poor oral hygeine
High carbohydrate intake
Reduced salivary flow
Continous denture wear

 The important factors that can modulate the host-
parasite relationship and increases susceptibility
to candida-assosciated denture stomatitis:
Aging
Malnutrition
Immunosuppression
Radiation therapy
Diabetes mellitus
Antibiotics www.indiandentalacademy.com

Diagnosis
 Confirmed by finding of mycelia or
pseudohyphae in a direct smear of isolation of
candida species in high numbers(>50
colonies)

Management and preventive measures
 Institution of efficient oral and denture
hygiene and correction of denture wearing
habits
 Patient instructed to remove dentures after
meal and scrub them vigorously with soap
before reinserting them

 The mucosa in contact with denture should be
kept clean and massaged with a soft
toothbrush.
 Patients with recurrent infections should be
persuaded not to use the dentures at night but
rather leave them exposed to air.

 Rough areas on the fitting surface should be
smoothened or relined with a soft tissue
conditioner
 About 1 mm of internal surface being penetrated
by microorganisms should be removed and
relined
 Polishing or glazing of tissue surface of denture
should be done

 Treatment with antifungal agents is used in the
following patients:
1. In patients after the clinical diagnosis is confirmed by
mycological examination
2. In patients with associated burning sensation of oral
mucosa
3. In patients in whom the infection has spread to other
sites of oral cavity or pharynx
4. Patients with increased risk of systemic mycotic
infections due to debilitating diseases,drugs or
radiation therapy

 Local therapy with nystatin,amphotercin
B,miconazole or clotrimazole is preferred to
systemic therapy with ketoconazole or
fluconnazole because resistance of candida
species to latter drugs occurs regularly

 Treatment with antifungals should continue for 4
weeks
 When lozenges are prescribed,the patient should be
instructed to take out dentures during sucking
 The patient should be instructed meticulous oral and
denture hygiene; the patient should be told to wear
denture as seldom as possible & to keep them dry or
in disinfectant solution of 0.2%-2% chlorhexidine
during nights

 Surgical elimination of deep crypt formations
in type III denture stomatitis is a prerequisite
for effective mucosal hygiene.Achieved with
cryosurgery

Commisural cheilitis
 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

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

 Marked
fibrosis,inflammation
and resorption of
underlying bone is
seen
 They provide poor
support for denture.

 To improve stability of denture and minimize
ridge resorption , the tissue should be surgically
removed.
 In situation of extreme atrophy of maxillary
alveolar ridge,flabby ridges should not be totally
removed because the vestibular area would be
eliminated

Traumatic ulcers
 Develop within 1-2 days after placement of new
dentures.
 Small painful lesions,covered by a gray necrotic
membrane and surrounded by an inflammatory
halo with firm , elevated borders.
 Caused due to overextended denture flanges or
unbalanced occlusion.

 Conditions that suppress resistance of mucosa to
mechanical irritation are predisposing factors.e.g,diabetes
mellitus,nutritional deficiences,radiation therapy or
xerostomia.
 In a non –compromised host ulcers will heal after
correction of dentures.When left untreated,it subsequently
develops into denture irritation hyperplasia.

Denture Irritation Hyperplasia
 Common sequelae of wearing ill-fitting dentures is
occurrence of tissue hyperplasia of mucosa in contact with
denture border
 Lesions are a result of chronic injury by unstable dentures
or by thin , overextended denture flanges.
 Lesions may be single or quite numerous and are
composed of flaps of hyperplastic connective tissue.

 Inflammation is variable;however in bottom of deep
fissures,severe inflammation may occur.
 Treatment is adjustment or replacement of
denture.surgical excision of hyperplastic tissues
 If lymphadenopathy is present,the denture irritation
hperplasia may simulate a neoplastic process.

Clicking
 A clicking noise when teeth contact during
functional movements is a result of
insufficient interocclusal distance,vertical
displacement of mandibular denture.

 Treatment :
1. Correct stability and retention by rebasing or
remaking the dentures.
2. If dentures are not loose,if sufficent interocclusal
distance exists,and if teeth are porcelain,replace the
porcelain teeth with acrylic resin teeth.
3. When interocclusal distance is not sufficient,alter
the occlusal surfaces of teeth with remount
procedures to provide adequate space

Gagging
 Stimulation of sensitive areas in posterior pharyngeal
wall,soft palate,uvula,fauces or the posterior surface
of tongue results in series of uncoordinated and
spasmodic movements of swallowing muscles.This
is referred to as gagging

 Complete denture patient may develop gagging as
a result of:
1. Loose dentures
2. Poor occluion
3. Incorrect extension or contour of dentures
particularly in posterior area of palate and
retromylohyoid space.
4. Under extended denture borders.

5. Placing the maxillary teeth too far in a palatal
direction and the mandibular teeth too far in
lingual direction so that the dorsum of tongue is
forced into pharynx during the act of swallowing
6. Increased vertical dimension of occlusion
7. Psychogenic factors

Treatment
 Determine the cause
 Eliminate the biological and mechanical factors that
contribute to the problem.
 Prescribe a combination of hyoscine,hyoscyamine
and atropine with a sedative during initial period of
denture use.

Burning mouth syndrome
 Characterized by a burning sensation in one or several
oral structures in contact with dentures.
 Symptoms often appear for first time in association with
placement of new dentures.
 Common sites are tongue and upper denture bearing
tissues.Less common sites are the lips and lower denture
bearing tissues.Oral mucosa appears normal.

Classification
 3 types of BMS have been described by Lamey &
Lewis 1989
1. Type I: There are no symptoms on waking.A
burning sensation then commences and becomes
worse as the day progresses. This pattern occurs
everyday. 33% of patients fall into this category
and are likely to include those haematinic
deficiencies and defects in denture designs.

2. Type II : Burning is present on waking and persists
throughout the day. Occurs everyday. About 55% of
patients are placed in this category, a high proportion of
whom have chronic anxiety and are most difficult to
treat successfully.
3. Type III : Patients have symptom – free days.Burning
occurs in less usual sites such as floor of mouth,throat
& buccal mucosa.Main causative factors are allergy &
emotional instability (Lamey et al. 1994).They make up
for the remaining 12% of patients.

Causes
 Local factors: mechanical irritation , allergy due to residual
monomer , infection , oral habits and parafunction , myofascial
pain.
 Errors in denture design which cause a denture to move
excessively over the mucosa which increase the functional stress
on the mucosa or which interfere with the freedom of movement
of the surrounding muscles may initiate a complaint of burning
rather than soreness.Seen in 50% of BMS patients

 Systemic factors: vitamin deficiency , iron
deficiency anemia ,xerostomia ,menopause, diabetes,
parkinson’s diseases,medication.
 Psychogenic factors: depression, anxiety and
psychosocial stressors.

Management
 Initial assesment (history/examination/special test)
 Provisional diagnosis
 Initial treatment(elimination of local irritants &
investigating &treating haematinic deficiencies)
 Assessment of initial treatment
 Definitive diagnosis
 Definitive treatment (local/systemic/psychological
therapy)
 Follow -up

Residual ridge reduction
Residual ridge resorption (GPT 7): A term used for the
diminishing quantity and quality of the residual ridge
after teeth are removed.
Continous bone loss after tooth extraction and placement
of complete denture is seen.Reduction is a sequel of
alveolar remodeling due to altered functional stimulus of
bone tissue.It is a progressive and irreversible course that
results in impairment of prosthesis and oral function

The process of resorption is important in areas with
thin cortical bone(e.gbuccal and labial plates of
maxilla and lingual plate of mandible).
The annual rate of reduction in height in mandible is
about 0.1-0.2 and in general four times less in
edentulous maxilla.

CLASSIFICATIONS OF RESIDUAL RIDGE
RESORPTION
According to Brånemark et al in 1985, ridges were classified
on the basis of bone quantity and bone quality by
radiographic means.
BONE QUANTITY: (Brånemark)
Class A: Most of the alveolar bone is present
Class B: Moderate Residual Ridge Resorption occurs
Class C: Advance residual ridge resorption occurs
Class D: Moderate resorption of the basal bone is present
Class E: Extreme resorption of the basal bone

ATWOOD’S CLASSIFICATION:
Order I - Pre-extraction
Order II - Post – extraction
Order III - High, well rounded
Order IV - Knife edge
Order V - Low, well rounded
Order VI - Depressed

Etiological factors of residual ridge reduction
 Anatomical factors
Important in mandible versus maxilla
Short and square face associated with elevated
masticatory forces
Alveoloplasty
 Prosthodontic factors
Intensive denture wearing
Unstable occlusal conditions

Immediate denture treatment
 Metabolic and systemic factors
Osteoporosis
 Mechanical factors
transmitted by dentures or tongue to the residual ridges
results in remodeling process.

Consequence of residual ridge reduction
1. Apparent loss of sulcus width and depth
2. Displacement of muscle attachment closer to the crest
of residual ridge
3. Loss of vertical dimension of occlusion
4. Reduction of lower face height
5. Anterior rotation of mandible

6. Increase in relative prognathia.
7. Changes in interalveolar ridge relationship after
progression of residual ridge reduction.
8. Morphological changes of alveolar bone such as
sharp,spiny,uneven residual ridges and location
of mental foramen to the top of residual ridge.

 Rogers and Applebaum (1941) concluded from measurements
made in cadavers with dentulous and edentulous jaws that in the
maxillae the vertical height of the ridges had decreased and the
crest of the edentulous ridges had shifted palatally after tooth
extraction. They felt that in the mandible the most extensive
resorption of the alveolar bone occurred on the superior surface of
the ridge and on the lingual surface of the posterior part of the
ridge.

 Tylman and Tylman (1960) found that in the maxillae,
the labial and the buccal alveolar plates resorb much
faster than the palatal plates, while in the mandible the
amount of bone resorbed in the lingual and labial are
approximately the same

Treatment
Pre-prosthetic surgery includes the following:
 Ridge preservation procedure as a preventive
measure.
 Corrective or recontouring procedures of the
defects and abnormalities.
 Ridge extension procedures:
Relative methods Eg. sulcus extension
(vestibuloplasty)
Absolute methods Eg. Ridge augmentation
methods.

 Reconstruction methods like correction of
abnormal ridge relationship.
 Provision of accessory undercuts.
Creating favorable undercuts
Dental implants.
Onlay denture.
 Modified denture construction procedure Eg.
Immediate denture where construction of the
denture proceeds surgery

The prosthetic factors to be considered include
 broad area coverage (to reduce the force per unit area decreased
number of dental units,
 decreased buccolingual width of teeth, and
 improved tooth form (to decrease the amount of force required to
penetrate a bolus of food);
 avoidance of inclined planes (to minimize dislodgement of
dentures and shear forces);
 centralization of occlusal contacts (to increase stability of
dentures and to maximize compressive forces);
 provision of adequate tongue room (to improve stability of
denture in speech and mastication);
 adequate inter-occlusal distance during rest jaw relation (to
decrease the frequency and duration of tooth contacts)

Overdenture abutments:caries and
periodontal disease
 Wearing of overdentures is often associated with a high risk
of caries and progression of periodontal disease of abutment
teeth.
 This is due to bacterial colonization beneath a close fitting
denture is enhanced,and good plaque control of fitting
denture surface is difficult to obtain.
 Predominant micro organisms are streptococcus,lactobacilli
and actinomyces.

 These species initiate gingivitis after 1-3 days of
plaque accumulation when oral hygiene is
discontinued.
 Presence of streptococcus mutans and lactobacilli in
dental plaque flora in high proportions results in
caries.

Management
 Abstain from wearing dentures in the night.
 Application of flouride-chlorhexidine gel and polishing,
mechanical & chemical plaque control.
 Placement of copings that cover the exposed dentin and root
surface is indicated where caries is more deeply penetrating .
This is to reduce risk of new or recurrent caries.
 Periodontal pockets greater than 4-5 mm should be surgically
eliminated

Indirect sequelae:atrophy of masticatory
muscles
 Masticatory function depends on the skeletal
muscular force and the facility with which the
patient is able to coordinate oral functional
movements during mastication
 In complete denture wearers, particularly in women
atrophy of masseter and medial pterygoid muscle is
seen
 The decrease in bite force and chewing efficiency
results in impaired masticatory function.

Preventive measures & management
 Retention of a small number of teeth used as
overdenture abutments helps in maintenance of oral
functions.
 In completely edentulous patients , placement of
implants is usually followed by an improvement of
masticatory function & an increase of maximal
occlusal forces.

Nutritional status and masticatory
functions
 4 factors are related to dietary selection and nutritional
status of wearers of complete dentures:
1. Masticatory function and oral health
2. General health
3. Socio-economic status
4. Dietary habits

Management
1. Re-education of elderly denture wearers regarding
dietary habits.
2. Replacement of ill-fitting dentures.
3. Mechanical preparation of food before eating will help
mastication and reduce its influence on food selection.

Conclusion
 The essential consequences of wearing complete dentures
are reduction of residual ridges and pathological changes
of oral mucosae. This results in poor patient comfort,
destabilization of occlusion , insufficient masticatory
function and esthetic problems.

 Effort should be made to retain some teeth in
strategically good positions to serve as overdenture
abutments.The maintenance of tooth roots in
mandible is important.
 The patient should follow a regular follow - up
schedule at yearly interval so that an acceptable fit
and stable occlusion can be maintained

 Patients should be aware of implant supported prosthesis.In
young patients,advantage would be reduced residual ridge
reduction.In elderly patients , the main advantage are
improved comfort and maintenance of masticatory function.
 Patient should be motivated to practice proper denture
wearing habits and maintenance of oral hygiene and follow a
program of recall and maintenance for continuous monitoring
of dentures and oral tissues.

References
 Zarb –Bolender : Prosthodontic treatment for edentulous
patients, 12th
edition .
 Arthur.Rahn.O,Charles.Heartwell.M,Jr: Textbook of complete
dentures, 5th
edition.
 Sheldon Winkler:Essentials of complete denture prosthodontics,
2nd
edition .
 Basker RM & Davenport JC: Prosthetic treatment of edentulous
patient, 4th
edition.
 Tallegren A:The continuing reduction of the residual alveolar
ridges in complete denture wearers:mixed longitudinal study
covering 25 yrs,J Prosthet Dent 27:120-132,1972.

 Budtz-Jorgensen E:Oral mucosal lesions assosciated with
wearing of removable dentures,J Oral Path 10:65-80,1981.
 Conny DJ,Tedesco LA:The gagging problem in
prosthodontic treatment,Part I:description & causes, J
Prosthet Dent 49:601-606,1983.
 Hillerup S:Preprosthetic surgery in the elderly , J Prosthet
Dent 72:551-558,1994.

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