HAVE PROBLEMS EVEN WITH A BRAND NEW DENTURE??
NEW DENTURE PROBLEMS
Does the denture hurt?
Not satisfied with a new denture?
Got irritation after wearing your new dentures?
Still not able to eat or talk even with the new dentures?
If your patient is unsatisfied with your new denture, he/she won’t come back to you.
If you want to practice well, you must not only know to deliver a denture but also be skilled to solve the problems patient come up with later on.
In order to do so, identification, evaluation of the root cause of the problem is a must.
We often come across in our dental practice, recently delivered patients coming back complaining about it.
And if you are not able to satisfy the patient, he/she is going to lose faith in you.
I am revealing the secrets of a successful denture practice and the reason my patients obliged to me rather than visiting other prosthodontists.
Usually, complaint of pain, discomfort or dissatisfaction is associated after denture delivery.
One end of this spectrum is an easily satisfied patient who returns after insertion for only 1 or 2 minor adjustments.
Another end of this spectrum is patient who becomes an office fixture. He/she visit frequently with a short interval.
The complaints are of excessive discomfort, a poor function which is of nonspecific and bizarre symptoms that lead to massive frustration for the patient.
The prosthodontist/ dentist need a thorough knowledge of anatomy, physiology, pathology, and psychology to treat these problems.
We must be capable of differentiating between normal and abnormal tissue response.
We must distinguish between physical disorders that are aggravated by the psychic and emotional process of a patient and one that is solely physical.
“Can I ever talk with these dentures?”- The most common question asked by the patient during the insertion of the first denture.
Normal patient speaks with ease, speed and spontaneously because the tongue is accustomed to the keys of teeth and mucosal contour.
The situation is similar to one’s finger on keys of a piano the finger knows where to find keys.
The patient is assured that eventually accommodation will take place and be will experience no difficulty in speaking.
When dentures are first worn there is always some temporary alteration in speech owing to the thickness of denture covering the plate, necessitating slightly altered position at tongue.
Commonly this is only a temporary inconvenience most rapidly overcome by patient reading out loud.
However, some knowledge of phonetics in relation to denture is necessary in order to correct the speech defects that may occur in denture.
The tip of the tongue in all vowel sound (There are the sounds produced by oral air streams passing through oral cavity) lies on the floor of mouth either in contact with or close to the lingual surface of lower anterior teeth and gum.
The application of this in denture construction is that lower anterior teeth should be set so that they do not impede the tongue positioning for this sound.
The upper denture must be kept thin and posterior border should merge to the soft tissues.
One of the reasons for loss of tone and incorrect articulation of speech is the decrease of air volume and loss of tongue space in the oral cavity resulting from unduly thick denture base.
The periphery of denture must not be over-extended so as to encroach upon the movement of the tissues since the depth of the sulcus will vary, with the movement of tongue, lips and cheek dealings production of speech.
If the anterior teeth are placed too far some effect may be noticed on the quality of the liguo palatal S, C and Z. resulting in the lisp due to the tongue making contact with the teeth prematurely.
Speech may be altered temporarily in some patients after insertion of new dentures.
The patient should be counseled relative to the adaptability of the tongue.
Reading aloud and slowly for a few minutes every day helps them to become more proficient in the use of his altered valving mechanism for speech.
If these difficulties do not disappear, reassessment of the total occlusal scheme should be considered.
Improper placement of teeth in the vertical, horizontal and frontal planes usually contributes to speech changes to which the patient cannot accommodate.
Minor speech imperfections might be related to the excessive flow of saliva, large tongue, the contour and thickness of the palatal denture base, or a combination of these factors.
The general areas in which ill-conceived designs one most frequently observed are the extension, border thickness, denture base counter, tooth position and selection, posterior tooth form, vertical dimension, relief and selection of materials.
In order to recognize an improper extension, it is first necessary to know the characteristics of proper extension.
One of the best guides to the identification of improving extension is the recognition of the landmarks of the border outline of an impression or denture that is properly extended.
The characteristics of proper extension that can be recognized in all areas are that the borders are nicely rounded.
No flare of labial and buccal tissue surfaces is present as in overextension and there is no sharp border as in under extension.
A denture is placed so that it is within 2-3 mm of being seated.
The labial and buccal tissues are gently retracted at a 900 angle to the ridge so that the mucous membrane is displaced only slightly from the position of rest and the denture is seated the remaining distance.
If the border nestles gently into the border tissue the extension in that areas is correct. All the borders should be checked in this way.
The posterior palatal extension is evaluated by tracing with an indelible pencil along the border and seating the denture in place after drying the tissues.
A mirror is then used to palpate the hamular notches to check extension in these areas.
The lingual extension for lower denture is checked in a different manner.
1) After retracting the labial and buccal tissue to break the border seal the patient is asked to elevate the tongue gently. If the denture doesn’t raise there is no overextension.
2) With the tongue at rest, the sublingual area is evaluated with a mouth mirror.
Lingual borders require more experience for proper evaluation than do the labial and buccal borders. A problem with extension can usually be determined but the exact location is more difficult.
Characteristics of overextension
Each area of the denture border has some characteristic forms, which when present are suggestive of overextension.
- Labial and buccal borders –
If the counter of the tissue surface of the flange changes from vertical to horizontal and if the tissue surface of frenal notches has a labial (or) buccal flare overextension is probable.
The buccal border may show an extension onto the zygomatic process. This is not an infallible indicator of overextension, but it raises suspicion and intraoral evaluation must be used to confirm it.
On the denture border opposing the anterior surface of medial pterygoid muscle a definite notch (or) flattering should be visible.
Posterior palatal border –
At the hamular notches, the borders should terminate in the most superior posterior part of each notch.
In the presence of overextension, the record of the notch will be clearly anterior to the posterior border.
Overextension in the midline is more difficult to recognize.
If the midline extension is posterior to the straight line joining the two hamular notch areas, one can be fairly certain that the border is overextended.
The fovea palatine usually is within the denture outline and within a few mm of the desired extension.
A posterior palatal seal extension that is farther posterior than this should be suspected of being overextended.
- Labial border is same as with the upper denture.
Buccal border –
The external oblique ridge is an important landmark in this area.
A denture that extends beyond this ridge is suspected as being overextended.
Retromolar pad –
If the retromolar pad has been recorded in a relatively undistorted manner, the direction of the surface outline will be changed from predominantly horizontal to predominantly vertical. The denture should not extend beyond this directional change.
Posterior lingual border –
Any extension beyond a straight or slightly convex line extending from the distal border of the retromolar pad to the deepest part of
Retromylohyoid eminence –
This is an important landmark, which lies in the retromylohyoid fossa and should be included in the denture outline.
The denture should not extend inferior to this and if the denture outline flares medially, beyond the fossa and beneath the tongue overextension is present.
Mylohyoid border –
Viewed from the lingual aspect, the outline should be relatively straight from the
Pre-mylohyoid eminence –
This landmark is usually clearly recorded. It is produced because the anterior portion of the mylohyoid muscle is inferior to the sublingual gland.
The posterior border of the gland often causes a soft-tissue depression in this area, which produces an eminence in this border. This landmark is obscure if overextension is present in adjacent areas.
Sublingual borders –
This border is evaluated intraorally by retracting the buccal tissues in order to destroy the border seal. If the denture rises anteriorly, it is overextended. The lingual frenum is often recorded in the tissue surface of the denture.
The border should end at the point of insertion of this frenum.
If the frenum is vertically displaced the border should be recorded until there is no record of it on the tissue surface of the denture.
Characteristics of under extension
It is more difficult to identify by landmarks on the outline form of the denture border.
Labial and buccal border
The labial and buccal frenum are not clearly recorded and the borders are usually not rounded nor exhibit the bands of tissue or muscles in detail.
Posterior palatal border
– The distal upward curve of the tuberosity is missing.
– If there is no recognizable tissue surface contour that extends into the hamular notch.
– If the border curves forward too severely in the center of the palate.
Labial and buccal border –
The absence of clean frenal markings and the presence of sharp or poorly rounded borders
– In the buccal shelf area –
The absence of more horizontal contour medial to the external oblique ridge
Retromolar Border –
The apex and base of the pad if clearly invisible in under extension
Posterior lingual border –
The most common characteristic of underextension is a mesial (or) anterior slop of this border as it continues from retromolar pad to retromylohyoid fossa.
With under extension – This area does not show a definite eminence on the denture.
Mylohyoid border –
The principal characteristic of underextension is the absence of ‘S’ shaped contour of the lingual border.
Premylohyoid eminence –
This landmark is absent from underextension.
It may also be absent if the mylohyoid muscle has been displaced laterally so that the S. shaped of the lingual border is absent.
The most common error in border thickness is to make it extremely thin. No definite limitations for all cases can be placed on border thickness, but there is some average thickness that serves as a basic design from which individual variations can be made
Labial border – 3mm
Buccal border – 3-8mm
Palatal border- 2mm
The frenal areas are usually somewhat thinner than the adjacent borders.
Don’t forget to round of each and every border surface.
Labial and buccal border – 3mm
Retromolar pad – 2mm
Mylohyoid region – 3mm
The sublingual borders are variable. They should fill the sublingual space when the tongue is at rest or slightly protruded.
Irritation after wearing dentures
How to check it?
Clicking of teeth while talking without movement of the dentures is a positive diagnosis of increased vertical dimension
Shifting the lower denture anteriorly while the patient closes his jaw in centric relation indicates disharmony between centric occlusion and centric jaw relation.
Lack of balance of contacts in eccentric movements (sideways and forward) indicates the presence of interferences.
The presence of wear facets in a tense and anxious patient is typical of bruxomania.
A generalized irritation of the mucosa that subsides after 24 hours of rest from the dentures is characteristic of an allergic reaction to denture base material, to denture cleaner, or to both. This can be verified by using a skin-patch test.
The presence of thin, sticky food debris on the tissue surface of the denture with corresponding irritation of the mucosa suggests poor oral hygiene.
Subsequent to consideration of these possibilities without determination of a cause is the possibility that an underlying systemic condition could render the oral mucosa unfavorable for denture support. The possibility of more than one cause for each problem also exists.
Generalized irritation of denture-bearing area
is due to –
1) Increased vertical dimension of occlusion
2) Disharmony between centric occlusion and centric relation
3) Occlusal interferences in eccentric positions.
4) Bruxomania, bruxism, or clenching habits
6) Tissue reaction to denture material or denture cleaners
7) Poor oral hygiene
8) Unfavorable denture-bearing tissues
Biting of tongue, cheek, and lip
Find out cause
The vertical dimension of occlusion should be re-evaluated by using multiple methods to arrive at an acceptable level.
Excessive inter maxillary space while speaking is often an initial clue.
End-to-end relationship of the buccal cusps of posterior teeth indicates an insufficient amount of horizontal overlap.
Improper posterior tooth placement is noticed on visual examination. Posterior tooth placement should allow adequate musculature control and should not encroach on the retromolar pad or the tuberosity. Visual examination of those parts of the denture base that covers the tuberosity and the retromolar pad will verify the need for increased space between the bases.
Observation of the tongue in relation to the plane of occlusion determines proper placement of the plane of occlusion. The dorsum of the tongue should be 1½ to 2 mm above the plane of occlusion.
Lack of muscle tone may be evident with aging or with neurologic deficiencies. If other motor activities are impaired in localized or generalized areas, consultation with a neurologist may be indicated.
Irritation in the tuberosity region
How to know?
Irritation in the tuberosity region is most frequently attributed to the presence of bilateral undercuts. Upper dentures that do not seat easily are likely to exhibit pressure areas when checked with pressure-indicator paste.
If a lack of tissue contact with the denture base is noted along the posterior border, dimensional change related to processing should be suspected.
If the lesion is located at the hamular notch, overextension of the border probably is the cause. Displacement of pressure-indictor paste near the lesion indicates pressure from the denture base.
Irritation on median raphe
How to identify the cause?
If the discomfort appears several days after insertion of a denture, it is often related to the loss of support from the primary stress-bearing area.
However, if the discomfort appears within 24 to 48 hours after insertion, the irritation is likely caused by lack of relief.
Rocking of the denture around the midline when exerting bilateral pressure with the fingers on the occlusal surfaces is diagnostic of insufficient relief
Forward and upward movement of the upper denture on occlusion in centric relation is indicative of excessive incisal contacts.
Irritation in labial sulcus, retromylohyoid region, and buccal surfaces of tuberosities
How to evaluate?
Patients who have been chewing with the remaining anterior teeth before becoming completely edentulous often develop poor masticatory habits that continue into the complete denture experience. Nibbling results in posterior dislodgment of the dentures and discomfort develop. Observation of the patient, while he is chewing, will often aid in the detection of an anterior chewing pattern. Such an observation might be made during simulated chewing after placing occlusal-indicator wax on the posterior teeth.
If the tongue is used to hold the upper denture in place, it is too loose. An upper denture that is loose while chewing and speaking is a positive indication that looseness is causing irritation.
Irritation of labial mucosa
Find out –
Place disclosing wax on the labial surface of the lower denture and instruct the patient to swallow water from a cup.
Observe the swallowing pattern of the patient. In normal swallowing, the teeth occlude in the centric position thus allowing stability of the mandible for deglutition. The tongue then forcibly contacts the palate and propels the bolus of food into the oropharynx.
With an atypical swallow, the teeth do not come in contact. The tongue is thrust forward and placed between the teeth while the cheeks are drawn inward. The muscles of the lower lip will try to maintain the denture in place. Thereupon, irritating develops.
Displacement of the disclosing wax on normal swallowing indicates an over contoured denture. Habit patterns encouraging excessive lip and facial grimacing should be noted.
Irritation on the crest of the residual ridge
How to examine?
A small opening in the center of a lesion with an associated hard, loose spicule indicates the presence of loose bone.
A positive diagnosis of deflective occlusal contacts is made by clinical observation while the patient closes his teeth in centric jaw relation. The lesion is usually found in the area of the deflective occlusal contact.
Irregularities on the tissue surface of the denture are confirmed by visual and digital examination.
Roentgenographic and digital examinations will confirm the presence of any sharp bone ridge with thin overlying mucosa, the mucosa being pinched between the bony ridge and the hard denture base.
If the foregoing causes have been eliminated, pressure from the denture base can be evaluated by the use of pressure-indicator paste.
Irritation near vestibules
How to check?
Irritation of the vestibule associated with an overextended or sharp denture border appears as a definite cut in the alveolar mucosa.
Pressure-indicator paste or disclosing wax should verify the offending denture area.
Irritation caused by an unpolished denture border causes an abrasion immediately adjacent to the denture.
This lesion should not be confused with an aphthous or herpetic lesion, which has a yellow base with an inflammatory halo.
Irritation on anterior lingual and lateral slopes of the lower ridge
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 or rotational movement of the lower denture.
If the occlusal relationships are satisfactory, pressure from the denture base can be verified with pressure indicator paste.
Irritation in the retromylohoid area
Overextension of the labial borders of the lower denture can be verified by asking the patient to close his teeth in occlusion and open his mouth slowly.
A positive diagnosis is made if the denture rises anteriorly and the labial musculature displaces posteriorly.
Overextension of the denture base at the retromylohoid region is confirmed by a definite cut into the tissue by the denture base, which is verified with pressure paste.
Instructing the patient to bring the teeth into protrusive contact will verify protrusive interferences; by moving their teeth into right and left-eccentric positions, contralateral and ipsilateral, deflective occlusal contacts may be diagnosed.
However, remounting the denture on an articulator may be the best diagnostic aid for evaluating deflective occlusal contacts.
The use of a pressure indicator paste confirms pressure from the denture base.
The type of tissue that may be present is varied.
– A localized inflammatory response can be caused either by pressure from a faulty impression or faulty processing of the denture.
It is usually detected by using disclosing pastes.
It is also caused by occlusal prematurity so a careful evaluation of the occlusion is essential before using pressure indicator paste.
If the occlusion is faulty, adjustment of the denture base will not correct the problem.
– Generalized inflammation is rare with usually made dentures except with a generalized poor tissue response which may occur with a patient who is generally in ill health, who has a severe nutritional deficiency.
To sum it up,
Well made denture enables the patient to have comfort, adequate function and an appearance that boost the patient confidence.
The insertion of new dentures in a patient’s mouth involves more than seating the dentures and telling the patient to call if there is any trouble. It is at this time that dentist’s evaluation is started.
The denture having being processed and polished are not completed. Inaccuracies in the material and methods used to get the dentures to this stage must be recognized and eliminated before the patient wear the denture.
Never forget to give post insertion instructions. Check out our INCREDIBLE POST INSERTION EDUCATION GUIDE.