Prostho lec #6b : difficulties in complete denture construction & solutions Mon : 28\11\2011
Today we will continue talking about difficulties and solutions in constructing complete dentures. We started with tray size and selection and small mouth opening, retching, anatomical factors related to denture bearing area’s like: undercuts, flabby ridges, short upper lip, V shaped palate, spike ridge, flat ridge, high ridge.
High ridge: Most of the patients have reduced ridge height, especially in the lower arch, but some patients especially those who have teeth extracted due to decay not disease, sometimes the upper and lower ridge heights might interfere with the denture, so there will be no enough space for the acrylic base and teeth. In this case the ridge height will be causing difficulties in constructing complete denture. Usually it is limited interocclusal space, and you can't open it because lower face height will be increased, and sometimes you find that in part of the ridge, like for example, lower anterior segment, upper anterior segment, most patients have posterior teeth extracted before anterior teeth, because of decay, class 1 carries happen in pit and fissure. What’s the solution? If we can play a little bit with setting of teeth, make the acrylic base as thin as possible. Move teeth a little bit without affecting the neutral zone, sometimes it interferes with the prosthesis so you need to do surgical reduction. (osteoplasty)
Prominent ridge: It's very common, in the upper anterior area, especially in patients where teeth are recently extracted, the bone would labially still not resorbed. Why is this area not important? Because if posteriorly if we push a little bit the cheeks it will not affect that much the esthetics but anteriorly if you ever stretch the lip it will be prominent and not acceptable esthetically.
1 . its no problem if you give them a denture with class 2 div 1
Large tuberosities: When the 3rd molar supra-erupts . in the area of prominent bone. the tuberosities follows. and when you raise the lip a little bit. open window denture. its PROCLINED bone. If 1 mm was still thick for some patients we can do an open flange denture. it might be one of these two: 1) fibrous 2) Bony 3) Combination of 1 and 2 Don’t use only palpation! Sometimes when you palpate fibrous tissue might seem bony. At the time the lip is contacting the borders of the denture. in this case class 2 div 1 its very significant . Sometimes even when we do extractions the tuberosities might do enlargements.
. there is no problem.I have told some of you in jaw relation to make the acrylic base as thin as possible labially. it doesn’t matter the idea is you don’t have a flange anteriorly. It’s a simple procedure and this will retrocline the labial plate of the bone. where we move the bone backward. retention is there. and mobility with decayed teeth. there will be loss of retention! There is another thing with the patients that have class 2 div. What’s the consequence of having no flange anteriorly? >> Loss of retention. cut the flange completely. The good thing with patients that have class 2 div 1 . it has many names sometimes they call it flangeless denture. when they extract the tooth they will use Rongeurs forceps (do you know the bone cutters ?) removing the interseptal bone and creating grooves labially. So from the start we create an interception for the denture. they will have proclined teeth. but don’t leave a knife margin of the denture so you don’t cause trauma! So usually we prefer acrylic to be 2 mm thickness but in this area we would prefer if it was 1 mm thick. because its not only prominent bone. we will teach you that with pre-prosthetic surgery.
Just to remind you the labial frenum doesn’t move laterally so it should be just a slot. The frenum is a very friable soft tissue. anterior and posterior.Now for large tuberosities when the patient just bites normal the patient tuberosity will bite on the ridges. So no way that you can do complete denture for this case without doing surgical reduction or cutting of the denture! Most patients would refuse surgery even though its simple surgery. Which has multiple techniques. And it’s a very common mistake with students. In cases where it's not severe enlargement we can do thin base acrylic where it doesn’t make any interference. Some people say tuberosities is very important in complete dentures some of them think its primary stress bearing area and if it has mild to moderate undercuts it can aid in retention so in some tuberosities we relief or do surgical reduction. most of the time it dislodges the denture. What will happen if you don’t relief the denture for the frenum? Sometimes things might happen straight away.
. How do you know if the patient has high frenum attachment? It might reach up to the embrasure between the teeth. one is large vertically. And others might have vertical tuberosities it will be fibrous tissue or bone. one is large buccolingually. Usually we do a slot but if it was really high we will use a technique in surgery called frenectomy. so when you leave it without relief and the patient comes for review you will see him with an ulcer. in both cases in surgery they will teach you how to do a surgery technique (wedge shaped) to reduce the tuberosity size. So when you raise the upper lip you will see blanching of the papilla. Large tuberosities is in two dimensions.
High frenal attachment: Sometimes we need to relief the record block and when we do insertion for the frenum. for example as soon as you insert the denture the denture will dislodge. So in complete denture there is no teeth and it will reach to the crest of the ridge. Some patients would have very big large tuberosities buccolingually and severe undercut but the heights are fine. Buccal frenum on the other hand should be V shaped as it moves up and down.
so in these patients the control of the muscles in there face is hard. keep in mind the neutral zone.
. dealing with patients with old age who have different expectations and you are dealing with them with YOUR behavior. especially the ones with disc displacement without reduction. In these patients the muscle is already pushing back.Tense muscles: Especially seen in mentalis. Also “you don’t know what you don’t know” à memorize this sentence. (above 50 or 60) so their behavior and communication skills is different. They will also have limited mouth opening. and this disease affects the retention of complete denture. most of them are hemi-paralyzed. Most of you are around 22 years old. tongue and lip! Also you should extend the lower denture as posterior as possible covering 2/3 to 3/3 of the retromolar pad area. Most old age patients has Parkinson's disease .
TMDs: Tempromandibular dysfunction and complete denture. Some patients may also take drugs that cause xerostomia. there is no contraindication. the best thing to do is make a concavity in the labial flange of the denture. This is usually because of tense mentalis or the modulus area. Also the occlusal plane should be below the tongue so tongue helps stabilize it. Now as for the behavior of the patient most of time it’s constructed for patients who are of old age. sometimes it works sometimes it doesn’t. Patient might have pain so he will not allow you to do centric relation in a proper way or he might have a problem in the TMD’s that create a deviation in the mandible so it will be hard for the operator to exactly locate the CR. in bad cases the labial surface of the ridge is sloped and the lower lip up to the ridge. and it's very tense so when you hold his lip you feel him resisting. and set the lower incisors as posterior as possible.
Systemic diseases behavior and communication: problems It's very common to make a complete denture for a patient with CVA.
or people might have good denture but the problem is in occlusion and occlusion problems they cause the denture to move and rock à trauma. as you can see complete denture science seems like an old science! Its common sense cause it was the only way to restore edentulous mouth.Even if you are a good student and work good with a good demonstrator . patients rarely complains of soreness. Hyperemia à you just see red mucosa. this disease is painless. from the posterior area of the vibrating line the area is normal. Usually its pinpoint
. Sometimes you might construct a denture that’s already rocking. and that’s during function. the other name for it is denture sore mouth. And the people with flabby ridges during function will cause trauma. something that will cause trauma. So he classified it into 3 types: Type 1: hyperemia associated with trauma from the complete denture It's so easy to diagnose because as soon as you remove the complete denture JUST the area covered by denture is affected. in upper jaw . the gag disappears we will take an impression without a problem! What will be the problem here? Communication problems
Oral diseases and pathologies:
This is very important. Firstly we will discuss denture induced stomatitis. the patient might not come to try in! So many patients has severe gag. because of the wide upper surface. the final denture might still have a problem because of the communication. Most of the time its upper . and as soon as the demonstrator goes and see the patient instead of the student. anterior to the vibrating line (place of denture) not normal. So type one is associated with trauma from denture. Denture stomatitis has 3 clinical pictures classified by “Gretchen” (I am not sure) in 1962.
they can be removed by surgery. so both these causes are the MAIN causes for denture stomatitis.is it the cause ? we don’t know! Bcz sometimes if u treat denture stomatitis with antifungal. prescribe medications)
Type 3: you will see papillary hyperplasia you will find enlargements. it happens in some patients. or incisive papilla area. So when you see denture stomatitis you must examine the complete denture and adjust the defects or faults of the denture. The lesion is sometimes superimposed with fungal infections >>They found that pts with denture stomatitis has candida albicans with higher percentage than normal people. This is irreversible. correct the faults. Both these cases are reversible (if you do a good denture. Poor oral hygiene is the second cause.Type 2: generalized erythema. All area covered by denture is red. the lesion doesn’t go >> but they found that many pts with denture
. there is a problem if it gets enlarged too much some patients might get neuroma’s which is a benign growth of the nerve bundle." candida albicans is part of the normal flora in many people 30-60% " . You don’t have to remove them but sometimes you will need to because they will affect the support of the denture!
The incisive papilla may be enlarged. So sometimes they can get neuroma’s in the mental area. Etiology and treatment? Etiology : most common cause from denture trauma.
Or they can use highly diluted bleaching agents " but these can even convert the pink acrylic into white" . then the treatment is "ideally" adjusting the denture b4 jumping into constructing new dentures unless the mistakes are uncorrectable. it can cause severe side effects in pts under anticoagulant therapy. Treatment: The etiology determines the treatment: >> if the cause is trauma. >>Then u adjust the occlusion : usually pts with old dentures have already flat teeth with class III postural position of the mandible. u adjust them by something called "occlusal pivots". In this case u need to make new dentures. Be careful when prescribing Miconazole bcz if it is systematically absorbed.stomatitis has candida on the fitting surface of the denture and on the oral mucosa >> as u know.2 chlorhexidine) >> pts should also buy soft brushes and "ideally" should brush them after every meal under tab water " with water underneath to avoid denture fracture if they were dropped" and brush the fitting. Antifungal drugs can be used : Nystatin .2 chlorhexidine solution. Miconazole "the most commonly used" in gel form >> paint it on the fitting surface of the denture 3-4 X daily. Poor denture hygiene >> this is common in 24-hour denture wearers >> always advice ur pts to remove the dentures at night and to put them in 0. Amphoterisin.
. polished and occlusal surfaces of the denture. fungal infections don’t happen in normal pts. it only happens in immunocompromised pts >> this means that diabetic pts are at high risk to develop denture stomatitis bcz of immune suppression and trauma. or they can use sodium hypochlorite highly diluted >> the best are denture cleansing tablets. but remember u can't take an impression of a diseased mucosa so: >> u either ask the pt to completely remove the dentures and wait for the tissues to recover or u use the tissue conditioner " visco-gel" which is a soft lining material so that it reduces the trauma on the denture bearing area bcz it absorbs forces. this will bring back new vertical dimensions and new centric relations with the existing dentures before constructing new dentures. these are available in pharmacies >> just one tablet in a cup of water is sufficient (these tablets r usually 0. then u make the new denture fixing the old denture problems .
they will have the burning sensation and u can see the mucosa red and reacted to the acrylic. but remember pts don’t complain of pain in denture stomatitis.Surgery might be needed in some cases of type 3. How to distinguish it from acrylic allergy? Simply when the pts wear the denture. Fungal infections can sometimes cause the syndrome. You usually open the pt mouth but u can't see anything abnormal. Remember this : females "there is female predisposition" & diabetics
Burning mouth syndrome:
The pts complain of a burning sensation " he exactly tells u : 7ass b nar in my mouth!". Differential diagnoses : denture stomatitis. So the most important differential diagnosis is allergy to acrylic. or u see general manifestations that aren’t specific to the syndrome like the tongue appearance similar to iron-deficiency anemia Etiology: It is a psychosomatic pain. of unknown etiology. Broad-spectrum antibiotics : these will kill the normal flora giving the chance to opportunistic microorganisms to cause the burning mouth syndrome.
Can be a pathology like in Sjoegren`s syndrome or secondary to medications like the antihypertensive agents that cause xerostomia >> post-radiotherapy pts bcz radiotherapy affects the salivary glands function why this is important in complete dentures? >>Adhesion cohesion: >>Trauma: more important: saliva doesn’t only help in dentures retention. but it also help in protecting the soft tissues from trauma bcz it acts as a lubricant. fungal infections bcz of the lack of the "wash effect of saliva " >>even patients with partial dentures and xerostomia will develop rampant caries and can lose all the remained teeth in something like 6 months!" U all know that u can clinically detect xerostomia using the dental mirror which will stick to cheeks. So what are the consequences of reduced salivary flow? >>Reduced retention >>Trauma >>Increased risk of opportunistic infections esp. Mucosa is wrinkled and dry and u can see ulcerations. Dry mouth is a very awful sensation >> if u want to try it: bring 5 tea biscuits and eat them at once without drinking water :P ! Xerostomia is degrees " it's not as sever in drug induced as in Sjoegren's syndrome"
The only problem is peri-implantitis In all the 3 conditions : visco-gel is used to rapidly relief the pain >> it is an elastic. The problem with visco-gel is that it becomes hard after one week. and don’t need saliva for retention.
>>Chew gum! Esp.Management: >>Synthetic saliva: most pts doesn’t like it!
>>Ask the pts to drink as much water as they can. of course this is in case of functioning salivary glands!
Luckily and interestingly. harbors a lot of plaque and can cause infection b itself!
. almost transparent highly viscous material even when it sets >> most pts indicate rapid relief after application of this tissue conditioner. it also helps to eliminate infections if they are present. paraffin wax. so it can be a solution in pts with xerostomia. implant dentistry isn’t affected by dry mouth bcz implants don’t decay.
and bcz he is young and edentulous he is shy : bt$ofhm by6l3o ymen w ysar lma yjo y$elo e dentures l2no ma bdhm any observer y$ofhm! >> so these pts have the age as a main concern. f ma balk ro7 yzb6 asnano b 7ooo! >> so hl mskeen ma 9fa 2damo ela CDs >> CDs are solutions and nightmares at the same time >> they don’t want their partner to know about the dentures >> this is cheating -.Pts age and expectations: U need to understand that u might have a young pt. Old pts just want something to eat and to speak .-! >> this can lead them to separate! >> keep in mind : pt confidentiality is very important!
. but we face them in the real life: Some pts who are heavy smokers and their oral hygiene is the last concern get their teeth extracted when they are in their 30s while they are still single! >> now when these want to get engaged mst7eel yro7 bdon asnan :P >> they need CDs >> most of them can't afford implants >> minimum number of implants in the DTC costs over 7ooo JDs >> hwe already ma m3o ytzwj . These Pts usually have very difficult social life : ldrjt enno he ignored his mouth y3ni he didn’t do any oral hygiene measurement bcz his mouth is the last concern or bcz he is depressed. y3ni they care about function and aren’t concerned about appearance even if they have a canted occlusal plane!! Now we will mention things that u might think are funny.
How do you know the case? Examine the dentures! e. it might just be unrealistic pts expectations. "Ideally " one month is enough for CDs. u need to be smart!
.. between 2ry impression and insertion bcz resorption is a continuous process esp. occlusion perfect >> in this case do you think that if you make a new denture the pt will be satisfied?! No. otherwise dismiss them!
Communication with laboratory technicians and quality of lab work: Laboratory technicians aren’t enemies! they are ur supervisors in the lab so plz follow their instructions.g.
Pts having bad experience with complete dentures: Bad experience doesn’t necessarily means bad work . the 1st denture: very bad occlusion 2nd denture : bad occlusion & poor fitting 3rd denture: retention perfect. It can also be the opposite: y3ni el pt bjeblk 5 dentures & all of them have mistakes that prevent pt satisfaction. in pts with recent extractions. Students need one semester! Intervals shouldn’t be very long esp.Appointments durations and intervals: A practitioner working correctly can see his pt every week. stability perfect. bejek pt w jayb m3o el 3$ere : e$e 9`3er e$e kbeer e$e 3l ymeen w e$e 3l $mal 8al e$ jayeen ytfrjo!! Behave professionally >> only keep the escort if the pt is very old and he helps in communication with the pt. It's an equation and need both sides to fabricate good work . In prosthodontics the relationship with the technicians is very important: all the issues should be understood between us & them.
Escorts: El mraf8en eli m3 el pt.
. Esam & Dr.The sweetest end -
Maram & Nadine
. Important note: The exam material included from the 1st lec to the end of the difficulties lec NOT including the lecs of Dr.U might have a pt with good dentures. but have complaints like worn teeth or loose dentures >> in this case copy dentures is the treatment of choice.