Prosthodontics

Preparation of the denture-bearing area-An essential component

of successful complete-denture treatment
Thomas A. Lynde*/John W. Unger**

Success in complete-denture treatment is often directly related to the health and condition
of the hard and soft tissues that make up the denture-bearing areas. Surgical alteration of
the denture-bearing area is frequently necessary to ensure a morphologically correct form
capable oj providing adequate support for the prosthesis. A number of these anatomic hard
and soft tissue obstacles are discussed, and methods for managing these hindrances to
complete-denture treatment are suggested. (Quintessence ¡nt !995;26:689-695.)

Introduction provide some suggested methods of treatment as

In this age of preventive dentistry and sophisticated
methods of replacing teeth, such as with dental implants,
conventional complete dentures still remain a viable
method of treatment for many patients. One critical
aspect of complete-denture treatment, which is often
confusing and poorly understood, is the proper
preparation ofthe denture-bearing areas.
Preparation ofthe denture-bearing area can at times
involve sui;gical alteration ofthe anatomic structures;
alternatively, depending on the needs ofthe patient, a
nonsurgical approach can be utilized. In many instan-
ces both forms of treatment are needed to return the
denture-bearing tissues to a state of optimal health
and form.
The purposes of this article are to review some
ofthe more common situations in which preparation
ofthe denture-bearing area would be indicated and to
' Assistant Professor. Department of Prosthodontics, School of
Dentistry, Medical College of Virginia. Virginia Commonwealth
University. Richmond, Virginia.
" W. Tyler Haynes Professor and Chairman, Department of Pros-
thodontics. School of Dentistry, Medical College of Virginia.
Virginia Commonwealth university, Richmond, Virginia.
Reprint requests; Dr Thomas A. Lynde, Assistant Professor,
Department of Prosthodontics, School of Dentistry, Medical College of
Virginia, Vtrginia Commonwealth University, Room 301-306, PO Box
980566. Richmond, Virginia 23298-0566.
well as the rationale for that treatment.
Unerupted teeth and retained tooth fragments
Survey reports of edentulous patients indicate that as
many as 24% to 33% had one or more retained roots,'
When evaluating retained teeth and portions of their
roots, the clinician must consider several factors that
in turn influence the type of preprosthetic surgery
ren-dered. Use of standardized, repeatable dental
radio-graphic techniques are essential to allow
assessment of any pathologic change associated with
retained teeth and roots.
Most impacted teeth should be extracted, parti-cularly
in young patients. In older individuals, if there is no
evidence of pathologic change and the removal of a
submerged tooth would result in a significant surgical
defect, the tooth may be left but must be carefLiUy
observed at recall visits for any sign of follicular space
enlargement. Regardless of the patient's age, if the
impacted tooth's follicular wall is close to or has
perforated the cortical plate, it should be removed.^
Areas of sclerotic bone must not be mistaken for
tooth fragments. In occlusal radiographie views, scle-
rotic bone will appear as irregular radiopaque areas
attached to the internal surface ofthe cortex. These
bodies will not have a definite lamina dura. These
areas warrant documented observation, but
preprosthetic surgery is usually not necessary.

Quintessgrr" i l¿QÍiimp,2E^Number 10/1995 689

Prosthodontics
persist after teeth are extracted. These often result from
the failure to remove jagged inter-septal bone at the time
of surgery. This condition is less common in the anterior
maxillae. The soft tissue that overlies these sharp
extensions is chronically irritated and becomes
redundant,*

Fig 1 Large maxillary Luberosity, The clinician must utilize radiographs and physical
examination to evaluate this situation clinically. It is
Fig 2 irigiit) Bilateral undercuts in the tubetosity area also essential to rule out any underlying systemic
complications. The ridge crest can appear razorlike,
Large bony maxillary tubero sities sawtoothed, or as discrete, large, spiny projections on
The presence of vertically enlarged bony maxillary
tuberosities can compromise proper occlusal plane
orientation, affecting fonction and esthetics of the
denture (Fig 1), The ocelusal plane ofa denture will
slope posteriorly and inferiorly, and the resultant
vertical occlusal forces will be directed obliquely to the
denture-bearing area. This can lead to instability ofthe
denture. An enlarged tubcrosity can also reduce the
amount of denture space to the point that strength of the
denture can be compromised by fracture or per-foration
ofthe denture. This situation can dramatically decrease
the retention ofthe denture.
Large osseous vertical tuberosities often are a result
of alveolar bone accompanying supraerupted teeth.
When these teeth are removed, the bone remains,
Dependitig on the proximity ofthe maxillary sinus,
which may expand into the tuberosity, the amount of
bone that ean be removed may be limited. The sinus
floor may be surgically collapsed upward if the sinus
limits the amount of bone that can be removed.^

Residuai ridge undercuts

Bony undercuts that are associated with the vertical
walls of residual ridges and obstruct the proper
extension of denture borders should be considered for
surgical removal. Undercuts in the ttiberosity areas (Fig
2), opposed by prominent anterior ridge under-
cuts, usually should be surgically modified in the
tuberosity area only. This will preserve the
important anterior cortical bone.
Mandibular residual ridge undercuts that appear
to interfere with a common path of placement of the
denture should be closely analyzed. If a rotational
placement is possible, then this should be
considered a better option than surgery, which
could eliminate vital supporting bone,

Siiarp residual ridges

Bony projections that underlie residtial ridge morpho-
logy are common sources of chronic pain and discom-
fort during denture wearing. This condition occurs more
frequently in the severely resorbed anterior mandible.
The situation results when the more accel-erated
resorptive pattern of the buccal and lingual surfaces
leaves a thin sharp bony crest. Also, sharp spicules may
690 Quintessence International Volume 26, Number
Prosthodonties
Fig 3 Sharp residuai ridge thaf can be improved by
surgery
dental roentgenograms. Palpation of the suspected
areas usually elicits pain. Clinical features of a
knife-edged ridge often appear as an overlying soft
tissue bulge delineated inferiorly by buccal and
lingtial undercuts or grooves.^
Treatment may consist of occlusal adjustment and
judicious rehef of the tissue surface ofthe denture.
This is ustially only a temporary remedy. Surgery
can be attempted and is more successflil in situations
where the residual ridge is broad and has some
clinical vertical height (Fig 3). Surgical treatment of
an atrophie residual ridge may eliminate what httle
denture-bearing area exists. If surgery is the only
treatment option to create a smooth, broad denture
foundation, then some success may be obtained with
denture construction techniques that redistribute
stress to areas of bony support, such as the buccal
shelf.
Sharp internal oblique and mylohyoid ridges
These osseous ridges (the oblique is superior to the
mylohyoid) can pose obstacles to mandibular denture
construction. As the posterior mandible resorbs in-
feriorly and laterally, these ridges become more
prominent- The soft tissue overlying these structures
is usually thin. This factor, coupled with the
underlying sharp medial shelf of bone, may inhibit
proper lingual border extension of a denture into the
retromylohyoid space. The result is often loss of
stability and retention ofthe denture because of gross
relief of the denture in this area (Fig 4).
These ridges should be surgically smoothed if they
umber 10/1995
Fig 4 Siiarp internal obiique ridge.
are tender to finger pressure during oral examination.
They should also be considered for surgical removal in
a severely resorbed mandible where there often is a
need to maximize the lingua! extension ofthe denture
border. Clitijcal studies have indicated that this pro-
cedure may substantially enhance patients' tolerance of
removable prostheses in the short term.^
Torus palatinus
This slow-growing bony convexity, located along
the midpalatal suture, can create significant
problems during maxillary complete-denture
fabrication. These osseous prominences can range in
size from that of a pea to a large muhilobular
structure that may fill and overflow the palatal vault.
The soft tissue that covers these hard enlargements
is ustially thin.' Consequently, if a denture is made
over the torus, adequate internal relief must be
provided to avoid irritating tbis very thin mucosa.
A conservative nonsurgical approach to manage-
ment of a torus seems to be popular. In this case, the
denture is constructed over the bony prominence, taking
into consideration the requirements for internal relief. If
the torus extends posteriorly to or beyond the vibrating
line, it should be removed to assure an adequate
posterior palatal seal. If this exostosis is so large tbat its
undercuts trap food, causing tissue irritation, it should
be surgically excised.
A very large torus may add excessive paiatal
contour to a denture, resulting in speech difficulties.
In this situation, the denture may also develop
instability because ofthe fulcrum potential (Fig 5).
691
Prosthodontics

Fig 5 (lettj Large torus palatinus extending beyond the

vibrating line while requiring increased palatai
thickness or the denture.

Torus mandibularis
Fig 6 (below) Tori mandibulari that will obstruct border
The mandibular torus is considered more of an obstacle
seai of a denture
to successful denture construction than is its maxillary
counterpart. Therefore, surgical removal is the frequent
choice of preprosthetic treatment. These tori vary in
size similarly to the maxillary torus. They are usually
bilateral and are located on the lingual alveolar surface
in the canine-premolar area. The mucosa covering these
hard convexities is thin and suhject to constant irritation
during denture function,'
Because of their size and location, these exostoses
frequently hinder proper lingual border seal of a denture
{Fig 6), The practitioner should not be misled by the
concept that provision of enough internal lingual relief
of a denture will obviate surgical correc-tion. These tori
are often large and provide undercut contours in close
proximity to the lingual sulcus and. therefore, should be
surgically removed.*
Small tori that do not present with the afore-
mentioned contours aud location may be retained.
Adequate relief can be provided without compro- Common locations are labial, lingual, and buccal
mising extension and seal ofthe demure border. areas. All frena, when too close to the alveolar ridge
crests, may interfere with proper border extension
leading to poor peripheral seal and fracture-prone
Unfavorable frena) positions
areas in the denture^ (Figs 7a and 7b). If a strong
Frena are fibrous bands of tissue that may have several force is applied by a frenum, then the extension of the
folds of movable mucosa. These structures attach to denture border may be compromised, A mandibular
bone, but are supertlcial to muscle attachments. lingual frenum may dislodge a denture with normal
tongue movements. It has been shown that a large
midline frenal notch in a denture complemented by a
narrow diastema between the central incisors greatly
increases the risk of denture base fracture through
this area,'
In the majority of situations, a high or strong
frenal attachment should be surgically corrected prior
to denture construction.

Fibrous residual ridge

The fibrous residual ridge can be a significant im-
pediment to the successfiil function of complete
dentures. Although often described as part of the
combination syndrome that afTects the anterior maxil-
lary residual ridge, fibrous changes in the composition
ofthe residual ridge can occur throughout the maxil-lary
and mandibular denture-bearing areas. The maxil-lary
tuberosity is an example of an area where fibrous tissue
enlargement is often encountered.

692 Quintessence Intemational Volume 26, Number 10/1995

 Prosthodontics

Fig 7a

Fig 8 (A) Natural mandibular anterior teeth functioning

against maxillary compiete denture (B¡ Maxillary
anterior librous ridge.
Figs 7a and 7b Labial trenum too olose to ndge crest.
Lingual frenum that will interfere with border extension
and seal.

Identilying the cause of the development of the
fibrons tissue is often impossible. Frequently, Irauma
to the residual ridge is thought to play a significant
role. This has been well described by other authors as
a major factor in the genesis of the combination syn-
drome.'**" Inadequate posterior occlusion combined
with natural mandibular anterior teeth functioning
against a complete maxillary denture is thought to
cause the development ofthe fibrous residual ridge in
the combination syndrome (Fig 8).
Treatment will var>' with the extent and location of
the fibrous tissue. Surgical removal is generally con-
Fig 7b
Fig 9 Thick layer of librous tissue overlying maxillary
tuberosit
sidered if the fibrous tissue can be removed and
adequate residual ridge height will remain to support
and retain the prosthesis. This treatment approach is
used principally where the fibrous ridge area is well
defined and limited. A common example of this
situation would normally arise in the maxillary tnber-
osity area (Fig 9). Sui^ical excision ofthe fibrous tissue
would generally be limited to the tuberosity area and
would usually not significantly reduce the ability of the
dentist to provide a retentive complete denture. The
implantation of alloplastic materials, implanted to
restore a firm consistency to the residual ridge, has

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Prosthodontics
Figs 10a and 10b Palatal papillary hyperplasia on labial and palatal surfaces oí anterior maxillae.
Fig 10a
been advocated by some individuals.'''^ Changes in
impression techniques aimed at recording the
fibrous residual ridge tissue in a nondisplaced state
has been suggested by others as an alternative to
any surgical intervention. '•"
The dentist often faces a significant treatment
dilemma in this situation; creating a single solution that
will fit each instance is an unobtainable goal. The
fibrous nature ofthe residual ridge will undoubtedly
affect the stability of any prosthesis because ofthe lack
of a firm, solid base of alveolar bone making up the
residual ridge. Removal of all the fibrous tissue from
the residual ridge will potentially improve the stability
ofthe prosthesis, but could create a situation in which
the residual ridge height is inadequate to provide
sufficient retention for the prosthesis. The dentist must
carefully analyze each situation and, along with the
patient, choose the treatment approach that will be most
beneficial.
Papillary hyperplasia
Papillary hyperplasia is characterized by the develop-
ment of numerous small papules usually located on the
hard palate under an existing maxillary prosthesis (Figs
10a and 10b}. Although papillary hyperplasia may occur
on the mandibular denturebearing areas, it is rare.
Papillary hyperplasia is generally believed to develop as
a result of chronic infiammation induced by continuous
denture wearing.'^"* The typical patient who presents
with papillary hyperplasia wears a maxillary prosthesis
continuously, 24 hours a day In addition to the papillary
formation, the tissues usually are red and inflamed.
White patches frequently asso-
694
Fig 10b
ciated with Candida albicans infection may also be
present.
Treatment is first aimed at resolving the infiam-
mation. Because the source of the problem is usually 24-
hour-a-day wearing of the denture, this practice must be
stopped. Improvement in the hygiene ofthe mouth and
the prosthesis must commence immediately. A properly
fitting denture with a stable occlusion is vital.
Provisional liners can be placed in the denture to
improve the adaptation of the prosthesis, and the
occlusion can be adjusted to reduce interferences and to
distribute the occlusal load properly. Patients should be
given home care instructions that involve specific
guidelines for both oral and denture hygiene. This most
often means brushing and/or massaging the denture
bearing tissues and brushing and soaking the denture to
ensure that it is clean.
Once the inflammatory component has been elim-
inated, the true extent and size ofthe papules can be
determined. Research has shown that papillary hyper-
plasia is not a malignant condition and therefore may
be treated in a conservative manner. '•' If the papules
do not interfere with denture construction or the
deve-lopment of an adequate peripheral border seal,
then removal ¡s not indicated. Removal of the
papules should be considered in any instance where
proper denture retention will be compromised or
where the size ofthe remaining papules will not allow
adequate hygiene. Ongoing observation by the
dentist, along with continued reinforcement to the
patient of the importance of removing the denture for
at least 8 hours in a 24-hour period and maintaining
proper hygiene practices, is essential to Ion.g-term
resolution of this condition.
Quintessence International Volume 26, Number 10/19ñ.s
 Prosthodontics
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