Management of difficult

complete denture cases

Prepared
by
Dr. Mohamed Ashour
Assistant Professor of Removable Prosthodontics
 Objectives
 Understanding CD retention and stability
factors.
 Describe methods for Management of some
complete denture patients.
 Describe methods for Management of flat
ridges.
 Explain impression techniques of flabby
ridges.
Retention & Stability
of Complete Dentures
 What are the factors affecting
retention of complete dentures?
Groups of factors in retention of complete dentures
Adhesion
Fitting &cohesion
Surface Undercut
area
Polished Acquired
Surface Muscular
Control
Factors
related to Atmospheric
Pressure
Denture
Periphery
Denture
Extension

Occlusal Balanced
Surface Articulation
Retaining forces acting on a denture:
(1) Force of the muscles of
mastication acting through the
occlusal surface;
(2) Muscular forces of lips, cheeks
and tongue acting through the
polished surface;
(3) Physical forces acting through the
impression surface.
1-Factors Relating to the Fitting Surface
(Physical & Mechanical forces)

A- Adhesion &Cohesion
Adhesion:
Force of attraction existing between dissimilar bodies in
close contact.
Cohesion:
Force of attraction existing between similar bodies in
close contact.
 The chain of intermolecular
forces between the denture
and the mucosa contributing
to retention.
Adhesion depends on the following factors

1- Shape of the palate

A flat palate provide a good surface adhesion
A V-shaped palate allows sliding and therefore
retention is reduced
Shape of the palate
 2- Surface area
2-Surface area in contact:

The force of adhesion.

A lower denture
Adhesion depends on the following factors

3. Saliva.

4. Closeness of denture adaptation.

5. Direction of the displacing forces.

1-Factors Relating to the Fitting Surface
(Physical & Mechanical forces)

B-Undercut area
 The engagement of undercut area in the edentulous
region is possible to allow mechanical resistance to
a direct dislodging force.

 Gross undercuts may cause problem on insertion

and removal of complete denture.

 Typical examples are:

 Postero-lingual mandibular undercuts,

 And lateral posterior maxillary ones.

Selection of path of insertion to improve retention by utilizing undercuts:
(a) single path of insertion to engage labial undercut;
(b) dual path of insertion to engage unilateral undercut.
2-Factors relating to denture periphery

Atmospheric pressure
The periphery of a denture should bed
slightly into the soft tissues in the sulci.
Relationship between the width of the
buccal channel and resistance to flow
of saliva:
a) Wide channel, rapid flow, poor
retention; and
b) Narrow channel, slow flow, good
retention.

Retention due to the pressure differential

between the saliva film and the air.
Lateral extension of the buccal flange to produce a facial seal.
 Drop in pressure of the saliva film beneath the denture causing
impaction of the buccal mucosa and greatly increased retention.
Right: denture poorly retained because the thin flanges failed to create a facial
seal and the palatal coverage did not make the most of the area available.
Left: the replacement denture corrected these errors and as a result had
excellent retention
 The post dam is a slight elevation at the
posterior border of the maxillary denture
which applies slight compression to the
soft tissues along the posterior palatal
edge of the upper denture, to aid in its
retention.
3-Factors relating to the polished surface

Acquired muscular control

Dentures are always foreign bodies in the
mouth
when placed for the first time most
muscular actions tend to expel them.
The tongue can also be unconsciously
trained to prevent the back edge of the
upper denture from dropping while the
front teeth are incising
The muscular cheeks can be trained
unconsciously to press downwards
on the buccal flanges of the lower
denture whilst still carrying out
their function of placing food
between the teeth
The tongue seats the mandibular denture against the
concave lingual polished surface while transporting the food
bolus onto the occlusal table. The action of buccinators
muscle prevents lateral displacement of the denture.
Influence of soft tissue forces on dentures: (a) seating the dentures when
the polished surfaces are correctly shaped; (b) displacing the dentures
when the polished surfaces are incorrectly shaped.
As the patient incises, the upper denture is controlled by
the tongue pressing against the posterior border.
Full use of muscular control of dentures,
requires that their design must follow certain
lines:

1. The teeth should be in a zone of neutral

muscular force (neutral zone)

2. The position of the lower teeth should allow

the tongue to rest on top of the lower
denture
3- The buccal and labial surfaces of the full
dentures must be concave to allow for
comfortable and free movement of the
buccinators and orbicularis oris muscles

4- The lingual surface of the lower denture

must be inclined inwards from above
downwards, affording no undercut areas in
which the tongue might lodge and unseat the
denture.
4-Factors relating to occlusion

Balanced articulation
Arrangement of the teeth where in any
occlusal relationship,
As many teeth as possible are in occlusion,
When changing from one relationship to
another
They move with a smooth, sliding motion, free
from cuspal interferences and maintaining even
contact
The interference and locking of cusps of the teeth
as the lower teeth move across the upper teeth
during chewing tend to displace both upper
and lower dentures from their seating
Tipping of the denture due to an unbalanced occlusal contact.
Aids to Retention
Overdentures
Root-submergence
Vestibuloplasty
Ridge augmentation
Implants
Denture fixatives (adhesives)
magnets
Management of difficult
complete denture cases
1-V-shaped palate
 V-shaped palate

Reason for the Difficulty:

 Retention by adhesion is diminished.
 Acrylic denture bases tend to warp during
curing imperfect fit at the sharp
angle of the palate.
Treatment:
 Relining.
 A cast metal.
 2-Flat Palate with Shallow Ridges
Reason for the Difficulty:
 No resistance to lateral movement during
mastication (lack of ridge support, lack of
peripheral seal).

Treatment:
 Careful peripheral adaptation.
 Balanced articulation or the use of cuspless teeth.
3-Gross Undercuts and Large Tuberosities
Reason for the Difficulty:
 Pain during insertion and removal of the denture (sometimes
it is impossible to complete seating of the denture)
 Retention will be reduced (duo to trimming of the denture during
fitting) loss of peripheral seal.
 Treatment:
 Path of insertion if undercut present in one
side.
 Undercut on both sides: Decrease the width
not height of the flange and relining (the flange
must be thickened by addition of more material).
Soft liners may also be used to engage the
undercuts.
 Flexible denture base.
 Alveoloplasty may be necessary.(complications ??)
 Large Tuberosities
 Enlarged tuberosities can be fibrous or bony in
nature.
 Resilient lining material is used.
 The bony tuberosity should be surgically
reduced only when it impinges on the
mandibular ridge and prevents optimal
extension of the mandibular denture.
 The maxillary sinus may extend into the
tuberosity and complicate tuberosity reduction,
a radiographic assessment is essential prior to
any surgery.
 4-Knife-Like Lower Ridge
Reason for the Difficulty:
 Pain during mastication.
Treatment:
 Relief.
 Resilient lining.
 Alveoloplasty.
 5-Large Tori
Reason for the Difficulty:
 The denture may rock across the midline and
eventually fracture.
 Retention may be reduced.
Treatment:
 A compression impression technique.
 Adequate relief of the denture in the area
of torus.
 A metal plate will withstand strain fatigue
better than an acrylic denture base.
 Surgical interference.
 6-Abnormal Frena
Reason for the Difficulty:
 The denture is more easily displaced when fraena
are attached near to the crest of the ridge.
Treatment:
 Frenectomy before, or at the time of insertion of
the denture.
 7-Tight Lip
Reason for the Difficulty:
 Instability of the lower denture due to the
backward displacement caused by the lip pressure
 Vertical lift occurring in the premolar and canine region
from the pressure modioli.

Treatment:
1. Keep the occlusal plane low thus reducing the contact
area with the lip.
2. Adequate extension on the retromolar pads to
counteract the lip pressure.
3. keep the denture narrow across the premolar region.
4. Upper canines and premolars should be prominent to
resist the modioli pressure on the lower denture.
8-Large Tongue
Reason for the Difficulty:
 The denture will be moved during function.

Treatment:
1.Keep the occlusal plane low.
2.Provide tongue space by using narrow teeth
or grinding away the lingual cusps.
3.Anterior teeth should be set up slightly
forward of the ridge, and
4.Peripherally trimmed impression technique.
 9-Abnormal Jaw Relationships
A- Close bite
Reason for the Difficulty:
 Lack of interalveolar space.
Treatment:
Acrylic posterior teeth.
B-Superior protrusion
Reason for the Difficulty:
 Narrow and retrusive lower arch in relation to a
normal size upper arch.
Treatment:
 Maintain the natural overjet which will be large.
 Periphery adapted impression technique.
C-Inferior protrusion

Reason for the Difficulty:

 Large and wide lower arch in comparison to
the upper arch, leading to an unstable upper
denture.
Treatment:
1. Peripherally adapted impression technique.
2. Metal plate.
3. Balanced articulation.
4. Posterior cross bite.
5. Anterior edge-to-edge bite.
Inferior protrusion
10-Flabby Ridge (Abused Tissues)

Flabby ridge can be defined as a mobile

soft tissue which is located on the
superficial aspect of the alveolar ridge.
Reason for the Difficulty:

Flabby tissue compressed during

mastication causes the denture to be
tilted and the seal thus broken.
Causes:
 Long denture use without serviceability i.e. without
relining or rebasing of the dentures when indicated.
 Load concentration on the anterior segment of the
ridge as a result of decreased vertical dimension
accompanying occlusal wear.
 Complete maxillary denture opposing natural
mandibular anterior teeth and partial denture(single
denture).
 Not removing denture during night.
 Badly constructed dentures such as (loose ill-fitting
dentures dentures with wrong centric occluding relation, occlusal disharmony).
Recovery program:
It consists of:
1. Instruct the patient to dissolve one-half teaspoon of
table salt in a half glass of warm water and
vigorously swirl the solution against the tissues.
2. The removal of the dentures from the mouth for at
least 8 hours daily. Patients usually agree to this
program, since it can be accomplished during
sleeping hours.

If the condition persists after this recovery program,

the treatment will be either:
 A modified impression making procedure (Sectional
impression technique)
 Surgical removal of the hypertrophic tissues.
The treatment is as follows:
1. Detect and Correct any pressure area or sore spot using
pressure indicating paste (PIP).
2. Correct the adaptation of the denture base to the underlying
tissues using tissue conditioning material (TCM) This material
should be changed every 72 hours as the plasticizer will be
leached out on long standing in the patient's mouth and thus, the
material will lose its conditioning effect.
3. Correction of occlusal disharmony by clinical remounting
procedure.
4. Elimination of contact between natural anterior teeth and
opposing artificial teeth.
5. Restoring the lost occlusal vertical dimension:
A dough of self curing acrylic resin is applied to the palatal cusps
of the second premolar and first molar of the maxillary denture
after Vaseline application to the opposing mandibular teeth
Tissue conditioning
A procedure in prosthodontics usually performed by
relining a removable complete denture, RPD, or a
maxillofacial prosthesis with a resilient resin and
allowing a short duration of time for the patient’s soft
tissue to heal.
Tissue conditioner
1. A resilient denture liner resin placed into a
removable prosthesis for a short duration to allow
time for tissue healing.

2. Used in functional removable relining procedures to

evaluate denture function and patient acceptance
prior to laboratory reline processing.
Tissue conditioning material application
 Restoring the lost occlusal vertical
dimension
(Sears and nelson occlusal pivots)

Dough of self curing acrylic resin is applied to the surfaces of the cusps of
the second premolar and first molar of the mandibular denture after Vaseline
application to the opposing maxillary teeth.
This will help to:
• Restore the correct vertical dimension.
• Restore the correct position of the condyle.
• Eliminate the load on the anterior segment.
 Prosthetic management
 Primary impression is made using alginate impression
material with low viscosity.

 Secondly impression is made utilizing the selective

impression technique . or using two stage (sectional)
impression technique as follows:

 Acrylicspecial tray is constructed having a window

opposite to the area of flabby tissues.

 Border molding is carried out in the usual manner and

zinc oxide and eugenol impression is made and
excess material passing through the widow is trimmed
out.
 11-Flat Lower Ridge
Reason for the Difficulty:

The shape of the ridge provides no resistance

to lateral movement of the denture.
 Direction of ridge resorption

 In the maxilla, resorption is usually

upwards and inwards,
 while in the mandible resorption is usually
inferiorly and lingually.
 Therefore, the maxilla appears to be
smaller, while the mandible appears to
become wider.
 Problems with flat ridge
1. Several muscles show proximity to the crest of the ridge,
which accounts for short flanges and so poor retention and
stability.
2. The mental foramen may migrate to the crest of the ridge,
which will be pressed by the denture leading to paresthesia
of the lower lip.
3. The superior border of the torus mandibularis may flush with
the crest of the ridge on the lingual side and the frenae
become attached to or close to the ridge.
4. The genial tubercle migrates to the crest of the ridge on the
lingual side of the mandible.
5. In severe cases dehiscence of the mandibular canal may
occur.
 Etiology:
The conditions causing alveolar ridge
atrophy can be:
 Biologic.
 Anatomic.
 Functional and prosthodontic factors.
 1-Biologic and metabolic factors:
1) Age:
2) Sex: Female
3) Nutritional:
4) Systemic health:
5) Treatment for systemic diseases: ( e.g Radiation therapy)
6) Loss of natural teeth:
 Extraction of the natural teeth.
 Severe periodontal disease.
 2-Anatomic factors:

1. Type of bone: Cortical bone will resorb

slower than cancellous bone.
2. Size and shape of the ridges.
3. Facial skeletal morphology:
 Individuals with longer faces and obtuse gonial
angle are more likely to have atrophy than
short faces and right gonial angle.
 3-Functional/prosthodontic factors
a) Functional factors:
Habits with complete dentures such as bruxing,
grinding and tapping of teeth.
b) Prosthodontic factors:
 Long denture use without serviceability.
 Improperly made dentures with improper vertical
dimension of occlusion, centric relation, non
balanced occlusion and incomplete coverage of
basal seat area.
 Constant wearing of dentures.
 Porcelain teeth and/or anatomic teeth with high
cusp angles
Management of advanced resorption
of the residual alveolar ridge.

 Prosthetic management with surgical

intervention.
 Prosthetic management without
surgical intervention.
 Prosthetic management with
surgical intervention.

 Vestibuloplasty.
 Removal of genial tubercles.
 Prominent mylohyoid ridge.
 Ridge augmentation.
 Distraction implants.
 Osseo-integrated implants.
 Prosthetic management without
surgical intervention.

Treatment:
 Careful peripheral adaptation(border tracing).
 Balanced articulation.
 Lowering the occlusal plane, if aesthetics permits.
 Use cuspless teeth.
 References
 Zarb et al., .PROSTHODONTIC TREATMENT FOR EDENTULOUS
PATIENTS: COMPLETE DENTURES AND IMPLANT-SUPPORTED
PROSTHESES. Mosby, 13th ed., 2013

 Nawaf Labban. Management of the flabby ridge using a modified

window technique and polyvinylsiloxane impression material. Saudi
dental journal, 2017, P. 89-93

 R.M. Basker, J.C. Davenport, J.M. Thomason. Prosthetic

Treatment of the Edentulous Patient. 5th ed. 2011. P 55-67

 Sarandha D.L. et al., Textbook of Complete Denture Prosthodontics.

1st ed., 2007, P. 59-63
THE END