CHAPTER 13 RELINING AND REBASING Terminology Diagnosis Objectives Indications Contraindications Procedures Clinical procedures Tissues preparation Denture preparation Impression procedure Static impression Functional impression Chair side reline Laboratory procedure Relining Flask method Articulator method Rebasing 189As the denture foundations change, the impression surface of the denture fail to fit the tissues properly. It would be a simple matter to re-establish the denture tissue relation if other relations were not disturbed by changes in the foundation. TERMINOLOGY Reline: Reline is the procedure used to resurface the tissue side of a denture with new base material, thus producing an accurate adaptation to the denture foundation area. Rebase: it is the laboratory process of replacing the entire denture base ma- terial on an existing prosthesis. DIAGNOSIS Changes in the basal seat or denture foundation may be indicated by obvi- ous looseness, general soreness and inflammation, loss of occlusal vertical dimension and bad esthetics, or dishar- monious occlusion. Dentures with occlusal errors. may not need relining. They may need only occlusal correction. Simple tests of the individual denture bases may show that stability and retention have not been lost even though the patient reports that the dentures are loase. In this situation the supporting tissues will show more irtitation or inflammation on one side than on the other, and the denture on one side will be clean, whereas those of the other side will be stained, The ap- parent loseness will have resulted from uneven occlusal contact that was not evident at first. The treatment involves keeping the dlenture out of the mouth for 1 10 2 days to allow the supporting tissues to be come healthy and then the occlusion is corrected, 190 Chapter 13 : Relining and rebasing Because of the strains inherent in the processed denture base that will be released on subsequent processing and thus cause some degree of warpage. It is better to rebase dentures rather than re- line them. Relining is generally used to correct the lower denture. Relining pro- cedure causes a thickening of the palate of an upper denture. Rebasing does not have this disadvantage and therefore to be preferred when correcting the fit of an upper denture. Both relining and re- basing procedures are used to increase the useful life of dentures probably without changing the occlusal relations of the teeth, without encroaching on the interocclusal space and without displac- ing the supporting tissues. OBJECTIVES 1- Improvement of retention and sta- bility: Loss of fit make the mainte- nance of peripheral seal impossible, this will greatly impair the retentive effect of adhesion and cohesion. It may also permit a rocking or tilting of the denture during function 2. Improvement of appearance: One effect of alveolar resorption in the lower jaw is that the lower denture sinks below the original occlusal plane, and thus the patient has to close beyond the original vertical dimension in order to occlude the teeth, This over closure is frequent- ly noticed by the patient as a protru- sion of the mandible and an undue approximation of the nose and chin, giving an appearance of age. Re- sorption of the upper alveolar ridge will not give a marked effect on the vertical dimension because the hard palate does not materially alter. The original vertical dimension can of- ten be restored by relining the lower denture alone.Chapter 13 : Relining and rebasing 3- Restoration the vertical dimension: If the vertical dimension of the denture is reduced masticatory ef- ficiency will be impaired. This can be restoted by relining, 4- Restoration of evenness of occlusal pressure: with any alteration in the fit of dentures there will be some alterations in the pressure transmit- ted to the tissues when the teeth are brought into occlusion, Denture re- lining may correct this condi 5- To alleviate pain: If the denture has been worn with comfort and then be- comes painfil, it is usually due to the fact that the supporting tissues have altered allowing the denture to tilt, rock or move, and thus transmit undue pressure to one area, Relining will al- Jeviate pain resulting from this cause. INDICATIONS. For relining or rebasing 1- When the residual alveolar ridges have resorbed and the adaptation of the denture bases to the ridges is poor 2- Three to six months following the placement of an immediate den- ture. 3- For geriatric or chronically-ill pa- tient because of the long or several appointments required for the con- struction of a new denture 4+ If the patient cannot afford the cost of having new dentures, 5- Rebasing is additionally required in cases of : a: Porous denture base. b- Discoloured or contaminated denture base. c- Using the denture for long time. CONTRAINDICATIONS The dentures should not be relined or rebased when one or more of the fol- lowing defects exists : 1- If dentures have poor esthetics or unsatisfactory jaw relationships. 2- If the dentures create a major speech problem, 3- When an excessive amount of re- sorption has taken place making it difficult to position the denture properly on the ridge. 4- When abused soft tissues are present. The relining is delayed until the tis- sues recover and retum as closely as possible to normal form. PROCEDURES Clinical procedures The clinical procedures for relining and rebasing are the same. It includes tissue preparation, denture preparation and impression procedures. ‘The first and most important prob- lem is to achieve a healthy condition of the tissues of the basal seat for the den- tures. This is achieved by what is called tissue preparation. Tissues preparation With any relining or rebasing tech- nique, abused tissues should be allowed to recover before making the impressions. The most favorable prognosis results when the abused soft tissues are allowed to recover to a normal healthy condition before impressions are made. The treat- ‘ment plan for tissue recovery may include any or all of the following procedures. (a) Tissue rest ~ The dentures should be left out the mouth for at least two to three days before making the final impression. 1912- Massage of the soft tissues two or three times a day to stimulate the blood supply and aid recovery. (b) The use of a tissue conditioner When the tissue abuse is extensive and the patient cannot leave the denture out of the mouth for tissue recovery, treatment with a tissue conditioner is indicated, consequently, the transmis- sion of masticatory force to the sup- porting mucosa are equalized, thereby eliminating isolated pressure spots typ- ical of a loose, ill-fitting denture. The material is renewed periodically every 3 to 7 days till the tissues return to a clinically healthy state Denture preparation After making certain that the tissues are healthy, the denture is placed in the mouth to determine the needed changes. 1- The occlusion must be balanced to en- sure that, when the impression is made, uneven contact does not bring about a bodily shift or tilt of the denture when the patient is asked to close. 2- Undereuts within ‘the impression surface must be eliminated so that the denture can be removed from. the cast. 3- Over extended flanges must be re- duced (1-2 mm) to allow the impres- sion material to form new borders 4- Four tissue stops in the denture base are outlined with a pencil in the ca- nine and molar regions 5- 1.5mm from the tissue side of the denture base is relieved in all areas covering stress bearing mucosa with an acrylic bur except: Pe Outlined t dam (never relieved) stops in the denture 192 Chapter 13 : Relining and rebasing Impression procedures a- Static impression technique. b- Functional impression technique. &- Chair side reline techniques. l- When an impression is made within an existing denture, care must be tak- en to ensure that the jaw relationship in the horizontal plane is not altered. This is achieved by carefully seating the denture in the mouth and asking the patient to close into normal tooth contact at each stage of the reline procedure. Invitably, the vertical di- menstion is increased slightly by the thickness of the impression material. As the increase should be kept to a minimum, it is usual to choose an impression material which is accu- rate in thin section, zinc-oxide-eug- enol impression pastes and polysul- phide elastomers are good examples of materials which can be used. 2. The borders of the denture must be refined with modeling compound. At this stage, the denture should be retentive and stable, 3- Zinc oxide eugenol impression paste is mixed in accordance with the man- uufacturer’s instructions and spreaded over the fitting surface of the denture (the opposing denture is inserted) the denture is then seated to contact the oral tissues and the patient is asked to close. 4- The denture is removed after the im. pression material has set. «The procedure is repeated for the op- posing denture. (6) Functional impression technique Tissue conditioning materials may be used for making a functional impres- sion, This type of impression is indicat.Chapter 13 : Relining and rebasing ed in dentures that require, modifica- tion of the occlusal vertical dimension. 1- The denture is checked intraorally to assess the need for peripheral reduc- tion. If they are over extended, den- ture flanges should be shortened un- til they are of the correct length and thickness, If they are short, they may beextended to the correct length with modeling compound or with autopo- lymerizing acrylic resin if the patient want to wear the denture. 2- All undercuts on the fitting surface of the denture bases must be re- moved. In addition, any pressure spots are relieved, and the entire fit- ting surface of the denture base is reduced approximately 1.0mm to allow room for the impression ma- terial. The denture borders should be reduced approximately 1.0mm for the same reason. Occasionally four compound stops may be re- quired on the impression surface of the denture to re-establish a proper ocelusal relationship or improved ocelusal plane orientation. 3. The tissue conditioning material is then mixed, and placed inside the denture, The material should flow evenly to cover the whole impres- sion surface and the borders of the denture. 4- The dentures inserted in the patient’s mouth and border molding can then be accomplished both manually and functionally. The patient’s mani ble is guided into a retruded posi- tion, to help to stabilize the denture while the material is setting, S- Afler approximately five minutes the denture is removed from the mouth. The impression should be free of imperfections, and shows an accurate reproduction of the denture bearing area, 6- After removing the excess tissue conditioning material with a hot scalpel, the patient may be allowed to wear the denture from four to twenty-four hours. After that, the patient should return for reevalua- tion of the impression. If it is con- sidered acceptable, the impression is boxed, and a cast is poured. Also in case where the vertical di- mension has to be reestablished in addi- tion to the fit, a layer of impression ma- terial of greater thickness must be used. In such cases the lower denture should first be lined with compound impression ‘material and the impression is taken with the teeth in occlusion, The thickness of the compound impression material used should be such that it almost restores the desired vertical dimension, The com- pound impression, chilled, dried and the final impression is made with a film of zine oxide paste. If the vertical dimen- sion is being increased beyond 3-4mm, and both dentures are being relined, as a general guide the incisal level of the upper anterior teeth should be studied in relation to the lip line, and the upper im- pression should be taken first, with suf- ficient thickness of material to bring the upper incisors into the desired position. (c) Chair side reline To avoid depriving the patient from his denture till the laboratory proce- dures of relining are completed. Several altempts have been made to produce an acrylic or other plastic lining material that can be added to the denture and al- lowed to set in the mouth to produce a direct chairside reline. Direct reline materials generally supplied as a powder and liquid which are mixed together 193The relining procedure starts with the least stable denture if the upper and lower dentures have to be relined. 1. The fitting surface of the denture must be relieved to create a space for the reline material. 2- Separating medium must be applied to the areas where bonding is not de- sired (polished surface and teeth), 3- The material is mixed according to the manufacturer’s instructions and poured into the denture and the den- ture is seated in the mouth after insert- ing the opposing denture. The patient is asked to close into centric occlu- sion and the borders are molded. 4- The denture is then removed from the mouth after the initial set of the material and placed in warm wa- ter for twenty minutes to allow the material to cure, the denture is then trimmed and polished. Disadvantages of the chairside re- line materials a) Some materials may produce a chemi- cal bum on the mucosa b) With some materials the resulting re- line is porous and subsequently de- velop bad odor. ©) Colour stability is low. 4d) If the denture was not positioned cor- rectly, the material could not be eas- ily removed in order to start again. Direct reline materials should be considered as only a temporary or at Jeast semi-permanent solution to the problem of an ill fitting denture. Laboratory procedures Relining 4) Flask method 1. The impression is poured in artificial stone to form a cast. 194 Chapter 13 : Relining and rebasing 2. The denture and the cast are not sep- arated at this point, but any excess impression material on the teeth or facial surface of the base must be removed. When heat cure acrylic resin will be used for relining, and if desired, the old palate of the max- illary denture may be removed by cutting a groove in the denture base with a round bur. The old palatal section can then be lifted off the cast without disturbing the relation of the remaining part of the denture to the cast. It is then replaced by a layer of baseplate wax to control the thickness of the base in this area. 3- the denture is flasked in the usual ‘manner. 4- After the investing plaster had set, the two halves of the flask are sepa rated, and all impression material is cleaned from the cast and the den- ture base. A post dam is prepared on the maxillary cast. 5- A thin layer of acrylic resin is re- moved from the fitting surface of the denture to freshen the surface 6- The borders are reduced with a bur 2-3mm to form a butt joint and fre- nal notches are depend. 7- Debris are removed from the denture and the flask, and the surface of the denture is swabbed with a cotton pellet moistened with monomer. The cast is painted with tinfoil sub- stitute (Separating meduim). 8- Heat or self cure acrylic resin is mixed in accordance with manu- facturer's recommendations, and added to the fitting surface of the denture and the borders of the cast. The flask is closed. 9- After curing, the denture is deflasked finished and polishedChapter 13 : Relining and rebasing (b) Articulator or Hooper dupli- cator method 1- The cast and the denture are mount- ed on the upper member of the ar- ticulator or Hooper duplicator. (Fig. 13.1a). It is a rigid jig which will maintain the relationship of the teeth to the cast. 2- Plaster is mixed and applied on the lower member of the duplicator, the upper member with its mounted up- per denture is closed into the soft plaster mix to a depth of I to 2mm (Fig. 13.1a). 3+ When the plaster sets a key or oc- clusal index is formed (Fig. 13.1b) into which the teeth can be repeat- edly set to maintain a fixed distance and relation between the cast and the occlusal surface Fig (13.1): Hooper Du (a) Upper and lower members of the Hopper duplicator with the mounted denture closed into the plaster mix (b) The lower member of the Hooper du. plicator showing the plaster index 4- When the plaster occlusal index has completely set, the top and bottom ‘members of the duplicator are sepa- rated. The denture is removed from the cast, and all impression mate- rial is cleaned from the cast and the denture base. 5. The denture borders are squared to form a butt joint, rather than a feather edge, for the attachment of the new acrylic resin material. The palatal portion of a maxillary den- ture is removed close to the palatal surface of the teeth. 6- The denture is positioned so that the teeth are placed in the occlusal index on the lower member of the Hooper duplicator. 7- The post dam is prepared on the maxillary cast. 8- The cast and denture are removed from the upper member of the Hoop- er duplicator to provide easier access for waxing, The denture is processed and fin- ished in the usual manner. An articulator may be used instead of the Hooper duplicator provided that itis used only in an open and shut hinge movement, After the denture and its cast have been mounted and the occlu sal index has been formed and before the plaster harden, the incisal guide pin must be adjusted to touch the incisal ta- ble so that the vertical dimension will be maintained. Rebasing The clinical procedure for denture rebasing are the same as those for relin- ing, The laboratory procedure are also the same till the hardening of the plas- ter occlusal index. Then the following steps will be: 1951- The top and bottom members of the duplicator is separated then the denture is removed from the cast. 2- All the denture base material is re- moved from the teeth if they are porcelain. But with acrylic resin teeth all the denture base material is trimmed leaving only what will hold the teeth together in a horse- shoe. This will facilitate positioning the teeth in the occlusal index and keep them together during waxing. 3+ The teeth are cleaned and reposi- tioned into their positions in the oc- clusal index. 4- A base plate is adapted and soft wax rim is prepared to the cast. 5- The top member of the Hooper dupli- cator is replaced in position and the original teeth are placed in the index and attached to the wax rim. 6- The posterior palatal seal is prepared on the maxillary cast. 7- the cast is removed from the dupli- cator, the trial denture is waxed up, processed and finished. Soft reline materials In some instances, complete denture patient can not tolerate a rigid denture base on their oral tissues probably because of the 196 Chapter 13 : Relining and rebasing type of ridge and the susceptibility of the ‘mucosa to bruising, being unable to with- stand the transmitted pressure of mastica- tion. Various soft lining materials provide a cushion which will relief some of these symptoms, it can also be used to improve the fit of an old denture while a replace- ments being fabricated. Itis desirable that these resilient materials shall remain soft during a prolonged period of time. The soft materials available for ining dentures include acrylic resins and sili- cone rubbers both of which may be heat or cold curing, The resilient liners, which are formulated to cure in the patient’s mouth (selfcure) are convenient to use, but deteriorate within a short time. Resil- ient liners which are cured in the labora- tory (heat cure) will lose its resiliency af. ter longer time, The denture, containing a corrected impression of the tissue surface, is poured, flasked, and processed with one of these products and then returned to the patient. Generally, the soft lining should be at least 2mm thick. A corresponding reduc- tion in the thickness of the hard acrylic resin of the denture base is necessary to make room forthe lining material, also the 2mm from the denture borders should be also removed, so that all the denture bor- ders will be from the resilient material.