CHAPTER 14 MANAGEMENT OF DIFFICULT COMPLETE DENTURE CASES Flat ridge Factors affecting atrophy of the alveolar ridge Systemic Prosthetic Anatomic Treatment Prosthetic treatment Surgical treatment Vestibuloplasty Ridge augmentation Ridge distraction Implant Flabby ridge Aetiology Treatment Conditioning Prosthetic Alveolar ridge augmentation V-shaped palate Flat palate with shallow sulci Undercut ridges Knife-edge lower ridge Large torus palatinus Large tuberosities Shallow sulci Abnormal frena Variation in tissue compressibility Tight lower lip Large tongue Abnormal jaw relations Length of time of edentulousness Retching and nausea during impression making Retching and nausea in denture wearers Prominent premaxilla Occupations Burning sensation of the palate and mouth when wearing denturesChapter 14 : Management of difficult complete denture cases FLAT RIDGE The most difficult problem for the prosthodontist is the construction of complete denture over a severly re- sorbed ridge. This is because the den- ture functions will be greatly affected, Edentulous ridges are subjected to continuous bone resorption due to the loss of tensile stimulation provided by the periodontal ligaments. The extent of ridge atrophy was found to be four times greater in the mandible than in the maxilla, This was attributed to the smaller denture bearing surface of the mandibular ridge. Therefote the forces applied to it would be much greater than those applied to the maxillary ridge. Factors affec ridge Systemic factors g atrophy of alveolar Age: Aging is frequently accompa- nied by osteoporotic changes in the hu- man skeleton. Sex: An atrophic ridge is frequently encountered in females during meno- pause, due to the reduction in estrogen hormone which in tum causes deminer- alization and osteoporosis of the bone. The patient's general health: Poor general health and debilitating diseases such as uncontrolled diabetes mellitus, anemia and hypertension, disturb the normal metabolic processes and lower the resistance of the tissues to inflam- mation and bone resorption * Calcium deficiency: Calcium defi- ceney, calcium phosphorous imbal ance and lack of protein in the diet are factors contributing to bone re sorption, Vit. C deficiency inhances decal cation of bone. * Vit. D deficiency disturbs the calci um-phosphorous balance and pro- motes bone loss. 198 + Vit..A.deficiency.gives.tise.to-oste~ oporosis and ridge atrophy. Also, hypervitaminosis A may increase the rate of bone resorption. Prosthetic factors 1-Faulty impression : Excessive pressure exerted on the mucosa while making the impression initiates soreness, in- flammation of the denture bearing mucosa, and bone resorption. 2- Excessive vertical dimension of occlu- sion: Adequate interocclusal distance is essential for the maintenance of tissue health. If the occlusal vertical dimension encroaches on the physi- ologic position, excessive contact of the denture teeth will occur. This transmits excessive pressure on the ridges and initiates inflammatory changes and bone resorption. 3- Disharmony between ceniric rela- tion and centric occlusion, and un- balanced occlusion will contribute to bone loss. 4- Excessive forces transmitted to the underlying basal bone from the con- tinuous wearing of dentures. 5. Long term wearing of dentures with- out serviceability and or lack of fol- lowup treatment. 6- Parafunctional habits, as in bruxism and clenching may cause advanced resorption of the ridges depending upon the frequency, direction and amount of force transmitted to the remaining ridges, Anatomic factors ‘ype of bone: Cortical bone resorbs at a slower rate than cancellous bone. 2- Loss of alveolar bone is more pro- nounced in the mandible than in the maxilla 3- Well formed broad ridges show less resorption than narrow thin ridge.Chapter 14 : Management of difficult complete denture cases Treatment. A- Prosthodontic treatment, Gross reduction in the alveolar ridges results in reduction in the resist- ance offered to horizontal movements of the denture. It also reduces the area of the jaw which provide effective sup- port and retention for the denture. All principles and techniques of complete denture construction in pa- tients with compromised ridges should be directed to minimize the forces transmitted to the supporting bone and decrease the movement of the prosthe- sis, and thereby reduce the rate of ridge resorption. these principles and tech- niques include I- Maximum extension of the denture base within the physiologic and func: tional limits is required to increase retention of the denture and to pro- vide wide distribution of masticatory forces. The entire peripheral border of denture should extend to the fune- tional depth of the vestibule. Tissue conditioning material is al lowed to remain in the mouth for eight to ten minutes, while the op- erator stabilizes the tray, directs the tongue to mold the lingual border and manipulating the cheek and lip tissues. Such impression procedure will allow accurate registration of the functional actions of the border tissues and improves retention. Definite pressure impression tech- nique can be used in cases present- ing flat ridges with firm muco order to provide maximum cov age of the denture bearing area. final impression is made while the patient is closing on occlusion rims (closed mouth technique) in 199 Neutral zone determination;-Phe neu- tral zone philosophy is based uppon the concept that for each individual patient there exists within the denture space a spacific area where the fumne- tion of the musculature will not un- seat the denture and where the forces generated by the tongue are neutral- ized by the forces generated by the lips and cheeks, positioning the arti- ficial teeth in the neutral zone makes the forces exerted by the musculature against the dentures are more favo- rable for stability and retention, also the teeth will not interfere with the normal muscle function. 3+ Proper orientation of the occlusal plane (in relation to the tongue and the residual ridge) and make it par- allel to the mean foundation of the ridge, stabilizes the denture in place. 4- Vertical dimension, increased verti- cal diminsion of occlusion should be avoided as it reduces the capacity of he denture bearing tissues to with- stand loading. An adequate interoc- clusal distance is required during the rest position of the mandible, to de- crease the frequency and duration of tooth contact and reduces the forces transmitted to the alveolar ridge. The use of acrylic teeth decreases the transmition of the masticatory forces to the weak ridge. 5- Reduction of the buccolingual width of the ocelusal table, reducing the number of artificial teeth, and im- proving theircuttingefficiency helps in reducing the forces transmitted to the supporting alveolar bone, and provides better centralization of oc clusal forces on the ridge. 6- The use of flat cuspless teeth arranged on the center of the ridge will central- ize the occlusal forces and improve stability of the denture,Chapter 14 : Management of difficult complete denture cases 7-Provision-ofadequate tongue space at- lows the tongue to move freely with- out displacing the lower denture. 8- Proper contouring of the denture polished surface improves stability nd retention of the denture, This increases the potential for the buc- cinator muscle and tongue to aid in lower denture stability. Perfection of occlusion before den- ture insertion is necessary. A metal denture base may some times be preferred, with flat ridge cas- es, to increase retention by interfacial surface tension. The use of metal base with soft liner was also recommended in these cases. B- Surgical treatment Surgical management of anatomi- cally compromised ridges should be considered only when conservative procedures cannot provide the patients with successful complete dentures. Tt should not be considered for patients with poor general health, or those rep- resenting an unfavorable surgical risk. Surgical treatment inchi (1) Vestibuloplasty Vestibuloplasty is a surgical proce- dure designed to restore alveolar ridge height and/or width by lowering mus- cle attachments and unattached mucosa from the ridge crest of the maxilla or mandible to a deeper position. It is indi- cated when there is sufficient vertical re- sidual ridge height to extend the sulcus, with high muscle attachements interfere with the development of adequate bor- der seal (2) Ridge augmentation The purpose of this procedure is to create an edentulous ridge with consid- 200 erable Height and width to afford betier denture functions. This process is carried out using bone or cartilage, hydroxy apatite or a combination of both. Mandibular ridge augmentation with autogenous bone can be accomplished by rib, iliac crest bone graft, placed on the superior or inferior border of the mandible, Max- illary ridge augmentation may also be carried out using iliac crest bone graft (3) Ridge distraction Distraction osteogenesis is a meth- od of initiating bone formation in an in- duced space created horizontally with- in the ridge with the help of a device called distractor. (4) Implant The use of dental implant with or without ridge augmentation is indi- cated in suitable cases to improve the condition of the ridge. FLABBY RIDGE The ideal condition of the ridge on which to seat a denture must be firm composed of bone covered by a layer of mucous membrane of suitable thickness, Those conditions will allow the denture to function with great efficiency. In some cases the bony ridges may be subjected to extra forces leading to resorption, and the resorbed bone is re- placed by fibrous tissue and the ridge becomes mobile on palpation. Rapid resorption results in narrow knife edge ridge while slow resorption results in flabby fibrous ridge. This type of ridge will present a problem as it allows the denture to move during function with resulting loss of retention,Chapter 14 : Management of difficult complete denture cases Etiology 1- Excessive stress being applied to an edentulous ridge particularly in a lateral direction, A common ex- ample of this is the occlusion of the lower natural anterior teeth against a complete upper denture, which frequently results in alveolar bone resorption and hyperplasia of the gingiva in the maxillary anterior re- gion, other areas of the mouth may undergo similar changes if subject- ed to excessive pressure or lateral stresses , 2- Combination of porcelain anterior teeth with acrylic resin posterior teeth in the same denture. The low wear resistance of acrylic resin teeth results in hyperocclusion of the an- terior porcelain teeth that will trau- matize both the anterior upper and lower foundation tissues 3- Interference between upper and lower anterior teeth due to lack of anterior clearance during mandibular move- ment. This may be the resultofasteep incisal angle caused by deep vertical overlap without sufficient horizontal overlap to provide anterior clearance during functional and parafunctional mandibular movement. Anterior in- terference also develop due to exces- sive wear of acrylic resin posterior teeth, leading to loss of occlusal ver- tical dimension and lack of anterior clearance. 4- Long term denture wearing without regular maintenance and serviceabili- ty. The residual ridges resorb continu- ously even with the best fitting den- tures, gradually the denture loose their adaptation to the underlying, basal seat and occlusal changes are brought about changes in the occlusal relation- ships induce shifting (instability) of 201 the denture bases and adverse stresses to the supporting tissues. Every edentulous patient should be placed on a recall schedule that permits timely re-evaluation of the denture ad- aptation and refinement of occlusion. Treatment (a) Conditioning Conditioning of hyperplastic flab- by ridges is based on the severity of the condition. a) If the movable tissue is localized and not expected to interfere with den- ture stability, then these tissues can be retained and a conservative prosthetic technique should be employed before denture construction, Hypertrophic ir- ritated hyperemic and displaced oral mucosa should be conditioned to re- duce the inflammatory condition and accordinglly the size of the tissues ‘Two techniques may be used either singly or in combination depending on the severity of the condition. This in- cludes: 1- Tissue rest accompanied by proper oral hygiene and tissue massage Tissue rest is achieved by instruct- ing the patient not to wear the exist- ing denture as long as possible. 2- Relining the denture with tissue conditioning material to aid in con- ditioning traumatized hyperplastic bearing mucosa. Lining the dentures with tissues con- ditioning material improves stability, re- licves and equalizes pressure, thereby al- lows tissue to recover To achieve the maximum efit from tissue conditioning material the following should be considered:Chapter 14 : Management of difficult complete denture cases 1- Denture base extension should be ad- equate. Whenever the denture base is short, it should be extended to the functional depth of the vestibule us- ing self cure acrylic resin to provide support for the soft material and al- low wide distribution of force. 2- Centric relation should be checked and corrected. Dentures are re- mounted using interocclusal record. Self cure acrylic resin can be used to restore the lost vertical dimension. Deflective occlusal contacts are marked using articulating paper, and eliminated to achieve harmony be- tween centric occlusion and centric relation. 3- Enough room should be created for the tissue conditioning material (Imm). All undercuts are reduced. 4- The selected material must be prop- erly proportioned, mixed and ap- plied to the dry denture fitting sur- face. The loaded denture is placed in position and the patient is guided to close in centric position. A new application of the material is need- ed every three to four days until the tissues have recovered. Proper oral hygiene and tissue massage help to improve the condition. When the tissues assume their nor: mal non inflammatory condition, den- tures can be fabricated. Easily displaceable hyperplastic tissues present unstable denture base foundation that contribute to excessive horizontal and vertical movement of the denture. All principles and techniques for denture construction should be di- rected to minimize the forces transmit- 202 ted to those movable supporting tissues in order to stabilize the dentures. (b) Prothetic treatment 1- Final impression technique Since easily displaceable tissues are unable to provide efficient support to the denture base, they need to be ré- corded in their resting position using freely flowing impression material. If these tissues are displaced during mak- ing the final impression they will tend to rebound creating unseating forces and denture instability. Movement of the denture in any direction on their basal seat causes additional tissue damage. A. selective pressure impression technique is required to decrease oc- clusal forces over the affected area and distributes them over favorable areas capable to tolerate masticatory forces. Sufficient relief and escape holes drilled in the special tray opposite to the hy- perplastic tissues will ensure relief of pressure over this area and proper load distribution. A sectional impression technique is preferred if the hyperplastic tissue is present on the anterior maxillary ridge. In this technique secondary im- pression of the arch is made using zine oxide eugenol in a special tray. The labial portion of the ridge crest. (The area in the impression where the hy- perplastic tissue is present) is removed to expose the hyperplastic tissue while the impression is in the mouth, Plaster impression material is mixed and ap- plied over the exposed area. This tech- nique ensure relief of pres: this area. We averChapter 14 : Management of difficult complete denture cases 2+ Centric relation record Static interocelusal record, using softened wax or thin mix of plaster will minimize the amount of tissue dis: placebility and ensure correct centric relation record. 3- Occlusal form and arrangement ofposterior teeth Flabby, hyperplastic tissues offer little resistance to horizontal forces. To effectively control the amount of hori- zontal displacing forces, flat cuspless teeth are indicated, Proper vertical or entation and inclination of the occlusal plane, together with placement of the teeth in a central position in relation to the residual ridge and tongue will en hance denture stability. Reduction of the buccolingual width of the occlusal table, and using fewer number of arti- ficial teeth will ensure better centrali- zation of the oF teroposteriorly and mediolaterally. (c) Alveolar ridge augmentation Preservation of the mobile tissue and augmentation of the underlying ridge with a ridge augmentation mate- rial will improve the ridge condition The use of sclerosing solution such as (sodium morhiate) injected in the flabby tissue gives good results as it transforms the movable flabby tissue to a hard sclerosed one. V-SHAPED PALATE Reason for the Difficulty. Reten tion by adhesion is diminished because th ing sloping offers only a small area which is horizonta a vertical displacing force. Also, plastic denture bases tend to warp during cur ides palate, hi ing, and the imperfect fit at the sharp angle of the palate further reduces the forces of adhesion and cohesion Treatment, An impression tech- nique involving careful peripheral trim- ming, and which includes compression of the soft tissues of the denture-bearing, surface. A cast metal palate produces a more accurate fit. Prognosis. Satisfactory results will depend on the excellence of the pe- ripheral seal obtained in the impression technique, because the main retentive factor in these cases is the atmospheric pressure. FLAT PALATE WITH SHALLOW SULCI Reason for the Difficulty. The denture may easily be displaced during mastication through lack of ridge sup- port; the shallow sulci adversely influ- ence peripheral seal Treatment, An impression tech- nique incorporating careful peripheral adaptation, An anatomical bite regis tration and set up, or the use of cuspless teeth, to reduce the lateral drag from cuspal interference. Prognosis. Good results are obtained provided the periphery is adequately sealed and is free from interference by the adjacent musculature. The flat pal- ate allows excellent retention by ad esion, and an anatomical articulation prevents displacement by cuspal inte ference UNDERCUT RIDGES Reason for the Difficulty. R tion will be reduced as the d will have to be trimmed, during fitting, in order that it may pass over the bulbousChapter 14 : Management of difficult complete denture cases areas of the ridge, thus causing loss of peripheral seal, Treatment. (a) An alveoloplasty to reduce the undercut; or (b) Careful blocking out of the undercut areas on the model. This eliminates the possibility of over trimming which might occur when the denture is being fitted. A hydrocol- loid impression may be necessary. Prognosis. The most satisfactory re- sult is obtained when alveoloplasty is carried out, as the operator is then able to construct a denture having the maxi- mum peripheral seal. When a denture is trimmed, or the undercuts blocked out on the model, some reduction in peripheral seal is inevitable. KNIFE-EDGE LOWER RIDGE Reason for the Difficulty. The pa- tient with a ridge of this type frequently complains of pain during mastication as the pressure exerted on the mandible via the denture compresses the soft tis- sue between the fitting surface and the knife-edge process forming the crest of the alveolar ridge. Treatment a- Alveoloplasty to reduce the sharp process; or b- A relief for the knife-edge ridge area; or c- Construct a denture having a re- silient lining; or d- An implant supported prosthesis Reducing the vertical dimension in such cases may be advantageous as this reduces the force applied during mastication Prognosis, Usually the most sat- isfactory results are obtained after an alveoloplasty since this removes the 204 cause. However, when surgical treat- mentis contraindicated some reduction in the pain and discomfort may be ob- tained by relieving the ridge area, there- by placing the greater proportion of the occlusal stress on the lateral borders of the ridge; but this, occasionally, can be as painful as the previous condition. A denture constructed with a resilient lin- ing, forming a cushion, usually reduces the symptoms LOWER RIDGE CONSIDERABLY HIGHER IN THE INCISOR REGION Reasons for the Difficulty. Anteri- or teeth of normal length would in this case present a large surface area for the lip to press against. Treatment, (a) Short incisor teeth to reduce the area which the lip can press against; (b) Alveoloplasty. Prognosis. A more stable denture is obiained if the anterior teeth are short as lip pressure is limited to a smaller area and the denture is not so readily displaced backwards. Alveolplasty may permit normal sized teeth to be used anteriorly but it may result in a loss of very necessary ridge support. LARGE TORUS PALATINUS Reasons for the Difficulty. The den- ture may rock across the mid-line and eventually fracture; retention may be re- duced, as an under-relieved torus prevents the denture bedding into the soft tissue. Treatment. (2) A compression im- pression technique; or (b) Adequate re- lief of the denture in the area of the torus, A metal palate will withstand strain from fatigue better than a plastic denture base, (c) surgical removal. eedentures which do not exhibit any rock across the mid-line, and if a metal pal- ate is incorporated in the denture it will withstand any slight rock that occurs. In addition, the health of the tissues un- der metal base will be much better than that under acrylic base and this may re- duce bone resorption, LARGE TUBEROSITIES Reason for the Difficulty, Fitting the finished denture requires consider- able trimming with loss of peripheral seal. Y Treatment. (a) Surgical removal of patt of the tuberosity; or (b) Undercut area blocked out on the cast; or (c) Den- ture flange carried only slightly into the undercut area, Prognosis. The most satisfactory denture is produced if the undercut is eliminated by surgical means as the op- erator can then achieve the maximum peripheral seal. If the undercut is only blocked out a space will exist, allow- ing the ingress of air and food between the denture and the tissue in that area, which will have an adverse effect on retention. If the flange is carried only slightly into the undercut area, intimate contact between the denture and tissue is maintained but since the flange does not extend into the full depth of the sulcus the peripheral seal is reduced. SHALLOW SULCI Reason for the Difficulty. The den ture tends to tilt and move readily due to lack of ridge support and peripheral seal is thus easily broken. Treatment. A peripherally trimmed impression technique and the teeth set up to give balanced articulation, or sul cus deepening 205 “Prognosts: THproved etention and stability due to well-developed periph- eral seal and freedom from cuspal in- terference. ABNORMAL FRENA Reason for the Difficulty. The den- ture is more easily displaced when frena are attached near to the crest of the ridge. Treatment. Division of the frena surgically before, or at, the time of in- sertion of the denture. Prognosis, Increase in denture sta- bility during function and increased pe- ripheral seal VARIATION IN TISSUE COMPRESSIBILITY FROM AREA TO AREA Reason for the Difficulty. (a) The air seal is broken due to the denture moving during mastication; (b) The den- ture may fracture because the occlusal pressure transmitted through the tissue to the supporting bone is uneven. Treatment. Compression impres- sion technique and balanced occlusion when setting up the teeth. Prognosis. Equalization of the pres- sure exerted on the bony support re- duces denture fatigue and therefore the tendency to fracture. A balanced arti lation reduces denture movement dur- ing mastication and thereby assists in maintaining the peripheral seal, TIGHT LOWER LIP Reason for the Difficulty, Instabil- ity of the lower denture due to the back- ward displacement caused by lip pres- sure, and vertical lift occurring in the premolar and canine region from the pressure of the modioli.Chapter 14 : Management of difficult complete denture cases Treatment. (a) Keep the occlusal plane low thus reducing the contactarea with the lip; (b) Adequate extension on to the retromolar pads to counteract the lip pressure; (c) Keep the denture nar. row across the premolar area Prognosis. The combination of many of the above points as possible will considerably aid lower denture stability and should enable the patient to use the prosthesis satisfactorily. LARGE TONGUE Reason for the Difficulty. If the tongue is cramped, or the teeth,set up So that they overhang it, the denture will be moved during function, Treatment. (a) Keep the occlusal plane low; (b) Provide the maximum intermolar distance by using narrow teeth or grinding away the lingual cusps: (c) Anterior teeth should be set up slight. ly forward of the ridge; (d) Peripherally trimmed impression technique. Prognosis. A satisfactory denture can only be produced, provided the tongue can move freely and be brought to rest easily on the occlusal surface of the lower teeth. ABNORMAL JAW RELATIONSHIPS I- Close bite Reason for the Difficulty. Lack of interridge space. Treatment. Acrylic posterior teeth Prognosis. A satis obtained. tory denture is 2- Superior Protrusion Reason for the Difficulty. Narrow and retrusive lower arch in relation- ship to a normal-size upper arch, 206 Treatment. (a) Maintain the natural overjet whieh will bE TATEE: (6) Periph: erally adapted impre n technique. Prognosis. Little difficulty is en- countered if nature’s arrangement is followed but trouble should be antici- pated if extensive aesthetic corrections are contemplated. 3+ Inferior Protrusion Reason for the Difficulty. Large and wide lower arch in comparison to the upper arch, leading to an unstable upper denture, Treatment, (a) Peripherally ada- Pted impression technique; (b) Metal palate; (c) Balanced occlusion; (d) Pos- terior cross bite; (¢) Anterior edge-to- edge bite, (f) Surgical correction Prognosis. A metal palate incorpo- tated in a denture having the maximum peripheral seal enables the technician to set the upper posterior teeth outside the ridge, and the balanced articulation ensures that the denture remains stable during mastication, thus producing the most satisfactory result. Excessive dif. ference in the size and protrusive rela- tionship of the lower jaw to the upper usually necessitate a posterior crossed occlusion and an anterior edge-to-edge occlusion, or the upper anteriors set dig tal to the lower anteriors. This involves some loss of stability as it is impossible fo maintain balanced articulation LENGTH OF TIME THE Pa- TIENT HAS BEEN EDENTULOUS Reason for the Difficulty, Individu. als without teeth, or having anterior teeth only for many months, develop a habit of protrusive chewing which caus. difficulty when recording the position of occlusionChapter 14 : Management of difficult complete denture cases Treatment. Patience, tolerance and. perseverance, the patient is asked to place the tip of the tongue as far back on the palate as possible to bring the mandible in the most retruded position. Inthe most difficult cases a Gothic arch tracing may obtain the desired result. Prognosis. The Gothic arch trac- ing, provided it is carried out on sta- ble bases, is probably the most certain method of obtaining the true position of centric occlusion. RETCHING AND NAUSEA DUR- ING IMPRESSION MAKING Reason for the Difficulty. Appre- hension and sensitivity. Treatment, (a) Zinc oxide cuge- nol paste impression, (b) 1:80 phenol mouthwash. (c) A Benzocaine tablet to suck; (d) A thin acrylic base-plate worn by the patient until tolerance is gained. Prognosis. Minimum bulk of im- pression tray and material is used However, when this does not succeed a phenol mouthwash or a Benzocaine tablet to suck prior to the taking of the impression may assist in mild cases of nausea and retching. Severer e- quire that an acrylic base plate be con- structed and worn by the patient until sufficient tolerance has been gained. RETCHING AND NAUSEA IN DENTURE WEARERS. Reason for the difficulty. (a) A thick back edge to the palate of the upper de ture; (b) Insufficient post-dam seal, of- ten placed in the wrong position. Treatment. (a) Thin down the back- edge; (b) Re-postdam on the soft com- pressible tissue of the soft palate ante 207 tior-to-the-vibrating-line-~Trace;-and readapt, the periphery of the denture and reline for better retention. Prognosis. The distressing symp- toms can usually be relieved by correctly placing, and keeping suitably thin, the posterior border of the upper denture, PROMINENT PREMAXILLA Reason for the Difficulty, Causes excessive prominence of the upper lip when a denture possessing a labial flange is fitted. Treatment. (a) Set the anterior teeth to the gum without a labial flange; (b) Severe cases require alveoloplasty. Prognosis. Gum-fitted anterior teeth lead to some loss of retention varying in degree according to the support given by the posterior ridges and other factors of retention. Alveoloplasty produces a satisfactory result as a labial flange can be utilized thus providing maximum pe- ripheral seal OCCUPATIONS Singers and public speakers Reason for the Difficulty, The sud- den loss of retention due to the air seal being broken in the vocal effort. Treatment, A peripherally trimmed impression technique and the correct positioning, with adequate seal, of the posterior border of the denture, Singers require a very thin metal palate. Implant supported fixed prosthesis is the treatment of choice of the condi- tion. If the case is suitable for such line of treatment Prognosis, Satisfactory retention can be achieved provided the maxi seal bas been obtained gen mum periphChapter 14 : Management of difficult complete denture cases BURNING SENSATION OF THE PALATE AND MOUTH WHEN WEARING DENTURES Reason for the Difficulty. (a) Allergy to a particular denture base. Treatment: New dentures using a different denture base; (b) Pressure on nerves and blood ves- sels leaving the palatal or mental fo- ramina. Treatment: Relief of pres- sure over these areas. 208 (c),Cause is unknown, Treatment: Re. fer to a physician for an opinion. Prognosis. These symptoms are often difficult to eradicate in some pa- tients, others will respond readily to new dentures of a different material, with or without foramina relief. This condition is frequently manifested by female patients at the menopause and disappears of its own accord when this change is completed.